Top Things to Know: Assessment of the 12-Lead ECG as a Screening Test for Detection of CVD in Healthy General Populations of Young People
Published: September 15, 2014
- Sudden death (SD) of young people is often due to a variety of complex predominantly genetic/congenital cardiovascular diseases that are often unsuspected. Cardiovascular screening here is defined as an initiative intended to prospectively identify or raise suspicion of previously unrecognized and largely genetic/congenital cardiovascular diseases known to cause sudden cardiac arrest and SD in young people.
- This scientific statement includes considerations for screening of large, young, and general populations (school-aged, 12-25 years old, of both sexes) and is not limited in scope to universal mass screening for athlete populations. A summary of prior consensus recommendations concerning ECG screening is included in this statement.
- This potential screening population would comprise about 60 million young people nationally, including as many as an estimated 10 million competitive athletes. There is no evidence at present that the specific causes of SD differ significantly in non-athletes.
- Estimates for the incidence/prevalence of SD in young people in large general populations (not confined to athletes) suggest that mortality rates generally exceed those reported for competitive athletes. Specifically, pediatric out-of-hospital cardiac arrest incidence has been reported variously as 6.4/100,000 p-y [person-years], 3.2/100,000 p-y in the pediatric population, and 2.3/100,000 p-y in pediatric and young adult populations.
- A variety of mostly congenital/genetic diseases (about 20) are responsible for most of the SD events with ventricular tachyarrhythmias being the mechanism of death in the majority of the events.
- Hypertrophic cardiomyopathy
- Congenital coronary anomalies
- Other
- Non-structural cardiac abnormalities
- ECG screening for genetic or congenital disorders in young people has important potential and inherent scientific limitations. The usefulness and consequences of routine ECG screening depends on the purpose of acquisition, technical quality of the recording, selection of the study population, distinguishing factors within population subgroups (such as age, sex, race, and level of physical activity), inherent performance characteristics of the ECG for the identification of prognostic abnormalities, quality of interpretative analysis, and balances among benefits, risks, and costs of the derived information.
- The 14 elements for cardiovascular screening (originally used for preparticipation cardiovascular screening of competitive athletes and modified for this scientific statement) are listed in a table and include the following.
- Medical history – personal and family
- Physical examination
- Additionally, parental verification of the medical history is recommended.
- These recommendations are made for general populations of healthy young people ages 12-25:
- Use by examiners of the AHA’s 14-point screening elements and those from other societies as part of a comprehensive history–taking and physical examination to detect or raise suspicion of genetic/congenital and other cardiovascular abnormalities is recommended.
- Use of 12-lead ECGs (or echocardiograms) in relatively small cohorts of young healthy people 12 to 25 years of age may be considered to identify or raise suspicion of genetic/congenital and other cardiovascular abnormalities as long as close physician involvement and sufficient quality control can be achieved. Additionally the limitations of the12-lead ECG as a population screening test should be known (false positive and negative results, costs, etc.).
- Mandatory and universal screening mass screening with 12-lead ECGs in large populations of young healthy people 12-225 years of age (including on a national basis in the US) to identify genetic/congenital and other cardiovascular abnormalities is not recommended for athletes and non-athletes alike.
- Consideration for large scale general population universal cardiovascular screening in the age group 12-25 years with history and physical examination alone is not recommended.
- Pursuit of standardization of the questionnaire forms used as guides for examiners of high school and college athletes in the US is recommended.
- Cardiovascular screening programs (independent of size, scope, or design) should be driven by sound scientific principles and policy.
- More widespread dissemination of automatic external defibrillators, which are effective in saving young lives, is a healthcare initiative worthy of consideration.
Citation
Maron BJ, Friedman RA, Kligfield P, Levine BD, Viskin S, Chaitman BR, Okin PM, Saul JP, Salberg L, Van Hare GF, Soliman EZ, Chen J, Matherne GP, Bolling SF, Mitten MJ, Caplan A, Balady GJ, Thompson PD; on behalf of the American Heart Association Council on Clinical Cardiology, Advocacy Coordinating Committee, Council on Lifelong Congenital Heart Disease and Heart Health in the Young, Council on Cardiovascular Surgery and Anesthesia, Council on Epidemiology and Prevention, Council on Genomic and Precision Medicine, Council on Quality of Care and Outcomes Research, and American College of Cardiology. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12–25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology [published online ahead of print September 15, 2014]. Circulation. doi: 10.1161/CIR.0000000000000025.