New AHA Guidelines for Screening Athletes Excludes EKG

The new recommendations for screening of athletes for competitive sports was issued by the American Heart Association and endorsed by the Americal College of Cardiology yesterday in the journal Circulation and includes careful evaluation of personal symptoms of the patient, family history, and physical examination findings. The recommendations significantly differ from the European Society of Cardiology (ESC) and the International Olympic Committee (IOC) by excluding the requirement of an electrocardiogram (EKG).

Although the Switzerland-based IOC and the ESC have advocated that all young competitive athletes be screened routinely with a 12-lead ECG (in addition to history-taking and physical examination), the updated 2007 AHA guidelines do not make this recommendation. No federal or state laws currently mandate that American physicians adopt the ESC16 and IOC guidelines. American law permits US medical organizations and physicians to assess independently the relevant variables (including the current infeasibility of routinely performing ECGs on populations of asymptomatic US athletes) and to make their own recommendations about the appropriate nature and scope of cardiovascular screening. Thus, a US physician’s decision to follow the updated AHA recommendations rather than those of the ESC and IOC does not itself constitute medical malpractice.

Part of the reason for exclusion of the EKG from screening is logistics.

For the AHA to officially adopt (or even condone) the ESC screening recommendation for routine ECGs without a reasonable expectation that such a program could be implemented in the near future could have a paradoxic, chilling effect on US preparticipation screening. Practitioners involved with screening would be potentially compromised by being unable to comply with the proposed screening strategy incorporating an ECG. Therefore, it is possible that the willingness of qualified US physicians to participate in screening would be reduced if the ESC/IOC recommendations were mandated.

Part of the reason for the exlusion of the EKG is cost:

Given the theoretical cost of a mass cardiovascular screening program of $2 billion per year, the dollar amount attached to detecting each athlete with the suspected relevant cardiac diseases would be $330 000. Assuming that (more than) 10% of these 9000 athletes with cardiac disease (1800) would harbor evidence of increased risk for sudden death, then the cost of preventing each theoretical death would be $3.4 million. We recognize that some may not regard these estimated costs per athlete as excessive for detecting potentially lethal cardiovascular disease in young people; however, the fundamental issue defined by these calculations concerns the practicality and feasibility of establishing a continuous annual national program for many years at a cost of approximately $2 billion per year.

They conclude as follows:

Indeed, on humanitarian medical grounds, the AHA supports any public health initiative with the potential to identify adverse cardiac abnormalities. On the other hand, because the panel cannot ignore the many epidemiological, social, economic, and other issues that impact this screening proposal, it must view the European model in realistic terms from a US perspective. Therefore, for a number of reasons, it is difficult to consider the European-Italian strategy as potentially applicable to preparticipation screening in the United States.

So, although the EKG is out, practitioners must not forget to take a thorough personal and family history, listen for murmurs, check the blood pressure from the arm, check for femoral pulses in the legs (to exclude coarctation of the aorta), and note physical characteristics of Marfan's Syndrome.

-Wes