Electrocardiogram testing during athletic preparticipation physical examinations.
BACKGROUND
Sudden cardiac death (SCD) is a relatively rare yet unfortunate risk of athletic participation. To reduce the incidence of SCD, electrocardiogram (ECG) use during athletic preparticipation examinations (PPEs) has been proposed to detect underlying cardiac abnormalities.


OBJECTIVE
To estimate the effectiveness of ECG use during athletic PPEs.


METHODS
Epidemiologic modeling.


METHODS
Public high school athletes.


METHODS
Estimates of ECG sensitivity (70%) and specificity (84%) were drawn from the literature, as was the estimate of overall prevalence of cardiac conditions relevant to SCD (0.3%). Participation rate by sex was determined from National Federation of State High School Associations data. Participation by ethnicity was assumed to be proportionate to the public high school attendance rates for grades 9 through 12 (18.4% African American). Population-specific ECG effectiveness (positive predictive value), estimated total costs, cost per year of life saved, and cost to identify 1 additional case were computed. Total annual PPE screening costs reflected a cardiologist's office visit, including echocardiogram for those athletes with a positive ECG screen.


RESULTS
The model predicted that 16% of all athletes would be expected to have a positive ECG, but only 1.3% of athletes with a positive ECG would have a cardiac abnormality capable of causing SCD, including hypertrophic cardiomyopathy, structural defects, and various conduction abnormalities. Total annual cost estimates for ECG screening and follow-up exceeded $126 million. Average cost per year of life saved across groups was $2693, and the cost to identify 1 additional case averaged $100 827. Compared with females, males had both lower cost per year of life saved and lower cost to identify 1 true case. Similarly, black males exhibited lower costs than white males. Across groups, false-positive ECG screening exams accounted for 98.8% of follow-up costs.


CONCLUSIONS
Large-scale, mass ECG testing would be a costly method to identify athletes with cardiac abnormalities. Targeting high-risk populations can increase the effectiveness of the ECG for athletic PPE screening.
O'Connor
Daniel P
DP
University of Houston, Department of Health and Human Performance, 3855 Holman Street, Houston, TX 77204-6015, USA. doconnor2@uh.edu
Knoblauch
Mark A
MA
D000293:Adolescent; D016757:Death, Sudden, Cardiac / Q000517:prevention & control; D004562:Electrocardiography / Q000191:economics*; D005006:Ethnicity; D005080:Exercise Test; D005260:Female; D017048:Health Care Costs; D006304:Health Status; D006331:Heart Diseases / Q000175:diagnosis*; D006801:Humans; D015994:Incidence; D008297:Male; D008403:Mass Screening; D018803:Models, Economic; D010807:Physical Endurance; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D012574:Schools; D012680:Sensitivity and Specificity; D013177:Sports; D013178:Sports Medicine / Q000191:economics*; D013334:Students; D013781:Texas / Q000453:epidemiology; D013997:Time Factors
Heart. 2000 May;83(5):588-95
10768917
Eur J Cardiovasc Prev Rehabil. 2006 Dec;13(6):859-75
17143117
N Engl J Med. 2003 Sep 11;349(11):1064-75
12968091
Cardiol Clin. 2007 Aug;25(3):399-414, vi
17961794
Pediatr Exerc Sci. 2007 Nov;19(4):373-83
18095402
N Engl J Med. 2008 Jan 10;358(2):152-61
18184960
Heart Rhythm. 2005 Dec;2(12):1283-5
16360078
JAMA. 2002 Mar 13;287(10):1308-20
11886323
Circulation. 2007 Mar 27;115(12):1643-455
17353433
J Am Coll Cardiol. 2003 Mar 19;41(6):974-80
12651044
Cardiol Clin. 2007 Aug;25(3):391-7, v-vi
17961793
Pediatrics. 2009 Apr;123(4):1217-22
19336382
JAMA. 2006 Oct 4;296(13):1593-601
17018804
Circulation. 2000 Jul 18;102(3):278-84
10899089
Circulation. 1996 Aug 15;94(4):850-6
8772711
Am J Sports Med. 1999 Jan-Feb;27(1):108-21
9934429
Cleve Clin J Med. 2004 Jul;71(7):587-97
15320370
Circulation. 2006 Oct 10;114(15):1633-44
17030703
Am J Cardiol. 2007 Dec 1;100(11):1709-12
18036373
Med Sci Sports Exerc. 1997 Sep;29(9):1131-8
9309622
Eur Heart J. 2005 Mar;26(5):516-24
15689345
Eur Heart J. 2006 Sep;27(18):2196-200
16831826
Curr Opin Cardiol. 2001 Jan;16(1):30-9
11124716
JAMA. 1996 Jul 17;276(3):199-204
8667563
Heart Rhythm. 2007 Apr;4(4):520-4
17399645
J Bone Joint Surg Am. 2004 Mar;86(3):607-20
14996892
J Am Coll Cardiol. 1998 Dec;32(7):1881-4
9857867
Heart Rhythm. 2007 Apr;4(4):525-8
17399646
Cardiovasc Clin. 1991;21(3):297-320
2044112
Med Sci Sports Exerc. 2008 May;40(5):787-98
18408622
Med Sci Sports Exerc. 2000 May;32(5):887-90
10795776