Cardiac preparticipation screening for the young athlete: Why the routine use of ECG is not necessary

• ECG PPE screening is not a sound strategy for SCD reduction in the United States because the prevalence of SCD is low, the risk of false positives is high, and there are no outcomes studies demonstrating SCD reduction across the young athlete population.
• There is not a sufficiently trained work force in the United States to make mandatory ECG screening a helpful intervention and the reliability of ECG interpretation among experts is not sufficient for consistent results.
• There is no uniform interpretation of what is included in the denominator (i.e. the number of persons at risk) or in the numerator (i.e. what is considered a “SCD”) to calculate a standardized SCD rate.
• Assuming an SCD incidence of 17 per million athlete-years (1 in 60,000), a 5% false positive rate and a 0% false negative rate in the athletes screened; the number needed to screen (NNS) is 58,823, the positive predictive value (PPV) is 0.00034, and number of athletes who will not suffer SCD but are subject to further testing for every true positive test is 2941.

The addition of an electrocardiogram (ECG) to the current United States athlete preparticipation physical evaluation (PPE) as a screening tool has dominated the PPE discussion over the past decade despite the lack of demonstrable outcomes data supporting the routine use of the diagnostic study for reduction of sudden cardiac death (SCD). A good screening test should influence a disease or health outcome that has a significant impact on public health and the population screened must have a high prevalence of the disease to justify the screening intervention. While SCD is publicly remarkable and like any death, tragic, the prevalence of SCD in young athletes is very low and the potential for false positive results is high. While ECG screening appears to have made an impact on SCD in Italian athletes, the strategy has made no impact on Israeli athletes, and the overall impact of ECG screening on American athletes is unclear. Until outcomes studies show substantial SCD reduction benefit, the addition of routine ECG PPE screening in young athletes should not be instituted.