What is the evidence for the diagnostic effectiveness of a 12-lead electrocardiogram (ECG) compared to history and physical examination (H&P) alone in pre-participation screening of young athletes for detecting underlying cardiac disease and conditions associated with sudden cardiac death (SCD)?
AMSTAR Rating
Summary
Patient Population:
A total of 9 prospective and retrospective studies published between 2015 and 2020 met inclusion criteria, encompassing a combined sample size of n = 28,011 young competitive athletes (aged 10–35 years; mean ages across studies 15–21 years). Overall, 77% of participants were male (n = 21,574), with diverse international athletic cohorts from the United States, United Kingdom, Canada, Denmark, Qatar, and Spain.
Intervention:
Pre-participation screening utilizing a 12-lead electrocardiogram (ECG), interpreted primarily via modern athlete-specific criteria (such as the Seattle Criteria or 2010 European Society of Cardiology criteria). Across all 9 studies, 1,125 positive ECG screening results were recorded.
Comparison:
Standard pre-participation cardiovascular screening performed via personal medical and family history questionnaires combined with a focused physical examination (H&P). Across all 9 studies, 2,857 positive H&P screens were recorded.
Outcome:
Across the 28,011 screened athletes, 124 new true cardiac diagnoses were established, 103 of which were conditions directly associated with sudden cardiac death (SCD-AC, such as hypertrophic cardiomyopathy, Wolff-Parkinson-White syndrome, long QT syndrome, and arrhythmogenic right ventricular cardiomyopathy).
Random-effects meta-analysis demonstrated that the odds of detecting overall cardiac disease with a 12-lead ECG were statistically significant (Odds Ratio [OR] = 60; 95% CI, 26–137; p < 0.001), whereas screening via H&P alone was not statistically significant (OR = 3.4; 95% CI, 0.88–13; p = 0.076).
When restricted specifically to conditions associated with sudden cardiac death, the diagnostic superiority of ECG screening was even higher (OR = 148; 95% CI, 84–260; p < 0.0001), compared to H&P alone which remained statistically non-significant (OR = 2.9; 95% CI, 0.88–9.4; p = 0.078).
Guideline Recommendations
| Source | Recommendation |
|---|---|
| AEPC, ESC, IOC, FIFA | Endorse a mandatory 12-lead ECG |
| AHA, ACC | Recommend personal/family history and physical exam ALONE |
Outcomes Assessed
- Benefit
- Harm
- Inconclusive
Detection of life-threatening cardiac conditions
12-lead ECG detected 103 life-threatening conditions
History and Physical alone detected less than 15% of these conditions
False Positives
Approx. 90% of 1125 positive ECG's were false positives
Relevant Clinical Info
Malhotra A, Dhutia H, Finocchiaro G, et al. Outcomes of cardiac screening in adolescent soccer players. N Engl J Med. 2018;379(6):524-534. doi: 10.1056/NEJMoa1714719.
Malhotra et al. (2018) was the benchmark prospective cohort study included in this meta-analysis, evaluating an impressive population of 11,168 elite adolescent soccer players (mean age 16.4 years; 95% male) in the United Kingdom over a 20-year period under the English Football Association screening program. All athletes underwent concurrent screening with health questionnaires, physical examinations, and 12-lead ECGs, with echocardiography used for secondary testing. The study identified 42 athletes (0.38%) with cardiac disorders associated with sudden cardiac death. Crucially, 86% of these life-threatening conditions were identified primarily via ECG screening, whereas personal history and physical examination failed to detect the vast majority of silent structural and electrical abnormalities, demonstrating the real-world diagnostic yield of universal ECG protocols in young competitive populations.
Participant Information
of participants
were Male
The sample size was 28,011
There were 9 studies used.
