Pre-participation Electrocardiography as part of the Pre-participation Physical Examination: A Systematic Review

Context: Sudden cardiac death (SCD) in athletes most often occurs in those with underlying heart abnormalities that havent been identified during the pre-participation exam (PPE). In the US, the PPE recommendations include a cardiovascular (CV) medical history and physical examination (H/P). The ability of the CV medical history and H/P to identify cardiac abnormalities has been questioned for some time... There is debate as to whether mandatory electrocardiography (EKG) testing should be added to the PPE. Objective: To determine whether an EKG as part of the standard PPE for young athletes is a cost effective and diagnostically appropriate option. Data Sources: Searches were conducted using Proquest, Ovid Journals, Academic Search Premier, and ScienceDirect with key words: sudden cardiac death, hypertrophic cardiomyopathy, electrocardiogram, athletic pre-participation exam, sensitivity, specificity, and cost-effectiveness. Limits included peer-reviewed studies less than 30 years old and English language. Study Selection: Studies were initially chosen based on the inclusion of relevant information in the title or abstract, which were: athletic PPE guidelines, SCD prevalence and associated CV conditions, diagnostic effectiveness of EKG screening in detecting SCD-related abnormalities, and cost-effectiveness of cardiac screening methods. A subsequent evaluation of the full-text articles resulted in 11 original studies being selected for inclusion spanning 3 specific areas (CV screening procedures, Diagnostic Capabilities of EKG, and Cost Effectiveness of EKG). Data Extraction: The methodological quality of selected articles was evaluated independently by two raters using the PEDro scale and ranged from 4-8. Data related to sensitivity, specificity and cost effectiveness were extracted and utilized. Data Synthesis: Related to CV screening protocols; an EKG-mandated protocol decreased the incidence of SCD by 89% in the young competitive athletes (YCA) vs. the general population while also bringing person years from 3.6/100,000 to 0.4/100,000 in YCA. Diagnostic capabilities showed that H/P + EKG = 99.8% sensitivity, EKG alone = 90.9% sensitivity while H/P alone was 45.5% sensitive. Others reported sensitivity to range from 60-70%, specificity to be 97.8%, with false positives equaling 2.2%. Cost-effectiveness of implementing mandatory EKG testing showed $44,000/year of life saved in comparison to the AHA-recommended H/P at $84,000/year of life saved. Conclusions: One of the main arguments against PPE EKG testing historically is that it has a low specificity, which is negatively associated with cost-effectiveness as unnecessary referrals are made due to higher false positives. It has been suggested that adjusting diagnostic criteria to be more representative of YCAs can increase specificity to as high as 97.8%. Despite numerous variations in study methods and results, the data generally suggests that PPE EKG testing has the potential to be an acceptable and cost-effective addition to the PPE and ultimately decreases SCD. Word Count: 43