ORLANDO -- A comprehensive cardiac workup for young athletes proved feasible but cost too much to be practical, investigators reported here.
The addition of a limited echocardiogram to history, physical, and ECG identified five athletes with an increased risk of sudden death from 659 screenings at a cost of about $9,000 per event, not including physician costs.
The results did little to define the optimal approach to screening athletes, Jeffrey D. Anderson, MD, of Cincinnati Children's Hospital Medical Center, reported here at the American Academy of Pediatrics meeting.
"History and physical exam alone are not adequate to capture all cardiac abnormalities that may put someone at risk for sudden death," Anderson said. "Echocardiography can reduce the false-positive rate of ECG screening, but mass echocardiography also will identify heart disease that does not pose an immediate risk."
Future investigation should focus on obtaining more precise estimates of sudden cardiac death epidemiology in young people, identifying the key cardiac abnormalities that screening should uncover, and developing a cost-effective approach to screening athletes, he added.
False Positives a Problem with ECG
Sudden cardiac death (SCD) remains the most common cause of death in young athletes. Etiology of the condition usually involved cardiomyopathy and anatomic abnormalities of the heart or vasculature.
History and physical exam represent the usual approach to a screening cardiac workup for young athletes, but often are not performed appropriately, said Anderson. ECG alone can provide additional information about an athlete's potential risk of SCD but carries the risk of a wide range of false-positive findings.
A limited, focused echocardiographic evaluation might overcome the limitations of current approaches to screening athletes. However, the feasibility and cost of such an approach were unknown.
"We hypothesized that the addition of a limited echocardiogram would decrease the false-positive rate of ECG alone and would identify additional abnormalities not found with examination and ECG," said Anderson.
Investigators recruited adolescents 14 to 18 who were participating in school or other forms of organized athletics. Each participant underwent a history and physical examination, ECG, and limited echocardiography. Upon completing the screen, the athletes met with a pediatric cardiologist to discuss the findings.
Anderson said the history and physical examination were performed in accordance with recommendations of the American Heart Association, the AAP, and the American Medical Society for Sports Medicine.
The ECG was used to identify ventricular hypertrophy by voltage criteria, QTc >460 or <350 ms, ventricular pre-excitation, more than three premature ventricular contractions (PVCs) per recording, and Brugada pattern.
The limited echocardiography consisted of imaging of the left and right ventricles, coronary artery origins, aortic and pulmonary valves, aorta, and off-line measurements for z-scores >2.5.
The 659 students screened had a mean age of 15.4, and boys accounted for 422 of the study participants. The most common sports were basketball (221), soccer (186), track (165), and football (141). Some of the athletes participated in more than one sport.
Abnormalities Identified
The history and physical examination revealed abnormal findings in 177 (27%) of the study participants. The most frequently identified abnormalities were exertional chest pain (97), exertional dyspnea/fatigue (96), a family history of sudden death before age 50 (86), elevated systolic blood pressure (60), and unexplained syncope/near syncope (27).
Subsequently, 532 (81%) athletes (including 50 with abnormal findings) received clearance to participate in sports. Of the remaining athletes, 51 (7%) were referred for follow-up ECG and 76 (12%) were referred for further evaluation by a cardiologist.
ECGs were normal in 580 (88%) study participants. Among those with abnormal ECG findings, the most common abnormality was left ventricular hypertrophy (LVH) by voltage criteria (35), followed by QTc prolongation (eight), right ventricular hypertrophy (five), right bundle branch block (two), and one case each of junctional bradycardia, ventricular pre-excitation, PVCs, and Brugada pattern.
Of the 79 athletes with abnormal ECG findings, 11 also had abnormal findings on the history or physical exam. Echocardiography revealed dilated cardiomyopathy in one of the 35 patients with LVH by ECG criteria.
Echocardiography results were normal in 624 (95%) of the athletes and abnormal in 35.
In addition to the one case of dilated cardiomyopathy, echo showed increased LV mass or thickness in four participants, dilated aortic root in four, LV noncompaction cardiomyopathy (LVNC) in three, atrial septal defect in two, and one case each of below-normal ejection fraction, small ventricular septal defect, and small patent ductus arteriosus.
Six of the 35 athletes in the abnormal echocardiography group had abnormal history or physical examination, and seven had abnormal ECGs.
Of the participants referred for follow-up evaluations, five subsequently had diagnoses associated with an increased risk of SCD: two patients with congenital long QT syndrome and one case each of Brugada syndrome, dilated aortic root, and dilated cardiomyopathy.
An additional 16 patients had diagnoses that led to additional cardiology follow-up: four with increased LV mass/thickness, three with dilated aortic root, three with LVNC, two each with bicuspid aortic valve and atrial septal defect, and one each with low-normal ejection fraction and double-orifice mitral valve.
The time to completion of a screen averaged 82 minutes, including 18 minutes for the echocardiography. Investigators originally estimated that the echo assessment would require 5 minutes. ECGs had to be repeated in 10 cases because of improper lead placement, and the echocardiography provided adequate coronary imaging in 71% of cases.
Anderson said the estimated cost of identifying the five patients at risk of SCD ranged between $8,500 and $9,200 per event. The total cost of screening was estimated at $44,000, and the cost per screened athlete was $66. None of the costs included physician time.
The project involved three pediatric cardiologists, four pediatricians, four cardiovascular technicians, seven to 10 sonographers, and a research staff of 10.
SOURCE: Med Page Today