The American Heart Association (AHA) has released its updated guidelines on the medical screening of competitive athletes, and notably has declined to recommend that all prospective athletes be screened with an electrocardiogram (ECG). Indeed, the screening guidelines are essentially unchanged from the AHA's previous set of guidelines, published in 1996. The AHA's decision not to support the use of routine ECG screening is a surprise to some, because such routine ECG screening was included in recent guidelines published by the European Society of Cardiology (ESC) and the International Olympic Committee (IOC). Instead, the AHA guidelines continues to rely on the medical history and physical examination to identify cardiovascular disorders.
DrRich comments:
There is little doubt that screening every athlete with ECGs would uncover a number of individuals who have occult cardiovascular abnormalities that ought to preclude their participation in competitive sports. In the face of this fact, there are two reasons the AHA decided not to recommend ECG screening for competitive athletes.
The first is cost. There are over 2.5 million amateur competitive athletes (high school and college combined) in the United States, and performing yearly ECG screening on all of them would cost an estimated $2 billion annually (this number takes into account the additional tests that would be performed to chase down the significance of ECG abnormalities that are identified.)
The second is that, while ECG screening would indeed identify individuals who should not participate in sports, it would also identify many other individuals who, despite ECG abnormalities sufficient to deny them permission to play sports, are probably in fact at very low risk for cardiovascular events. For instance, one of the most common cardiac abnormalities in younger athletes is hypertrophic cardiomyopathy (HCM) While individuals who have HCM and also have symptoms (or a family member with symptomatic HCM) are felt to be at a relatively high risk, the risk is unknown for athletes without any symptoms and with no family history, whose HCM is discovered on a routine ECG. Is it right to "ground" such athletes because of their ECG findings? Nobody knows - but the AHA has come down on one side of the question, and the ESC/IOC on the other.
The two sets of guidelines - one European and one American - define the competing risks of the "routine ECG" question. A) The risk of not doing the ECG may mean that 1 athlete out of every 200,000 may suffer cardiovascular death each year. B) The risk of doing the ECG would certainly mean that many, many more than 1 in 200,000 may be barred from participation in sports unnecessarily. Those are the competing risks. The Europeans have decided Risk A is the more important one, while the AHA apparently gives more weight to Risk B.
Why did these highly respected professional organizations go in opposite directions in this case? DrRich suspects two reasons. First, it is possible these differing decisions reflect the relative importance assigned to sports within these two geographies. And second, while guidelines are not supposed to be "rules" but merely strong suggestions, in a litigious America any doctor not following guidelines provided by an august body such as the AHA is toast if sued. So, while European doctors may have some leeway if an athlete's screening ECG shows abnormalities the doctor thinks are not really significant, doctors in the US would more likely feel boxed in to a less negotiable position - if your ECG isn't normal, you don't play.
In any case, any American athlete (or parent) not agreeing with the AHA's risk/benefit calculation is free to insist on a screening ECG. Just keep in mind that there's no free lunch, and that either option does indeed carry a risk.
Sources:
Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update. Circulation 2007; DOI: 10.1161/circulationaha.107.181423. Available at: [/link] <A> http://circ.ahajournals.org[/link].
