12-Lead ECG as an Athletic Pre-Participation Screening
Element: Good? Bad? Feasible?
James P. Daubert, MD
Professor of Med...
Daubert: Presenter Disclosure Information (<2y)
Type of Support Entity
Consulting: Boston Scientific, Medtronic, VytronUS ...
Hank Gathers
ESPN: 30 for 30: Guru of Go - Hank Gathers Last Moments
Sudden death after winning basket in undefeated season
Maron B. Heart Rhythm 10/2011
The 12-Element AHA Recommendations for Preparticipation
Cardiovascular Screening of Competitive Athletes
Compliance with 1997 AHA Recommendations: Poor
for High School Athletes
Glover, Maron: JAMA. 1998;279(22):1817
By 2005, th...
NEJM 2014
Chaitman / Myerburg & Vetter, Circulation. 2007;116:2616-2626
Annual Incidence of Sudden Cardiac Death Expressed per 100,000 Person-Years in the 3 Studies Evaluating
the Effects of Scr...
Editorial on Italian Screening Experience
• The annual incidence of sudden cardiac death in athletes decreased from
3.6 de...
Mandatory ECG Screening of Young Athletes: Con
• High profile tragic events
• However, infrequent events (although data so...
Distribution and overlap of QTc values for healthy individuals compared to patients with
genetically confirmed LQTS.
Drezn...
Evaluation of ECG Abnormalities in Italian Olympic Athletes
Pelliccia A et al, Circulation 2000; 102: 278
Seattle criteria
Drezner JA, Fischbach P, Froelicher V, et al. Br J Sports Med 2013;47:125–136.
ESC ECG Criteria for Athletes
{Corrado, EHJ 2010 #19566}
This figure illustrates the ‘Teach-the-Tangent’ or ‘Avoid-the-Tail’ method for manual
measurement of the QT interval.
Drez...
ECG of a 28-year-old asymptomatic Caucasian handball player demonstrating a junctional
escape rhythm.
Drezner J A et al. B...
ECG shows Mobitz type I (Wenckebach) second-degree AV block demonstrated by
progressively longer PR intervals until there ...
Normal variant in black athlete
V1-V4 (not V5-V6) and often preceded by convex ST-segment elevation
Wilson B et al, Br J S...
Abnormal ECG in Both Kinds of Football Players
• Schmied: 25.8% of U-17 African
elite football players by 2005 ESC,
19.5% ...
High School Student ECG Screening: Chicago YH4L Project
• Retrospective cohort study of 32,561 HS students not just athlet...
YH4L
HS Students
*Other: A-paced, EAT, dextrocardia (3), atypical RBBB (4), NW QRS axis (9), short QT (2)
Most frequent:
L...
HS Athlete ECG Screening Study
• 2017 HS athletes screened prospectively with H&P, ECG, 2-D
echo; 71% male; ~30% AA
• H&P ...
Chandra N, JACC 2014
Malholtra, Heart Rhythm May 2011
UVA D1 ECG Screening
1473 athletes over 5 y period
Malholtra, Heart Rhythm May 2011
UVA D1 ECG Screening: Costs to Institution or Insurance
• Additional (marginal) cost of a...
Medicolegal Issues
• Legal action has occurred for:
– Failure or inadequate screening
– Failure to diagnose / disqualify a...
ECG Screening for Athletes
• What is a “normal” ECG for an athlete? Importance of normal
variants. ESC and Seattle criteri...
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SCD 2014: ECG Screening: Good? Bad? Feasible?

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  • With the score tied and 30 seconds left in overtime, Wes Leonard, a 16- year-old point guard for the Fennville Blackhawks, sank the winning layup that carried his team to a 57-55 victory on March 3, 2011. It was a Hollywood triumph for the final game of an undefeated season. Leonard’s teammates from his Michigan high school hoisted their star player skyward. Seconds later, to the horror of the packed stadium, the boy collapsed. Doctors at a nearby hospital soon pronounced Leonard dead of cardiac arrest.
  • Comparative frequencies of death from all causes for people &lt;35 years of age. CV = cardiovascular; ECG+ = suspicion of cardiovascular disease raised by an abnormal electrocardiogram.
  • Parental verification is recommended for high school and middle school athletes. †Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion. ‡Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction. §Preferably taken in both arms.3
  • Combined assessment of history and physical examination questionnairesused in 43 states, judged with respect to inclusion of the 13 specific 1996American Heart Association (AHA) recommendations for preparticipationcardiovascularscreening of high school athletes (28% of 43 states have 4 or fewer recommendations;40% have 9 or more recommendations). The8 other states have no formal questionnaires.
  • Figure 2 We therefore analyzed the impact of the National Sport Law enacted in Israel in 1997—which mandates screening of all athletes with resting ECG and exercise testing—on the incidence of sudden death among competitive athletes.MethodsWe conducted a systematic search of the 2 main newspapers in Israel to determine the yearly number of cardiac arrest events among competitive athletes. The size of the population at risk was retrieved from the Israel Sport Authority and was extrapolated to the changes in population size over time.ResultsThere were 24 documented events of sudden death or cardiac arrest events among competitive athletes during the years 1985 through 2009. Eleven occurred before the 1997 legislation and 13 occurred after it. The average yearly incidence of sudden death or cardiac arrest events was 2.6 events per 100,000 athlete-years. The respective averaged yearly incidence during the decade before and the decade after the 1997 legislation was 2.54 and 2.66 events per 100,000 person years, respectively (p = 0.88).The sudden death of a competitive athlete is a dramatic event that generally is covered by the media. Therefore, we limited our analysis to sudden death events in competitive athletes. As in previous studies (1), we systematically screened the general media for reports of sudden death in athletes. For that purpose, we assigned 2 professional media researchers to perform a systematic day-by-day search of the 2 leading newspapers in Israel (YediotAharonot and Maariv) ( 7). Of note, YediotAhronot reached 70% of the daily newspaper readership in Israel during the study period, whereas YediotAhronot and Maariv combined covered 90% of the readership ( 8 and 9). Beginning in September 2009 (and ending in December 2009), the professional media researchers scrutinized the newspapers published daily between January 1985 and December 2009. This 24-year period was targeted because we wanted to compare 2 equally long periods. Consequently, because the law mandating pre-participation ECG screening of athletes became effective 12 years previously (on November 1997) ( 5), we compared the 12-year period of 1985 through 1997 with that of 1998 through 2009. All the reports of deaths or dramatic medical events in competitive athletes were brought to the consideration of 3 investigators to determine (by consensus) whether the report could be considered as an athlete&apos;s sudden cardiac death or cardiac arrest. Sudden death was defined as a witnessed instantaneous death with futile resuscitation. Cardiac arrest was defined as instantaneous collapse with successful resuscitation. Sudden deaths related to trauma were excluded. As in previous studies ( 4), annual incidence rates were calculated by counting the events in 2-year periods and halving the result.Estimation of the population at riskAccording to the Israeli Sports Authority, the official Israeli sports organization acting under the Israeli Ministry of Sports, the number of registered athletes who engaged in competitive sports during 2009 was 45,000. We extrapolated these data to the growth of the Israeli population who were 10 to 40 years of age during the last 24 years as available from the Israeli Central Bureau of Statistics (10). In addition, because some data suggest that the percentage of the adult population engaging in sportive activities has increased by 50% during the last decade (11), we repeated our calculations of the number of athletes at risk, assuming a gradual doubling of the percentage of athletes over the 24 years of our study.
  • Van Camp: Nontraumatic deaths occur each year in organized high school and college athletics, resulting in considerable public concern. We conducted a study of the frequency and causes of nontraumatic sports deaths in high school and college athletes in the USA through the National Center for Catastrophic Sports Injury Research to define the magnitude of this problem and its causes. Over a 10-yr period, July 1983-June 1993, nontraumatic sports deaths were reported in 126 high school athletes (115 males and 11 females) and 34 college athletes (31 males and 3 females). Estimated death rates in male athletes were fivefold higher than in female athletes (7.47 vs 1.33 per million athletes per year, P &lt; 0.0001), and twofold higher in male college athletes than in male high school athletes (14.50 vs 6.60 per million athletes per year, P &lt; 0.0001). Cardiovascular conditions were more common causes of death than noncardiovascular conditions. Hypertrophic cardiomyopathy and congenital coronary artery anomalies were the most common causes of death. In high school and college athletes, males are at increased risk for nontraumatic sports deaths compared with females even after adjustment for participation frequency; college males are at greater risk than high school males. In all groups the deaths were primarily due to cardiovascular conditions.
  • T-wave inversions in leads V1–V4 were usually asymmetric or biphasic and frequently proceeded by convex ST-segment ele- vation. In black athletes, T-wave inversion was only preceded by ST-segment elevation or isoelectric ST-segments but never ST-segment depression. Detailed evaluation of these athletes with echocardiography, exercise stress tests, cardiac MRI and 24 h Holter failed to demonstrate any of the broad phenotypic features of HCM or ARVC, and following an almost 7-year follow-up episode there were no adverse events in black ath- letes with T-wave inversions in leads V1–V4. The same study also revealed that black controls of similar age had a T-wave inversion prevalence of 10% T-wave inversion beyond lead V2 is excep- tionally rare in caucasian athletes aged &gt;16 years (0.1%) and are an indication for further investigation. In contrast, T-wave inversion in the anterior leads (V1–V4) is common in adult black athletes (figure 2B). A recent study examining 904 black athletes and 1819 white athletes aged 14–35 years participat- ing in 22 different sporting disciplines revealed that T-wave inversions were present in up to 25% of athletes and half of these individuals exhibit deep (−0.2 mV) T-wave inversions.14
  • Among 88 athletes with distinctly abnormal ECGs, 33 (38%) had echocardiograms, including only 1 with borderline septal thickness of 14 mm. Systolic anterior motion of the mitral valve (or any other feature of hypertrophic cardiomyopathy), mitral valve prolapse, and evidence of coronary anomalies of wrong sinus origin were absent in each of the 203 athletes.
  • Criticques; Most probably false positive (prevalence of 0.2-.07%) [maron 2007 circ]; 3 PVC; mostly caucasian; only 30% athletes;
  • A total of 2017 high school athletes seeking clearance for competitive sports were prospectively evaluated using a stand- ardized history and physical examination, 12-lead ECG, and two- dimensional echocardiogram (echo). Primary outcome measures included the identification of cardiac disorders associated with sudden cardiac death. Secondary outcome measures included identification of abnormal, but nonlethal, cardiac conditions that required medical follow-up. RESULTS Of these athletes, 14.7% had an abnormal history or physical examination and 3.1% had an abnormal ECG based on modern ECG interpretation criteria. Five primary outcomes (1 hypertrophic cardiomyopathy, 4 Wolff-Parkinson-White syn- drome) and four secondary outcomes were identified. History and physical examination detected 40% of primary and 50% of secondary abnormalities. ECG detected all five primary abnormal- ities but none of the secondary abnormalities. Echo was abnormal in 1.2% and detected one primary and four secondary abnormal- ities. The false-positive rates for primary and secondary outcomes for history and physical examination and ECG were 14.5% and 2.8%, respectively. CONCLUSION ECG adds value to PPS through increased detection of arrhythmogenic and structural cardiovascular conditions asso- ciated with sudden cardiac death. Use of modern ECG interpretation standards allows a low false-positive rate. Routine echo may detect other clinically important cardiac abnormalities, but its role in PPS remains uncertain.
  • Chandra N, Bastiaenen R, Papadakis M, Panoulas VF, Ghani S, DuschlJ, Foldes D, Raju H, Osborne R, Sharma S, The prevalence of ECG anomalies in young individuals; Relevance to a nationwide cardiac screening program, Journal of the American College of Cardiology (2014), doi: 10.1016/j.jacc.2014.01.046. Between 2008-2012, 11,845 consecutive individuals aged 14-35 years (7,764 non-athletes and 4,081 athletes) underwent evaluation comprising a health questionnaire and 12-lead ECG. A transthoracic echocardiogram was performed in individuals with Group-2 ECG patterns suggestive of cardiomyopathy or structural cardiac abnormality.
  • At the University of Virginia, all 1,473 competitive athletes over the course of 5 years were screened with history and physical and with ECGs using ESC guidelines with follow-up testing as dictated by clinical symptoms and ECG findings.ResultsHistory and physical alone uncovered five significant cardiac abnormalities. ECGs were abnormal in 275 (19%), resulting in 359 additional tests. Additional testing confirmed eight significant cardiac abnormalities that were not found by history and physical: 1 bicuspid aortic valve, 4 rapidly conducting accessory pathways, 1 long QT patient, 1 with frequent premature ventricular contractions and low ejection fraction, and 1 with frequent premature ventricular contractions but normal ejection fraction. No cases of hypertrophic cardiomyopathy were found. Total cost of the program was US $894,870. Cost of history and physical screening alone was $343,725 or $68,745 per finding. The marginal cost of adding ECG screening, including resulting tests and procedures. was US$551,145 or US$68,893 per additional finding.
  • At the University of Virginia, all 1,473 competitive athletes over the course of 5 years were screened with history and physical and with ECGs using ESC guidelines with follow-up testing as dictated by clinical symptoms and ECG findings.ResultsHistory and physical alone uncovered five significant cardiac abnormalities. ECGs were abnormal in 275 (19%), resulting in 359 additional tests. Additional testing confirmed eight significant cardiac abnormalities that were not found by history and physical: 1 bicuspid aortic valve, 4 rapidly conducting accessory pathways, 1 long QT patient, 1 with frequent premature ventricular contractions and low ejection fraction, and 1 with frequent premature ventricular contractions but normal ejection fraction. No cases of hypertrophic cardiomyopathy were found. Total cost of the program was US $894,870. Cost of history and physical screening alone was $343,725 or $68,745 per finding. The marginal cost of adding ECG screening, including resulting tests and procedures. was US$551,145 or US$68,893 per additional finding.Staff salaries and ECG machines were paid for by the University of Virginia. Using salaries with benefits, we calculated a 5-year personnel cost of $192,000 for the history and physical screening program (estimated as 10% of the salary and benefits for each of two internists per year for 5 years based on standard University of Virginia quarterly effort reports). The 5-year personnel cost for ECG screening was $176,100 (5% of additional salary for each internist, 2% per year of an electrophysiologist&apos;s salary, and $40,000 for technicians for 5 years). The University of Virginia purchased two ECG machines for $10,000 each. We assumed these machines depreciated at 10% per year, giving a 5-year cost of $14,095.Although most follow-up studies were paid for by insurance, these costs were included in our cost analysis. To estimate these costs, we used the average collection from private insurance companies at the University of Virginia for the athlete population. Reimbursement for an echocardiogram was $900, MRI $1,000, drug challenge $1,200, Holter studies $175, treadmill stress test $300, and electrophysiologic study (EPS) $25,000. We prospectively defined significant cardiac abnormality as any finding that required invasive therapy or interval follow-up testing (e.g., annual echocardiogram). We then took the total cost of the program (including follow-up tests) and divided it by the number of significant cardiac abnormalities to determine a cost per finding.
  • SCD 2014: ECG Screening: Good? Bad? Feasible?

    1. 1. 12-Lead ECG as an Athletic Pre-Participation Screening Element: Good? Bad? Feasible? James P. Daubert, MD Professor of Medicine Director, Electrophysiology Section Duke University Medical Center
    2. 2. Daubert: Presenter Disclosure Information (<2y) Type of Support Entity Consulting: Boston Scientific, Medtronic, VytronUS (DSMB), Northwestern Univ. (DSMB) (All under $5,000 per year) Advisory board: Biosense-Webster; Gilead; Premier, Inc. (All under $5,000/y) Honoraria for Educational Symposia: Boston Scientific, Medtronic, Sorin, St. Jude, Biotronik (All under $10,000 per year) Research Grants: Boston Scientific, Medtronic, Biosense-Webster, Gilead. (All > $10,000 per year to Duke Univ.) Institutional Fellowship Support: Boston Scientific, Medtronic, St. Jude, Biotronik, Biosense- Webster, Bard (All > $10,000 per year to Duke Univ.) Stock: None Stock Options, Royalties: None Salary Support: None Speaker Bureau: None Unlabeled,Off-Label Use Disclosure: NA
    3. 3. Hank Gathers ESPN: 30 for 30: Guru of Go - Hank Gathers Last Moments
    4. 4. Sudden death after winning basket in undefeated season
    5. 5. Maron B. Heart Rhythm 10/2011
    6. 6. The 12-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes
    7. 7. Compliance with 1997 AHA Recommendations: Poor for High School Athletes Glover, Maron: JAMA. 1998;279(22):1817 By 2005, this aspect had improved but 35% of states allowed a chiropracter or naturo- pathic physician to conduct examination (Glover D et al, Circulation. 2006;114:II-502 .
    8. 8. NEJM 2014
    9. 9. Chaitman / Myerburg & Vetter, Circulation. 2007;116:2616-2626
    10. 10. Annual Incidence of Sudden Cardiac Death Expressed per 100,000 Person-Years in the 3 Studies Evaluating the Effects of Screening on the Mortality of Athletes Over Time The Italian study... Steinvil et al, Journal of the American College of Cardiology, Volume 57, Issue 11, 2011, 1291 - 1296 Does screening reduce sudden death?
    11. 11. Editorial on Italian Screening Experience • The annual incidence of sudden cardiac death in athletes decreased from 3.6 deaths per 100 000 person-years (1 death per year per 27 777 athletes) in 1979-1980 to 0.4 deaths per 100 000 person-years (1 death per year per 250 000 athletes) in 2003-2004, an 89% reduction. • Recent description of ARVC could have helped reduce SCD • Observational not randomized study • ECG not compared to other aspect of the screening • ARVC predominance vs HCM predominance • Training of sports medicine physicians • Regression toward mean (high starting endpoint an anomaly?) • Reduced rate in Corrado study similar to some rates reported in US w/o ECG screening from National Center for Catastrophic Sports Injury Research of 0.44/100,000 athletes over 10-y period [Van Camp SP, et al. Med Sci Sports Exerc. 1995;27:641] Thompson P, Levine B JAMA. 2006;296(13):1648-1650
    12. 12. Mandatory ECG Screening of Young Athletes: Con • High profile tragic events • However, infrequent events (although data sources challenging and #s vary); similar order of magnitude to lightning strike deaths • ECG screening used in Italy since 1982 • Benefit demonstrated in Venetto region of Italy (Padua, Venice); data not reported for Italy as a whole • HCM vs. ARVC (in Venetto) as #1 culprit • No apparent change in deaths in Israel in 12-y pre/post ECG screening usage • Low incidence in Minn., US, Israel similar to post-ECG screen in Venetto • Would this be viewed as excluding non-athletes? Screen all 60 M school age and college students? • False negative ECG in ~10% of HCM • False positive in ~10%; 9/10 of positives false + ? • Cost could be modeled as high as $3.4M/life saved Maron B. Heart Rhythm 10/2011
    13. 13. Distribution and overlap of QTc values for healthy individuals compared to patients with genetically confirmed LQTS. Drezner J A et al. Br J Sports Med 2013;47:153-167
    14. 14. Evaluation of ECG Abnormalities in Italian Olympic Athletes Pelliccia A et al, Circulation 2000; 102: 278
    15. 15. Seattle criteria Drezner JA, Fischbach P, Froelicher V, et al. Br J Sports Med 2013;47:125–136.
    16. 16. ESC ECG Criteria for Athletes {Corrado, EHJ 2010 #19566}
    17. 17. This figure illustrates the ‘Teach-the-Tangent’ or ‘Avoid-the-Tail’ method for manual measurement of the QT interval. Drezner J A et al. Br J Sports Med 2013;47:153-167 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
    18. 18. ECG of a 28-year-old asymptomatic Caucasian handball player demonstrating a junctional escape rhythm. Drezner J A et al. Br J Sports Med 2013;47:125-136 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
    19. 19. ECG shows Mobitz type I (Wenckebach) second-degree AV block demonstrated by progressively longer PR intervals until there is a non-conducted P wave (arrows) and no QRS complex. Drezner J A et al. Br J Sports Med 2013;47:125-136 Copyright © BMJ Publishing Group Ltd & British Association of Sport and Exercise Medicine. All rights reserved.
    20. 20. Normal variant in black athlete V1-V4 (not V5-V6) and often preceded by convex ST-segment elevation Wilson B et al, Br J Sports Med 2012 46: i51-
    21. 21. Abnormal ECG in Both Kinds of Football Players • Schmied: 25.8% of U-17 African elite football players by 2005 ESC, 19.5% distinctly abnormal by Pelliccia criteria (36.4% mildly abnormal). • (20%) had significant T wave inversions in the anterior and/or lateral leads…none of the abnormal ECG findings we observed was related to an unequivocal structural abnormality on echocardiography. Schmied, Br J Sports Med 2009;43:716 Magalski : 25% of elite American football (NFL) players and twice as many black players (30%) vs white (13%) had an abnormal ecg; wide receivers >quarterbacks, kickers. Magalski, J Am Coll Cardiol, 2008; 51:2250
    22. 22. High School Student ECG Screening: Chicago YH4L Project • Retrospective cohort study of 32,561 HS students not just athletes from 38 ECG screenings was performed between September 2006 and May 2009; voluntary participation (56%); 30% organized sports; 51% male; 66% Caucasian, 8% AA, 6% Hispanic, 8% Asian, 11% unknown. • Modified Corrado criteria • 2.5% abnormal requiring further evaluation • Small group of readers (6) experienced with adolescent ECG • Uncertain ones reviewed by panel of pediatric, adult and EP • Accepted as normal: sinus bradycardia >40, low atrial rhythm, PAC, early repolarization, <3 PVC per tracing • Repeat for: 1st AVB – repeat after hyperventilation and pass if WNL; TWI V2-V4: lead position rechecked and repeat 50 mm/s to detect epsilon; Type III Brugada: repeat in 3rd or 2nd intercostal space; tachycardia: repeat after rest in quiet room • Cost: $9/ECG using physician volunteers; if paid hourly add $5-$20 Marek et al, Heart Rhythm 2011;8:1555–
    23. 23. YH4L HS Students *Other: A-paced, EAT, dextrocardia (3), atypical RBBB (4), NW QRS axis (9), short QT (2) Most frequent: LVH 17%, ST-T abn’s. 17%, Prolonged QT 12%, LAD 14% (of the abnormals); all more common in boys Except QT Marek et al, Heart Rhythm 2011; 8:1555–
    24. 24. HS Athlete ECG Screening Study • 2017 HS athletes screened prospectively with H&P, ECG, 2-D echo; 71% male; ~30% AA • H&P abnormal in 14.7%, ECG abnormal in 3.1% by 2010 ESC • 5 CV diagnoses: 1 HCM, 4 WPW • ECG 5/5 • The most common ECG abnormalities were right ventricular hypertrophy (n 1⁄4 17), biventricular hypertrophy (n 1⁄4 16), and T-wave inversion (n 1⁄4 6). An additional 4.2% of athletes met isolated voltage criteria for LVH, which is considered a normal ECG finding due to regular training in athletes • False-positive ECG rate was 2.8% (less than FP for H&P). Price et al, Heart Rhythm 2014;11:442–
    25. 25. Chandra N, JACC 2014
    26. 26. Malholtra, Heart Rhythm May 2011 UVA D1 ECG Screening 1473 athletes over 5 y period
    27. 27. Malholtra, Heart Rhythm May 2011 UVA D1 ECG Screening: Costs to Institution or Insurance • Additional (marginal) cost of adding ECGs to H&P: (including resultant follow- up testing and ablations) = $551,145, – including 1,463 ECGs (cost of $14,095 for an ECG machine and $40,000 for technicians), – 227 echocardiograms ($204,500), – 44 MRIs ($44,000), – 10 stress tests ($3,000), – 7 drug studies ($8,400), 6 Holter monitors ($1,050), – 4 ablations ($100,000), and physician cost ($136,100). • ECG identified 8 asymptomatic findings that required either therapy (4) or regular follow-up (4). • Marginal cost of ECGs per diagnosis =$68,893. • Exclusions 2 (0.14%) of 1473 athletes • Aggressive Rx of abnormalities identified and clearance without which 11 exclusions instead • 13 abnormalities that required intervention – 5 by H&P – 8 by ECG
    28. 28. Medicolegal Issues • Legal action has occurred for: – Failure or inadequate screening – Failure to diagnose / disqualify athlete – Unfair restriction from sport based on medical disability • Preparticipation screening – Use AHA recommendations for comprehensive personal/family history and exam – Complete screening before signing clearance – Specialty referral when necessary – Perform PPS of college athletes in on-campus center if possible – Physician-patient (legal) relationship may be different in athletic screening scenario • Eligibility / Disqualification – Withdraw athlete if CV disease suggested until specialty evaluation – Bethesda Conference guidelines to determine eligibility/risk SCD – Limit disqualification decisions to highly probable /definitive diagnosis – Competing interests, extrinsic pressures (family, athlete, coaches), financial implications and potential for clouding the physician’s medical judgment Timothy E. Paterick, MD, JD et al, JAMA 2005
    29. 29. ECG Screening for Athletes • What is a “normal” ECG for an athlete? Importance of normal variants. ESC and Seattle criteria • Racial and ethnic and sports-specific, even position specific differences • Italian experience suggests benefit but controversy • What are we looking for? (HCM, ARVC, LQT, etc) • US high school and collegiate pilot projects • Cost controversies • “Just do it” vs. “ostrich” approach • Variation in positive ECG’s even by adjusted criteria • Probably feasible but careful multidisciplinary implementation critical

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