The most effective protocol for cardiovascular screening of competitive athletes remains highly controversial. This study was a prospective, multicenter trial of cardiovascular screening at 35 National Collegiate Athletic Association institutions. Screening included a standardized history and physical examination (PE) as recommended by the American Heart Association and a 12-lead electrocardiogram (ECG) at rest. Centralized electrocardiographic interpretation was provided using the Seattle criteria. Athletes with screening abnormalities underwent additional evaluation directed by the host institution medical team. Primary outcomes included the proportion of total and false-positive screens; the sensitivity, specificity, and positive predictive value of history, PE, and ECG; and the prevalence of serious cardiovascular disorders associated with severe morbidity or sudden cardiac death. From August 2012 to June 2014, 5,258 athletes from 17 intercollegiate sports were screened: 55% men (mean age 20.1 years), 73% Caucasian, 16% African-American, and 11% other/mixed race. At least 1 positive cardiac symptom or family history response was reported by 1,750 athletes (33.3%). PE was abnormal in 108 athletes (2.1%), and electrocardiographic abnormalities were present in 192 athletes (3.7%). Thirteen athletes (0.25%) were identified with serious cardiac conditions including hypertrophic cardiomyopathy (1), large atrial septal defect with right ventricular dilation (1), and ventricular pre-excitation (11). The false-positive rate for history was 33.3%, PE 2.0%, and ECG 3.4%. The sensitivity/specificity/positive predictive value for history was 15.4%/66.9%/0.1%, PE 7.7%/98.2%/0.9%, and ECG 100%/96.6%/6.8%. In conclusion, electrocardiographic screening in National Collegiate Athletic Association athletes has a low false-positive rate and provides superior accuracy compared with a standardized history and PE to detect athletes with potentially dangerous cardiovascular conditions.
Sudden cardiac death (SCD) is a devastating event and the leading cause of death in college athletes during sports. A 10-year analysis of all-cause mortality in National Collegiate Athletic Association (NCAA) athletes indicates that the annual risk of SCD is substantially higher than initial estimates, with the highest risk found in men (2.65/100,000), black athletes (4.65/100,000), and Division I men’s basketball (19.2/100,000). These rates occur despite each of the nearly 500,000 NCAA athletes receiving a required pre-participation evaluation consisting at minimum of a history and physical examination (PE). The most effective strategy for cardiovascular screening of young competitive athletes remains highly controversial. The American Heart Association (AHA) and American College of Cardiology (ACC) define cardiovascular screening as an initiative intended to prospectively identify or raise suspicion of previously unrecognized and largely genetic/congenital cardiovascular diseases known to cause sudden cardiac arrest and sudden death in young people. The AHA/ACC promote use of a comprehensive personal and family history and PE as a potentially effective method to detect cardiovascular disease in athletes. Although mandatory screening with an electrocardiogram (ECG) is not recommended, the AHA/ACC support electrocardiographic screening where physician interest and local resources are in place to achieve sufficient quality control. The purpose of this study was to evaluate and compare the accuracy of cardiovascular screening in NCAA athletes using a standardized history, PE, and ECG.
Methods
This study was a prospective, multicenter study of cardiovascular screening in NCAA athletes from August 2012 to June 2014. A total of 35 different NCAA institutions participated, including 13 division I institutions in year 1 and 13 division I and 12 division II or division III programs in year 2. Study recruitment for year 2 was intentionally expanded to include division II and III programs with potentially less cardiology resources. Any athlete ≥18 years without previous electrocardiographic screening or a known cardiovascular condition was eligible for the investigation. Participation in the study was voluntary, and each athlete underwent verbal and written informed consent.
The screening protocol included the AHA 12-point history questionnaire and PE and a 12-lead ECG at rest. The study was conducted before publication of the updated AHA 14-point evaluation. The cardiovascular examination included a brachial artery blood pressure at rest, cardiac auscultation, and recognition of the physical stigmata of Marfan syndrome. The cardiac history questions and PE were done at the time of the ECG or pre-participation evaluation, and positive findings recorded. ECGs were performed at each institution using standard 12-lead placement and a portable ECG machine (CardeaScreen, Seattle, Washington). Electrocardiographic data were de-identified and transmitted electronically over a secure portal for overread at the University of Washington. Electrocardiographic interpretation was performed by cardiologists with experience in electrocardiographic interpretation in athletes and guided by the Seattle criteria intended to distinguish physiological cardiac adaptations in athletes from electrocardiographic abnormalities associated with pathologic cardiac disorders. The secondary evaluation of screening abnormalities detected by history, PE, or ECG was directed by the host institution medical team. Consultation with sports cardiology specialists at the University of Washington was available as requested.
Descriptive statistics such as proportions, means, and cross tabulations were used to analyze collected data. Symptom and family history responses, PE, and electrocardiographic findings were compared between student-athletes and statistical comparisons performed using independent t tests. Statistical significance was defined as a p value <0.05. Primary outcome measures as planned before data collection included: (1) the prevalence of detectable cardiovascular disease associated with severe morbidity or SCD; (2) the proportion of total and false-positive electrocardiographic screens and comparison with the AHA 12-point history and PE; (3) evaluation of sensitivity, specificity, and positive predictive value (PPV) for history, PE, and ECG; and (4) the performance of the Seattle criteria and examination of electrocardiographic abnormalities in NCAA athletes.
The study was approved by the Human Subjects Division at the University of Washington. A cooperative human subjects’ agreement or letter of human subjects deferment to the principal investigatory site (University of Washington) was obtained from each participating institution.
Results
Thirty-five NCAA institutions and 5,258 athletes participated in the study. In year 1, athletes from 13 division I programs participated (n = 2,465), and in year 2, athletes from 25 division I/II/III institutions participated (n = 2,793). No athlete was screened in both years 1 and 2. The athletes were 55% men (n = 2,892) and participated in 17 different intercollegiate sports. The average age was 20.1 years (range 18 to 28). Race was self-reported and representative of the overall NCAA athletic population with 3,812 athletes Caucasian (73%), 853 African-American (16%), 151 Asian (2.9%), 248 Hispanic (4.7%), 81 Pacific Islander (1.5%), 15 Native American (0.3%), and 93 other or mixed race (1.8%). Race was not reported in 5 athletes.
Positive history responses on the AHA-12 point are listed in Table 1 . At least 1 positive symptom or family history response was reported by 1,750 athletes (33.3%). Female athletes were more likely to report at least 1 positive cardiovascular symptom or family history response (36.9%) versus male athletes (30.3%; p <0.001).
| Personal and Family History Questions | Total Athletes (N = 5258) | Male Athletes (N = 2892) | Female Athletes (N = 2366) |
|---|---|---|---|
| ≥ 1 Positive Personal or Family History Response | 1750 (33.8%) | 876 (30.3%) | 874 (36.9%) |
| Have you ever experienced chest pain or discomfort with exercise? | 387 (7.4%) | 191 (6.6%) | 196 (8.3%) |
| Have you ever passed out or nearly passed out? | 599 (11.4%) | 254 (8.8%) | 345 (14.6%) |
| Have you ever had excessive shortness of breath or fatigue with exercise? | 677 (12.9%) | 313 (10.8%) | 364 (15.4%) |
| Have you been told you have a heart murmur? | 260 (4.9%) | 146 (5.0%) | 114 (4.8%) |
| Have you had high blood pressure? | 154 (2.9%) | 129 (4.5%) | 25 (1.1%) |
| Does anyone in your family have hypertrophic or dilated cardiomyopathy, Long QT or Marfan syndrome, or other heart arrhythmia problems? | 234 (4.5%) | 101 (3.5%) | 133 (5.6%) |
| Has anyone in your family (age<50) died suddenly or unexpectedly from heart disease? | 191 (3.6%) | 91 (3.1%) | 100 (4.2%) |
| Has anyone in your family (age<50) been disabled from heart disease? | 122 (2.3%) | 65 (2.2%) | 57 (2.4%) |
PE was deemed abnormal in 108 athletes (2.1%), including 88 athletes (1.7%) with a heart murmur and 17 athletes (0.3%) with physical stigmata of Marfan syndrome. In addition, 283 athletes (5.4%) had an initial blood pressure >140 systolic and/or >90 diastolic (8.7% men, 1.4% women; p <0.001), and 30 athletes (0.6%) had an initial blood pressure >160 systolic and/or >100 diastolic (0.9% men, 0.1% women; p <0.001).
Electrocardiographic abnormalities were present in 192 athletes (3.7%) ( Table 2 ). The rates of an abnormal ECG based on gender, race, and sport are shown in Figures 1 and 2 . There was a trend for African-Americans to have more abnormal ECGs compared with Caucasian athletes; however, this did not reach statistical significance (4.8% vs 3.4%; p = 0.069). Male basketball players had a higher rate of abnormal ECGs compared with female basketball players (10.3% vs 2.2%; p <0.001) and other male athletes (10.3% vs 4.0%; p <0.001). Compared with other male athletes, male basketball players more commonly exhibited abnormal T-wave inversion (ratio = 10.9; p <0.001), ST-segment depression (ratio = 6.8; p <0.001), and left-axis deviation (ratio = 5.0; p <0.01).
| 198 Abnormalities in 192 Athletes | ||
|---|---|---|
| ECG Abnormality | N | % of 198 Abnormalities |
| Q Waves | 72 | 36.4% |
| Anterior | 8 | 4.0% |
| Inferior | 28 | 14.1% |
| Lateral | 45 | 22.7% |
| T Wave Inversion | 38 | 19.2% |
| Anterior | 19 | 9.6% |
| Inferior | 11 | 5.6% |
| Lateral | 12 | 6.1% |
| Left Axis Deviation | 25 | 12.6% |
| ST Segment Depression | 15 | 7.6% |
| Inferior | 14 | 7.1% |
| Lateral | 5 | 2.5% |
| Ventricular Premature Complexes | 13 | 6.6% |
| Ventricular Pre-excitation | 11 | 5.5% |
| Left Atrial Enlargement | 8 | 4.0% |
| Prolonged QRS | 3 | 1.5% |
| Right Ventricular Hypertrophy | 5 | 2.5% |
| Prolonged QTc | 4 ∗ | 2.0% |
| Other | 4 | 2.0% |
∗ No athlete with a prolonged QTc on initial screening ECG was ultimately diagnosed with long QT syndrome.
The secondary evaluation of athletes with an abnormal ECG included echocardiography (135), cardiology consultation (108), exercise electrocardiographic testing (26), stress echocardiography (10), cardiac magnetic resonance imaging (9), electrophysiology study (1), ambulatory electrocardiographic monitoring (9), and multigated acquisition scan (1). The average time loss from sport to conduct secondary testing in athletes with electrocardiographic abnormalities was 2.6 days (range 0 to 75 days).
Thirteen athletes (0.25%) were identified with cardiac conditions associated with serious morbidity or SCD, including hypertrophic cardiomyopathy (1), a large atrial septal defect with right ventricular dilation requiring surgery (1), and ventricular pre-excitation (11). All athletes studied with a detected condition associated with SCD had an abnormal ECG, 2 had an abnormal history, and 1 had an abnormal PE ( Table 3 ). Athletes with minor cardiac abnormalities were also detected and included 2 athletes with a bicuspid aortic valve and 1 athlete with mitral valve regurgitation. No adverse medical events from secondary cardiac testing or therapeutic procedures occurred in this cohort.
| Final Diagnosis | Year | Gender/ Race | Sport | Abnormal History or PE | ECG Findings |
|---|---|---|---|---|---|
| HC | Fr | F / White | Swimming | (0) | Lateral Q waves, RAD |
| ASD with RV dilatation | So | M / Pac Isl | Football | (+) shortness of breath; murmur | LAD, incomplete RBBB |
| Ventricular pre-excitation – high risk pathway | Fr | F / White | Crew | (0) | Ventricular pre-excitation |
| Ventricular pre-excitation – high risk pathway | Se | M / White | Soccer | (0) | Ventricular pre-excitation |
| Ventricular pre-excitation – low risk pathway | Fr | F / White | Crew | (0) | Ventricular pre-excitation |
| Ventricular pre-excitation – low risk pathway | Jr | F / White | Crew | (0) | Ventricular pre-excitation |
| Ventricular pre-excitation – low risk pathway | Jr | F / White | Tennis | (0) | Ventricular pre-excitation |
| Ventricular pre-excitation – low risk pathway | So | F / White | Basketball | (0) | Ventricular pre-excitation |
| Ventricular pre-excitation – low risk pathway | Fr | M / White | Baseball | (0) | Ventricular pre-excitation |
| Ventricular pre-excitation – low risk pathway | So | M / White | Cheer | (0) | Ventricular pre-excitation |
| Ventricular pre-excitation – low risk pathway | Jr | M / White | Cross Country | (+) murmur | Ventricular pre-excitation |
| Ventricular pre-excitation – ? | Jr | M / White | Soccer | (0) | Ventricular pre-excitation |
| Ventricular pre-excitation – ? | Fr | M / Hisp | Tennis | (0) | Ventricular pre-excitation |
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