Twelve-lead ECG should not be used to screen healthy young people in the general population for occult cardiovascular abnormalities, according to a scientific statement jointly released Sept. 15 by the American Heart Association and the American College of Cardiology
Such screening has been advocated as a way to identify young people at risk for sudden death. Those at risk then could avoid participating in sports that could trigger a fatal CV event, and cardioverter-defibrillators could be implanted in young patients who would benefit.
The issue is ontroversial, however. Opponents argue that existing screening technology produces too many false-positive and false-negative results to be useful on a large scale. In addition, such screening would be exhorbitantly expensive, diverting scarce health care resources away from other, more practical programs that would be more beneficial to the approximately 60 million young people in this patient population.
“[We] acknowledge the tragic nature of sudden deaths in the young, but do not believe the available data support a significant public health benefit from using the 12-lead ECG as a universal screening tool,” said Dr. Barry J. Maron, chair, and Dr. Richard A. Friedman, cochair, of the AHA/ACC writing committee that presented the scientific statement published online in Circulation and the Journal of the American College of Cardiology (Circulation 2014 Sept. 15 [doi: 10.1161/CIR.0000000000000025]).
The Pediatric and Congenital Electrophysiology Society and the American College of Sports Medicine also endorsed the statement.
The investigators reviewed the evidence both for and against ECG screening for all young people and for the subgroup of young athletes, who number an estimated 10 million in the United States. They found that universal screening using ECGs “would be an undertaking of enormous magnitude, with massive resource demands.” Moreover, the net benefit would be “trivial,” given the very low prevalence of abnormalities that cause sudden death in youths and the extremely low risk of sudden death even in these at-risk people.
The nationwide registry of sudden deaths among athletes documents approximately 75 cardiovascular deaths per year – a frequency that is much lower than that for virtually every other cause of death in this age group. By comparison, motor vehicle accidents cause approximately 2,500-fold more deaths per year than cardiovascular events during sports, they noted.
In addition, 12-lead ECG would make an “imperfect” screening test, especially “in a real-world mass screening setting [when] readers and technicians [who have] vastly different expertise and efficiency are confronted with large numbers of studies to perform and interpret rapidly,” the authors noted.
The overlap between normal and abnormal ECG measurements is “a major obstacle,” with readings from people with high-risk cardiovascular disease sometimes indistinguishable from those of healthy patients. Misplacement of electrodes, selection of inadequate bandwidth, inadvertent lead reversal, and imprecise measurement of the QT interval are common operator-related difficulties.
At present, the rates of both false-positive and false-negative ECG results are unacceptably high for large-scale screening, the committee said. False-positive results lead to unnecessary and expensive further testing; unwarranted restriction from sports and other activities; anxiety and other adverse psychological consequences; and impediments to insurability or employment.
Even if the false-positive rate could be reduced to only 5% of all ECGs, the authors added, in a population of 10 million athletes, this would disqualify 500,000 healthy people from sports until they underwent further testing to exclude heart abnormalities.
Restricting ECG screening only to athletes would lessen these problems but would introduce others. For example, confining mass screening to a certain segment of the population necessarily excludes other segments. In the case of restricting ECG screening to college athletes, it could appear that this process moves from being exclusionary to being discriminatory and even elitist.
Overall, the statement’s authors concluded that “currently there is insufficient information available to support the view that universal screening ECGs in asymptomatic young people for CVD is appropriate or possible on a national basis for the United States, in competitive athletes or in the general youthful population, and practical issues essentially exclude either strategy from any realistic consideration.”
The statement is available from the AHA at http://my.americanheart.org and from the ACC at http://cardiosource.org.
This scientific statement was supported by the American Heart Association and the American College of Cardiology. The authors’ financial disclosures were not available.