Improving athlete ECG screening, interpretation, and reproducibility: an editorial by Jordan Prutkin, MD, and Jonathan Drezner, MD, of the University of Washington
A preparticipation evaluation is recommended before engaging in competitive sports, although debate continues whether to include an ECG in addition to a history and physical examination. The limitations of preparticipation screening by history and physical examination alone for the identification of athletes with disorders at risk for sudden cardiac arrest have been recognized by two recent consensus statements in the United States.ECG screening of young athletes is endorsed by several major medical and sporting organizations, such as the European Society of Cardiology (ESC), International Olympic Committee, and Fédération Internationale de Football Association (FIFA), as a means to improve the identification of conditions predisposing to sudden cardiac arrest. However, accurate implementation of an ECG screening program has many challenges and requires a physician infrastructure with adequate sports cardiology resources and training in contemporary athlete-specific ECG interpretation standards.
Dhutia et al examined the reproducibility of ECG interpretation using the 2010 ESC, 2013 Seattle Criteria, and 2014 Refined Criteria by four experienced and four nonexperienced cardiologists in 400 athletes. The study also analyzed the downstream costs of further testing depending on the experience level of the reader. Not surprisingly, the study found that interobserver reliability was better with experienced versus novice readers and improved for both groups with the newer criteria. This was a small sample, and no follow-up was available, so it is unknown if any athlete in this cohort had true disease.
Evolution of ECG Interpretation Standards
Physiological changes in the athlete’s heart make determination of normal ECG findings in the athlete a challenge...The biggest weakness of these criteria was a high false-positive rate, especially in blacks. In this study, the cost per athlete screened for inexperienced cardiologists was $175 USD and for experienced cardiologists was $101 USD.
Moving Forward
As this study was completed, the new International Recommendations for ECG Interpretation in Athletes were published. This expert consensus statement was designed as an update to the Seattle Criteria and the Refined Criteria. Endorsed by 17 international sports medicine and cardiology societies, this guideline likely will emerge as the standard of care for ECG interpretation in athletes.
The authors have shown that education on athlete ECG criteria can improve interpretation accuracy regardless of medical specialty and training level.Enhanced education will improve the reproducibility and accuracy of ECG interpretation. Like other medical skills, it must be done repeatedly so proficiency is enhanced.
As this study shows, the bias in ECG interpretation is to overcall abnormalities to be safe. Recognizing physiological findings is a critical step to minimize false-positive rates and the costs of unnecessary secondary testing. Fortunately, each revision of athlete ECG standards has improved specificity, and the international criteria should be no exception. A greater focus on physician education, training, and practical experience should continue to improve the accuracy and reproducibility of ECG screening in athletes.
SOURCE: Circulation: Cardiovascular Quality and Outcomes