Gymnastik- och idrottshögskolan, GIH

INTRODUCTION: Sudden cardiac arrest (SCA) in an athlete, is an uncommon event (1/50 000), caused by inherited/congenital cardiovascular disease (in younger athletes, >35 years), while in the older athletes, the cause is most often  underlying coronary artery disease (CAD). Cardiac societies, Sports Medicine Associations and subsequently international sporting bodies have developed cardiac screening programmes to prevent SCA in athletes. In addition, increased  awareness and recommendations regarding arena safety procedures (external automated defibrillators, medical action plans), have been introduced in recent years, to increase the chance of survival in case of a SCA. However, the most appropriate cardiac screening protocol and specifically, the role of the ECG in cardiovascular screening of athletes, is still debated.

AIM: This talk will discuss the sensitivity and specificity issues, connected with using the ECG or not, as part of cardiovascular screening of athletes.

MATERIALS AND METHODS: Both the American Heart Association (AHA) and the European Society of Cardiology (ESC) (1) as well as the International Olympic Committee (IOC) recommend regular screening of competitive athletes, including personal and family history and physical examination. However, the AHA does not recommend the routine use of the ECG in screening. In recent years, more evidence has emerged, making it possible to scrutinize the literature regarding sensitivity/specificity for screening with/without ECG.

RESULTS: Firstly, the available literature show that cardiovascular screening including an ECG will have much superior sensitivity for finding underlying relevant cardiac abnormalities. Traditionally, ECG has been found to also have a large number of false-positives, making the specificity of including the ECG low. However, in recent years, the international consensus-statements on ECG interpretation in athletes, have been repeatedly updated, due to scientific progress, making the specificity of cardiac screening with the ECG much higher, with unchanged high sensitivity (2). On the contrary, cardiac screening without the ECG has been shown to have a very low sensitivity, but more importantly will probably have also a low specificity, since many athletes do have a variety of often diffuse symptoms, which will necessitate further investigation, most readily an ECG. The few available cost-effectiveness studies worldwide, have shown that screening with the ECG is more cost-effective than screening without, but more high quality studies, are needed on cost-effectiveness.

CONCLUSION: Cardiovascular screening of athletes aims to prevent sudden cardiac arrest (and death) of athletes. The inclusion of an ECG in regular screening, will be accompanied by higher sensitivity, while the specificity using this approach has increased considerably in recent years. All in all, ECG should be an integral part of cardiovascular screening of athletes, and is also recommended by EFSMA in its latest statement on pre-participation examination in sports (3).