What's the best way to screen for risk of sudden cardiac death?


sudden cardiac death

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It’s a rare occurrence but a deeply troubling and tragic one nevertheless. Sudden cardiac death in young athletes raises serious concerns, especially because most victims report no warning symptoms. Pre-participation screening may help identify children, adolescents and young adults at risk, but there is still no consensus regarding the best way to put it into practice. Now, a new report in the Canadian Journal of Cardiology describes a new screening protocol that offers advantages over American Heart Association (AHA) recommendations and shows that the electrocardiogram (ECG) is the best single screening method.

Cardiologists from the University of British Columbia Vancouver Coastal Health compared their own innovative screening protocol to the one recommended by the AHA. Both protocols use 12-lead ECGs and questionnaires. However, one problem associated with the AHA questionnaire is the high rate of false positives.

A false positive result requires extensive further testing and consultation with a cardiologist, leading to worry, secondary testing and higher costs. The researchers’ new evidence-based questionnaire was designed to better differentiate between symptoms indicative of serious cardiac disease and those related to more benign conditions. The AHA method also involves a physical exam conducted by a physician that includes listening to the heart.

Investigators screened more than 1,400 young competitive athletes ages 12-35 years. Approximately half underwent the AHA recommended screening, and the other half the experimental protocol. Seven participants were found to have serious heart conditions, and six were identified by ECG. Only two of the seven would have been detected as the result of a medical history and physical exam.

“The current study provides further evidence to support the use of the ECG as an important tool in the screening of young competitive athletes,” explained lead investigator James McKinney, MD, MSc, of the Division of Cardiology of the University of British Columbia. “The ECG is more sensitive in detecting heart muscle problems and potentially life-threatening electrical disorders such as Wolff-Parkinson-White and long QT syndrome.”

In the study, the false-positive rate of the new protocol was less than half that of the AHA protocol — 3.7% versus 8.1%.

Investigators found that the physical examination was unhelpful and costly. The physical exam prompted further evaluation in 10 athletes without identifying any of the athletes who actually had heart disease and contributed to higher false positive rates.

The research indicates that a screening protocol that includes a more specific questionnaire and ECG, but excludes a physical examination, eliminating the need for an on-site physician, would be desirable to optimize efficiency and produce important cost savings. The researchers calculate that eliminating physician costs would result in huge reductions in per person screening costs ($14.42 for new protocol versus $97.50 for AHA protocol) and costs per diagnosis ($3,822.70 versus $41,320.49, respectively).

The results of this study indicate the need to harmonize the results of research findings with current practice. Still to be determined is the important question of whether screening saves lives.