Can ECG Help Prevent Sudden Cardiac Death in Young Athletes?

In the United States, roughly eight million high school students engage in sports, reports the NCAA, and according to incidence data from the Heart Rhythm Journal, about 10 of them die of conditions linked with sudden cardiac death (SCD) every year.

That rate is low, but devastating all the same. SCD often presents with no physical symptoms that can be detected by a standard evaluation in advance, which means it can be missed by medical staff and come as a shock to coaches, parents, and fellow students.

For years, many experts have recommended ECG to supplement standard medical evaluations for all student athletes. The thinking is that if you can detect problems early, physicians can recommend that athletes take precautions—or perhaps even withdraw from sports altogether—to mitigate their risk of sudden cardiac arrest and death.

Still, not everyone agrees with a universal ECG requirement for student athletes, particularly in the United States. But now, as the long-term cardiac implications of COVID-19 become more understood, many prominent sports groups are requiring ECG testing, and the evergreen debate has been renewed at the local and national levels.

The Longstanding Debate for Universal ECG Screening

Enthusiasm for screening students with ECG is strong. Guidelines from the European Society of Cardiology and the International Olympic Committee have recommended a universal ECG mandate for young athletes, and the NBA has long required all of its players to receive ECGs.

These mandates have merit: ECG is a lightweight, portable, and noninvasive technology that, according to one study in Circulation, has been found to show abnormalities in 95% of patients with hypertrophic cardiomyopathy, the most common cause of SCD in young people according to the Mayo Clinic. ECG is available at the bedside and can generate actionable results within minutes. More broadly, ECG is known for its ability to increase diagnostic accuracy, reduce costs, and improve patient outcomes.

But opponents of a universal requirement point to different concerns. When the American Heart Association (AHA) issued a 2007 update to its 1996 preparticipation guidance for youth sports in Circulation, it recognized the clinical value of ECG but declined to recommend that it be required for all student athletes. Authors noted workforce-related issues that could make compliance with such a rule difficult, such as having enough providers trained to conduct and read ECGs, and also cited concerns about ECG varying by sex and race.

Opposition to the rule was later countered by a 2014 opinion in Circulation, in which the author advocated for routine ECG testing for every baby, child, and teen, starting one month after birth. To address the AHA's concerns about workforce, the author suggested training more medical personnel—including NPs and PAs—on ECG interpretation. Regarding sex- and race-based variances, the author suggested modifying clinical decision-making to account for those factors—something more providers are doing today.

In the six years since that article was published, the debate has ebbed and flowed, with some experts still arguing for universal ECGs and others opposing them. But in 2020, the conversation took on new dimensions due to COVID-19.


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Implications of Emerging COVID-19 Guidelines

As researchers learn more about COVID-19's broader impact on the heart, many institutions have become more cautious about student athletes' cardiovascular health. Even asymptomatic infections—which adolescents are more likely to have—can lead to inflammation of the heart muscle, the NEJM Journal Watch reports. One physician from Nemours Children's told TCTMD that the pandemic might be putting more student athletes at risk of myocarditis, underscoring the need for broader screening.

Official guidelines have yet to recommend universal ECGs, though. Instead, some guidelines stratify recommendations based on attributes such as COVID-19 severity, age, and personal history.

In one analysis from the American College of Cardiology, authors noted that ECG would be clinically relevant only in certain scenarios, such as a child over 12 years old recovering from a moderate case of COVID-19 and wanting to return to play. Younger children (under 12) probably don't exert themselves enough to warrant cardiac testing, they added.

Return-to-play guidelines from the American Academy of Pediatrics had similar recommendations—limiting ECG requirements to those with moderate to severe COVID-19 or other case-specific attributes, such as a history of positive cardiac symptoms. Neither group has recommended ECG requirements for student athletes with asymptomatic cases.

Implementing ECGs When and Where Providers Can

Importantly, the AHA's 2007 update did not discount the clinical value of ECGs for young athletes—only the feasibility of requiring them. The guidance noted that local screening programs could still be useful.

Where does this leave the question of whether to conduct ECGs for all young athletes? In the absence of a federal mandate, whether or not to require ECGs may be left to the discretion of individual programs—and many groups are taking the initiative. For example, the Big Ten announced mandatory cardiac testing, including ECGs, for all student athletes who test positive for COVID-19. Even before the pandemic, SCD prevention was a priority for many youth sports leaders, with organizations such as the Parent Heart Watch and Who We Play For helping to make screening more available to student athletes.

If you have ECG readily available, your pediatric athlete patients may benefit from the low cost, convenience, and ease of ECG testing. But if you're in a position where access to technology or personnel are more restricted, consider the ACC and AAP stratifications by patient-based factors.

SCD may be relatively uncommon, but it's no less catastrophic for the individuals it affects. If you have the tools at the ready to save even one life, that's one less tragedy where a child is taken too soon.