In the United States, roughly eight million high school students engage in sports.1 But participation in school sports is not limited to America; for example, 65% of high school students in England played school-associated sports.2 Among these, a small percentage experience sudden cardiac death (SCD). While sudden cardiac arrest in athletes is rare, 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 routine ECG exams to supplement standard pre-participation medical evaluations for all student athletes.3 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. Recent research suggests that history-taking and physical examination still identify most disorders associated with SCD, such as heart murmur or excessive exertional dyspnea.4 But as a growing number of prominent sports groups require ECG testing, the evergreen debate has been renewed at 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.5,6
These mandates have merit and may help prevent sudden cardiac arrest in athletes. ECG is a lightweight, portable, and noninvasive technology that has been found to show abnormalities in 95% of patients with hypertrophic cardiomyopathy,7 the most common cause of SCD in young people.8 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, it recognized the clinical value of ECG but declined to recommend that it be required for all student athletes.9 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 in 2014, when one expert advocated for routine ECG testing for every baby, child, and teen, starting one month after birth.10 To address the AHA's concerns about workforce, the expert 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 opinion piece was published, the debate has ebbed and flowed, with some experts still arguing for universal ECGs and others opposing them.
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.9
Where does this leave the question of whether to conduct ECGs for all young athletes? In the absence of a federal mandate, the decision of whether or not to require ECGs may be left to the discretion of individual programs—and many groups are taking the initiative. For example, in 2020 the Big Ten announced mandatory cardiac testing, including ECGs, for all student athletes who test positive for COVID-19.11 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.12,13
If you have ECG readily available, your pediatric athlete patients may benefit from the low cost, convenience, and ease of ECG testing. But in all situations, the ACC and AAP stratification by patient-based factors should be considered while making a primary diagnosis. SCD may be relatively uncommon, but it's no less catastrophic for the individuals it affects. AHA guidelines should be followed and used together with clinical judgment to rule out cardiac factors that may promote SCD in athletes.
Estimated probability of competing in college athletics. NCAA. https://www.ncaa.org/sports/2015/3/2/estimated-probability-of-competing-in-college-athletics.aspx. Accessed June 27, 2023.
Children's competitive sports participation in England 2020. Statista. https://www.statista.com/statistics/421573/children-sport-involvment-england-uk-by-school-part/. Accessed August 1, 2023.
Turkoglu' 'Ebru Ipek. How do you answer a 20-year-old when they ask: can I participate in competitive sports? ESC. 2021;19:12. https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-19/how-do-you-answer-a-20-year-old-when-they-ask-can-i-participate-in-competitive
Maron BJ, Thompson PD, Maron MS. There is no reason to adopt ECGs and abandon American Heart Association/American College of Cardiology history and physical screening for detection of cardiovascular disease in the young. JAHA. 2019;8(14):e013007. https://www.ahajournals.org/doi/10.1161/JAHA.119.013007
Corrado D, Pelliccia A, Bjørnstad HH, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus statement of the study group of sport cardiology of the working group of cardiac rehabilitation and exercise physiology and the working group of myocardial and pericardial diseases of the European society of cardiology. Eur Heart J. 2005;26(5):516-524. https://pubmed.ncbi.nlm.nih.gov/15689345/
The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes: march 2009. J Athl Train. 2009;44(5):538-557. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742466/?tool=pmcentrez&report=abstract
Calore C, Cianfrocca C, Iacovella I, et al. Abstract 15703: Hypertrophic cardiomyopathy with normal ECG: Clinical meaning and prognostic implications. Circulation. 2011:124:A15703. https://www.ahajournals.org/doi/10.1161/circ.124.suppl_21.A15703
What to know about sudden death in young people. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/in-depth/sudden-death/art-20047571. Accessed June 27, 2023.
Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American heart association council on nutrition, physical activity, and metabolism: endorsed by the American college of cardiology foundation. Circulation. 2007;115(12):1643-1655. https://www.ahajournals.org/doi/10.1161/circulationaha.107.181423
Vetter VL. Electrocardiographic screening of all infants, children, and teenagers should be performed. Circulation. 2014;130(8):688-697. https://www.ahajournals.org/doi/full/10.1161/circulationaha.114.009737
The big ten conference adopts stringent medical protocols; football season to resume October 23-24, 2020. Big Ten. https://bigten.org/news/2020/9/16/the-big-ten-conference-adopts-stringent-medical-protocols-football-season-to-resume-october-23-24-2020.aspx. Accessed June 27, 2023.
Parent heart watch member screening programs. Parent Heart Watch. https://parentheartwatch.org/get-involved/find-a-heart-screening/. Accessed June 27, 2023.
Who we play for. https://www.whoweplayfor.org/. Accessed June 27, 2023.