Clinical Commentary Children and adolescents who regularly participate in sports have a lower risk of obesity, chronic disease, alcohol and drug use, and criminal activity, and have higher self-esteem compared with nonparticipants.1–3 However, only 24% of youth engage in the 60 minutes of physical activity per day recommended by national guidelines.4 Participation in structured sports has decreased from 45% to 38% in the past 10 years, and children in low-income households are one-half as likely to participate regularly in sports compared with children from higher-income households.4 The Aspen Institute found growing disparities in physical activity by income;the percentage of inactive children in households with annual incomes less than $25,000 increased from 24% in 2012 to 33% in 2018, whereas the percentage of inactive children in households earning more than $100,000 decreased from 14% to 9.9% during the same time frame.4 In the United States, 49 states and the District of Columbia require a preparticipation physical evaluation before participation in school sports (Vermont leaves the decision to screen to individual school districts).5 The major components of the preparticipation physical evaluation are a detailed family history, medical history, symptom history, and physical examination.6,7 Concern about undiagnosed cardiac disease in athletes has grown over the past several decades following high-profile cases of sudden cardiac death.8 Rates of sudden cardiac death in young athletes range from 0.4 to 4 per 100,000 athlete-years.8,9 One suggested role of the preparticipation physical evaluation is preventing these deaths through early identification of children at high risk. Israel implemented mandatory preparticipation physical evaluations with ECGs and exercise stress testing in 1997, but sudden cardiac death rates have not changed.19 When studied in the United States, preparticipation physical evaluation with or without an ECG did not significantly predict or reduce sudden cardiac death.9 Most athletes in the Football Association (England, soccer) with cardiac death had normal screening results despite mandatory preparticipation physical evaluations, ECGs, and echocardiography.20 Preparticipation physical evaluation with an ECG has a high false-positive rate (40%) and false-negative rate overall (4% to 5%), with both preparticipation evaluations and ECGs having higher false-negative rates specifically for hypertrophic cardiomyopathy (10%).11,21,22 A cost analysis showed that implementing preparticipation physical evaluations with ECGs in the United States would cost $470 per athlete per year or $51 billion to $69 billion over 20 years.23 Sudden cardiac death in an athlete is rare, totaling fewer than 100 deaths per year in the United States, at a rate of 1 in 150,000 athletes per year.8,9 In Denmark, the rate of sudden cardiac death in the general population is more than 20 times greater than the rate in teenaged and young adult athletes (0.43 to 0.47 per 100,000 athlete person-years).24 The preintervention rate in the Veneto study (4 per 100,000 athlete-years) was much higher than that observed in more contemporary studies. Considering the lower rates of sudden cardiac death in the United States, even if the benefit in the Veneto study could be replicated, the number of ECGs needed to prevent one sudden cardiac death would be 33,000 to 192,000.23 An estimated 2% of children are disqualified from sports participation through the screening process when it includes an ECG.22 Approximately 45 million children and adolescents participate in sports in the United States;therefore, 900,000 children and adolescents would be unable to participate in organized physical activity without clear evidence of benefit if universal ECG screening were recommended.25 Intensive exercise commonly causes cardiac remodeling, termed athlete’s heart, that can lead to asymptomatic bradyarrhythmia, first-degree heart block, and ventricular hypertrophy.25 ECG and echocardiogram changes can be mistaken for concerning pathology, prompting unnecessary testing. Screening patients at high risk during well-child examinations may be underused, regardless of sports participation;one survey of pediatricians found that 24% had never ordered an ECG.28 Notably, rates of sudden cardiac death are equivalent or lower in athletes compared with nonathletes.12,13,23 Emergency response plans that include training staff in resuscitation and use of an automated external defibrillator are recommended and have been shown to save lives.29–31 In an eight-year follow-up study of professional soccer players who screened negative for cardiac risk, three athletes experienced cardiac arrest during competition or training, and all of them were successfully resuscitated.32 TAKE-HOME MESSAGES FOR RIGHT CARE Screening for undiagnosed cardiac disease during well-child examinations using a validated tool such as the American Heart Association 14-element evaluation is a high-value, low-cost intervention for children and adolescents regardless of sports participation.
Appropriate Use of Electrocardiography in Preparticipation Physical Evaluations