Young Hearts: A study in today's Journal of the American Medical Association suggests we should be doing EKG's on young athletes. That's pretty radical. The conventional wisdom has been that EKG's are not good screening tools. They provide good information when people are having symptoms - passing out, chest pain, paliptations, but as predictive tools they are lousy. So what is it about this study that changes that?

The study looked at athletes in the Veneto region of Italy, ages 12-35, from the years 1979 to 2004. The region has an ethnically homogenous population of 4,379,900. In 1982, Italy began requiring that EKG's be performed on all young people as part of their pre-participation sports exams. The Italian guidelines povide clear rules for what constitutes a positive screen in a young athlete:

Family History

Close relative(s) with premature myocardial infarction or sudden death at <50 years
Family history of cardiomyopathy, coronary artery disease, Marfan syndrome, long QT syndrome, severe arrhythmias, or other disabling cardiovascular diseases

Personal History
Syncope or near-syncope
Exertional chest pain or discomfort
Shortness of breath or fatigue out of proportion to the degree of physical effort
Palpitations or irregular heartbeat

Physical Examination

Musculoskeletal and ocular features suggestive of Marfan syndrome
Diminished and delayed femoral artery pulses
Mid- or end-systolic clicks
Abnormal second heart sound (single or widely split and fixed with respiration)
Heart murmurs (systolic grade ?2/6 and any diastolic)
Irregular heart rhythm
Brachial blood pressure ?140/90 mm Hg on more than 1 reading

Electrocardiogram

Left atrial enlargement: negative portion of the P wave in lead V1 ? 0.1 mV in depth and ?0.04 s in duration
Right atrial enlargement: peaked P wave in leads II and III or V1 ? 0.25 mV in amplitude
Frontal-plane QRS axis deviation: right ?+120° or left –30° to –90°
Increased voltage: amplitude of R or S wave in a standard lead ?2 mV, S wave in lead V1 or V2 ?3 mV, or R wave in lead V5 or V6 ? 3 mV
Abnormal Q waves ?0.04 s in duration or ?25% of the height of the ensuing R wave, or QS pattern in ?2 leads
Right or left bundle-branch block with QRS duration ?0.12 s
R or R' wave in lead V1 ? 0.5 mV in amplitude and R:S ratio ?1
ST-segment depression or T-wave flattening or inversion in ?2 leads
Prolongation of heart rate corrected QT interval >0.44 s in men and >0.46 in women
Premature ventricular beats or more severe ventricular arrhythmia
Supraventricular tachycardia, atrial flutter, or atrial fibrillation
Ventricular preexcitation: short PR interval (<0.12 s) with or without delta wave
First-degree (PR ?0.21 s, not shortening with hyperventilation), second-degree, or third-degree atrioventricular block

It also happens that since 1979, the medical establishment in the Veneto area has been studying the hearts of dead athletes in great detail:

Since 1979, all fatalities occurring in young people aged 35 years or younger in the Veneto region have been collected and investigated in the setting of a prospective clinicopathological study. The medical centers participating in this research project constituted an active network that served 94.4% of the population and permitted an accurate monitoring of fatal events occurring in this well-defined geographic area. (Participating centers are listed at the end of this article.) Regional newspapers were also systematically used at the coordinating center (The Institute of Pathological Anatomy, University of Padua, Padua, Italy) for daily monitoring of articles on sudden death in young people that occurred in the Veneto region, either sports-related or sports-unrelated.

Athletes and nonathletes who died a sudden death were examined postmortem by the local pathologist or medical examiner at each collaborative medical center to rule out extracardiac causes of death by routine autopsy. The entire heart was subsequently forwarded to the Institute of Pathological Anatomy for detailed morphological assessment, including macroscopic examination and histopatogic study of coronary arteries, ventricular myocardium, and the specialized conduction system as reported in detail elsewhere.... Clinical history, athletic activity, and the circumstances surrounding the cardiac arrest were investigated in each athlete who had a sudden death. According to the 1995 World Health Organization classification,1 cardiomyopathies included dilated, hypertrophic, restrictive, and arrhythmogenic right ventricular cardiomyopathy.

The researchers looked at the incidence and causes of sudden death in young athletes before the 1982 screening guidelines, early in their implementation, and later, when they were standard of care. The incidence rates did go down during those successive years.

The authors claim this decline is due to the ECG portion of the pre-sports physicals, but there's no data to confirm that. The history and physical portion, may be just as important, and may be providing the real benefit. It also may be why here in the States, our rates of sudden cardiac death in young athletes are the same as in Italy, even though we don't routinely perform EKG's (we only recommend EKG's if the history or physical suggest a problem):

An accompanying editorial raised questions about the study, noting that the sudden cardiac death rate before Italy’s screening program was high compared to rates found in other studies. And the lowest annual death rate achieved after screening was similar to the U.S. rate for high school and college athletes from 1983-93.

The editorial also noted that different heart conditions are the most frequent cause of exercise-related sudden death in the two countries.

“I think we have to be very cautious,” said editorial co-author Dr. Paul Thompson of the University of Connecticut. “You can actually cause problems by screening. There are a lot of abnormalities out there that, if left alone, won’t actually do harm, and screening could lead to people getting procedures done that aren’t necessary.”

He added: “There’s a large medical-industrial complex willing to embrace screening, and they just happen to sell the tools used for screening.”

Drs. Gaetano Thiene and Domenico Corrado, co-authors of the Italian study, said their country’s higher mortality rates can be explained by the older age and higher proportion of men compared to the U.S. athletes.