ECG screening has limited life-saving potential and would result in “staggering costs”

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According to a study published in the Journal of the American College of Cardiology, a 20-year ECG screening programme of young athletes would only save 4,813 lives and would cost between US$51 billion and US$69 billion-resulting in enormous costs per life saved.

Amir Halkin, Department of Cardiology, Sourasky Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, and others wrote that the use of mandatory ECG screening of all competitive athletes is controversial. While the European Society of Cardiology (ESC) does recommend such a screening programme, the American Heart Association does not.

Also, according to the authors, the absolute risk reduction (of sudden cardiac death) and the costs of implementing an ECG screening programme has not been fully studied. They reported that they created a model to “estimate the number of athletes that would need to undergo screening if mandatory screening was enforced in the United States, compute the cost of this strategy, and determine the number of lives that would conceivably be saved.”

Based on the inclusion criteria of the retrospective Italian study by Corrado et al-the only study to show mandatory ECG screening to be beneficial-that led to the ESC to recommend ECG screening , Halkin et al estimated that 8.5 million young athletes would undergo ECG screening per year. They added that while they assumed that the number of athletes would increase by 2% per year in an unscreened population, the percentage (also assumed to be 2%) of athletes who would be disqualified from sports per year following the results of screening would balance out this increase in a screened population. Therefore, the number of athletes being screened per year would remain constant over a 20-year period.

Costs were calculated on the basis of the number of athletes that were likely to be screened each year. Halkin et al, on the assumption that the behaviour of screened athletes and screening physicians would be similar to their counterparts in the Italian study, assumed that 91% of athletes would have negative ECG tests and thus be eligible to compete and need to be re-screened the following year, that 2% of athletes would require additional tests and eventually be disqualified, and that 7% would undergo further additional tests but ultimately be allowed to compete. Halkin et al wrote: “Based on the number of tests and their costs, we estimate that a two-decade ECG-screening programme involving all registered competitive high school and college athletes in the United States would cost between US$51 billion and US$69 billion.”

In terms of the lives saved, the authors reported that there would be a total of 4,813 lives saved during a 20-year programme. However, they added: “Based on the ‘minimum’ and ‘maximum’ prices for the total 20-year screening and the total number of lives saved, the cost per life saved ranges from US$10.6 million to US$14.4 million.”

In the discussion section of their analysis, Halkin et al stated that their study probably underestimates the true cost of a mass ECG screening programme-firstly because “expensive tests are likely to be used more liberally in the United States” and secondly because “African Americans athletes have a higher prevalence of ECG abnormalities requiring additional tests and these athletes represent a high proportion of athletes in the United States but not in Italy”. Also, according to the authors, the suicide rate (two per thousand) for disqualified athletes following screening in Italy is “higher by several orders by the magnitude than the sudden cardiac death rate among unscreened athletes”. They wrote: “Although these suicide events may not necessarily be due to disqualification, they must serve as a reminder of the profound emotional and financial implications expulsion might have, particularly when resulting from screening that was enforced rather than solicited.”

Halkin et al commented that the “staggering costs” of widespread ECG screening of athletes have “profound implications for society” and concluded “Given the limited resources available to healthcare in the United States and the limited life-saving potential of ECG screening, it is clear that mandating such a programme rather than applying it selectively, is likely to hinder the penetration of other preventative measures for cardiac arrests victims.”

In an accompanying editorial, Antonio Pelliccia (Institute of Sport Medicine and Science, Rome, Italy) disputes the conclusions of Halkin et al. He comments that an estimation of the cost of implementing a screening programme should focus on calculating preparticipation screening as a package (including history, physical exam, and ECG) and that preparticipation screening should be priced as a preventative medicine programme, which he claimed would “by far less expensive than pricing the individual testing”. He added that forgotten benefits of ECG-based preparticipation screening included: “individuals timely identified with cardiovascular abnormalities who will be treated appropriately and avoid sudden cardiac death as well as the several disorders affecting the skeletal, ocular, and other non-cardiac systems, which do not convey risk for death and can be appropriately treated.”

The study’s senior author Sami Viskin, professor, Department of Cardiology, Sourasky Tel-Aviv Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel, told Cardiac Rhythm News: “Sudden death in athletes is a devastating event. Performing ECG screening to all athletes is advocated in Europe. There is some logic to that recommendation because the majority of athletes dying suddenly have underlying, yet unrecognised, heart disease that often leads to ECG abnormalities. However, the proof that such strategy actually saves lives is limited to a single retrospective Italian study that has many limitations. For this JACC manuscript we ignore the limitations of the Italian study and take it as a given that screening saves lives. We then calculate how much it would cost to implement the Italian strategy in the USA, and calculate how many lives such a strategy would save. The costs are staggering.

We have no objection to ECG screening of athletes. But, we do believe that mandatory ECG screening of all athletes cannot be justified at the present time.”

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