The effectiveness of screening history, physical exam, and ECG to detect potentially lethal cardiac disorders in athletes: A systematic review/meta-analysis
Introduction
The preparticipation examination (PPE) or periodic health examination (PHE) is the practice of regularly screening athletes prior to participation in sport. PPEs have been common place in the United States for over 50 years, in some countries such as Italy for decades, and in other countries like England PPEs are not required. Although there are many objectives to the PPE, it is widely agreed that the primary purpose of the PPE is to screen for potentially life-threatening disorders [1], [2], [3], [4], [5]. Cardiovascular pathology leading to sudden cardiac death (SCD) is the most common medical cause of death in athletes [6], [7], [8]. Therefore, a large portion of effort during the PPE is directed toward screening for cardiovascular disease. Screening has traditionally consisted of a history and physical examination although the utility of this approach has been questioned [9], [10]. More recently there has been interest in adding a resting 12-lead electrocardiogram (ECG) to the PPE to improve detection of conditions associated with SCD. ECG screening is supported by Italian data showing a 90% decrease in the rate of SCD with the inclusion of ECG as part of athlete screening [6], although other studies have questioned this result [11]. The debate regarding various screening strategies engenders passionate support on both sides. This paper examines the data related to preparticipation cardiovascular screening in athletes through a systematic review of existing studies. The sensitivity, specificity, and positive predictive value of history, physical exam and ECG in the individual studies are calculated and a meta-analysis of pooled data performed in an effort to better understand the value and limitations of these tests in order to guide rational evidence-based approaches for cardiovascular screening in athletes.
Section snippets
Methods
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines were followed conducting and reporting this review.
Results
The literature search initially yielded 787 articles. 756 articles were immediately excluded. There were 31 articles that potentially met the inclusion criteria and these were downloaded for further review. Of those 31, 16 articles were excluded because the study screened only with ECG and did not screen with a cardiovascular history or physical exam [15], [16], [17], [18], [19], [20], [21], [22] the athletes were screened with ECG, history and physical exam but the statistics needed were not
Discussion
The data on cardiovascular screening in a diverse population of over 47,000 athletes around the world is summarized by this systematic review. Cardiovascular screening examinations prior to participation in sport have a long history with various countries, states, and sporting organizations recommending or requiring differing elements. Most notably, the European Society of Cardiology (ESC), International Olympic Committee (IOC), Federation Internationale de Football Association (FIFA), and
Strengths and limitations
The strengths of this review are that it combines data on the screening of 47,137 athletes with a measure of the quality of the studies and meta-analysis of pooled data. The findings reinforce the emerging body of literature supporting the effectiveness of ECG in screening for potentially lethal cardiac disease in athletes while also demonstrating the low relative of history and physical exam.
There were several limitations to this review. The meta-analysis did not have the level of data to
Conclusions
The purpose of this study was to perform a systematic review/meta-analysis of evidence comparing screening strategies. There were fifteen articles identified reporting on 47,137 athletes. The sensitivity of 12-lead ECG was much higher than both history and physical with similar sensitivity. In addition, the false positive rate of ECG (6%) was less than that of history (8%), or physical exam (10%). ECG had the highest positive likelihood ratios and lowest negative likelihood ratios. There were a
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