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ECG Screenings for Youth Sports: Beneficial or a Waste of Time?

By Sarah Blanshan, APRN, FNP

According to Parent Heart Watch, one in 300 children under age 18 have a cardiac condition that puts them at risk for sudden cardiac arrest (SCA), though most will not go on to experience it. Athletes are thought to have a higher risk as well, as two-thirds of SCA events happen during physical activity or exercise.

It is currently unknown exactly how many children and teens are affected by sudden cardiac arrest (SCA) each year. In this analysis of National Emergency Medical Services Information System (NEMSIS) data, it was estimated there were about 23,000 out-of-hospital cardiac arrests for youth in the United States in 2020, giving a small glimpse into the impact of SCA on communities. 

Prevention through Screening

To prevent unfortunate incidents in school athletics, sports physicals, also known as preparticipation physical examinations (PPEs), are a well-established prerequisite in most places. Screening usually consists of a history and physical exam by a medical provider to identify any reason the child should not participate in sports or should participate with modifications. 

In 2021, the American Academy of Pediatrics (AAP) updated its policy to recommend screening all youths for cardiac risks at least every three years with targeted questions, regardless of athletic status. AAP recommends that an electrocardiogram (EKG or ECG) as the first test only if a concern is identified. An ECG is a quick, non-invasive test that records the heart's electrical activity through sticky electrodes placed on the body and connected to the ECG machine. 

Should Everyone Get an ECG?

Some contend that ECGs should become part of the standard protocol of PPEs since questioning and physical exams may miss cardiac problems. This 2018 study published in Circulation found that a history and physical were less likely to pick up on a problem and had a higher false positive rate than ECG. This meta-analysis of 15 different studies involving over 47,000 student-athletes found similar conclusions, noting that an ECG was much more likely to identify when a problem was present and recommended that current screening practices be reevaluated considering new data. 

ECGs will not pick up on all problems with the heart, but according to Parent Heart Watch, they can identify over two-thirds of the conditions that put a person at risk for SCA. These problems include cardiomyopathy, Wolfe-Parkinson-White syndrome, and long QT syndrome. 

No national laws require ECGs to be part of PPEs, though a few local counties have started requiring them. A handful of states, such as Texas and Pennsylvania, have started to require that information about SCA be given to students wishing to participate in sports. They can then choose to obtain an ECG on their own if they choose. 

Some of the concerns raised about using ECGs in sports physicals are the increased cost, false positives, and the need for the personnel required to carry out and interpret the tests. However, this study with a large school district in Florida shows that large-scale ECG screening is feasible, affordable, affordable, and beneficial with careful planning and coordination of resources. 

Another concern in weighing the benefits of ECG screening is the low rate of positive results that could lead to SCA (approximately 0.4% according to this study). However, since ECG is more accurate than history and physical exam alone, which is often required, it may be reasonable to include ECG screening before beginning participation in sports.

There is also a growing number of free or affordable options to get ECG screening. Parent Heart Watch has put together a resource list of available screenings by the state for parents or students who are interested. Many of these are run by families or communities who have lost a loved one to SCA and wish to prevent the same fate from happening to others. 

American Academy of Pediatrics

Harmon, Zigman, & Drezner. 2015.

Krivenko et al. 2022.

Okubo, et al. 2020.

Parent Heart Watch (a). 

Parent Heart Watch (b).

Parent Heart Watch (c).

Zigman et al. 2018.

Article written by Sarah Blanshan

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