Adding a 12-lead ECG to pre-participation screening for athletes finds more cardiovascular problems, but US states should not require it because of cost, lack of expertise, and potential inequities, according to a new American College of Cardiology (ACC) statement.

Florida passed a law last year mandating ECGs for high school athletes, and other states are considering such laws, said Jonathan H. Kim, MD, sports cardiologist and professor of medicine at Emory University in Atlanta. Kim is the statement’s primary author and chair of the ACC’s Sports and Exercise Cardiology Member Section and Leadership Council.

This statement follows a previous one on sports participation for athletes with cardiovascular abnormalities, which said ECGs should be added to screening only if there are “appropriately trained clinicians in the interpretation of athletic ECGs and timely access to appropriate resources for downstream secondary evaluations.”

But those key conditions are lacking in the US. “There’s a supply vs demand shortage — the demand to appropriately interpret ECGs and the supply of professionals who know how to accurately interpret ECGs from competitive athletes,” Kim said.

ECG Mandates Globally

Internationally, laws mandating ECGs as part of athletic screening have been enacted only in Italy and Israel, “where there is good infrastructure, and screening is provided at a very low cost compared to American medical standards,” said Sanjay Sharma, MD, professor of cardiology at the University of London, London, England, who was not involved in this statement.

Sharma agrees the US may not have enough cardiologists to process the ECGs, which could run into hundreds of thousands, and follow-up echocardiograms, exercise stress tests, and cardiovascular MRI scans.

Sharma and Kim agree that teams, organizations or schools may wish to conduct screening that includes ECGs. In the UK, eg, English Football Association has run a large screening program since 1997, Sharma said. The charitable organization Cardiac Risk in the Young also provides cardiac screening with the help of cardiologists, he said. Such efforts do not involve the mass screening that laws would require.

Harms and Inequities

In the US, several issues with ECG-based screening could unintentionally harm young athletes, said Kim, outweighing its benefits.

“Whenever you have a large influx of ECGs, what you worry about is a large number of inappropriately interpreted ECGs,” Kim said. Even correctly interpreted ECGs can have false-positive results. Under current ECG criteria, there is a higher rate of false positives among self-identified Black athletes.

False positives can lead to expensive follow-up procedures, as well as lengthy delays. The athlete cannot play while undergoing further testing, which can cause psychological stress as well as affect their season or even their future athletic career. The financial burden of testing can disproportionately affect athletes with lower income, lacking access to insurance, or living in underserved areas.

Kim worries about the stress on the medical system of a large volume of ECGs and follow-up procedures, which also could affect other patients’ care. Giving athletes ECGs leaves out other young people with undetected cardiovascular disorders that put them at risk for sudden cardiac arrest, he said.

Kim and Sharma also point out that many sudden cardiac arrests in young people happen at home, which laws for athletes and athletic facilities do not cover.

Emphasize Emergency Plans

What does work, according to research, are emergency action plans for sports programs and facilities for young people, including cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs), Kim said.

“There’s definitive data that a good emergency action plan — people knowing CPR, having an AED nearby — saves lives,” he said. Money spent on ECGs would be better spent “so schools in underresourced neighborhoods have AEDs,” he added.

“Right now, there’s a huge push to make sure states have laws” mandating such plans, led by the NFL’s Smart Heart Sports Coalition. The aim is to ensure such laws include emergency action plans in high school athletic venues, AEDs available at venues or within 3 minutes, and CPR and AED education for coaches.

To date, 29 states have passed laws incorporating all three measures, and other states have laws covering some of the measures.

Kim and Sharma reported having no competing interests.