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A nationwide ECG screening program for young athletes in the U.S. would save lives but would cost billions of dollars, according to a cost-projection model.

The model found that 4,813 lives would be saved over a 20-year span of screening at a cost-per-life-saved of $10.6 to $14.4 million, said Sami Viskin, MD, of the Tel-Aviv Medical-Center, and colleagues.

The 20-year cost of the screening would be $52 to $69 billion, they reported in the Dec. 4 issue of the Journal of the American College of Cardiology.

Viskin and colleagues noted that the European Society of Cardiology (ESC) recommends ECG screening of all competitive athletes, while the American Heart Association (AHA) does not.

In addition, screening is mandatory in Italy, the home of the study that prompted the ESC to recommend ECG screening for all athletes.

That study, published in 2006 by Corrado et al., found a 79% relative risk reduction of sudden cardiac death when screening was used. But there has been "considerable debate" regarding the Italian study, particularly a criticism that the mortality rate of four per 100,000 athletes in the pre-screening period is "excessively high," researchers noted.

Viskin and colleagues wrote that some details about a screening strategy remain sketchy, including the absolute risk reduction, cost, and economic ramifications of mandatory ECG screening of young competitive athletes.

In their model, Viskin et al. used Medicare reimbursement rates for the separate tests of a screening: $224 for a history and physical exam and $39 for the ECG, totaling $263 per athlete.

This is "clearly prohibitive in the United States, but most likely in all countries over the world," wrote Antonio Pelliccia, MD, in an accompanying editorial. Pelliccia is from the Institute of Sports Medicine and Science in Rome, a medical division of the Italian National Olympic Committee.

He called ECG screening a "unique medical procedure" whose cost should be "computed as a package, not for the individual tests."

In Italy, preparticipation screening is offered as a package that costs about $60, a price that is based on the "agreement between the Board of Sport Physicians and the federal government."

The fact that reimbursement for screening athletes does not exist as a "preventive medicine program" in Medicare is a major hurdle for implementing such a strategy in the U.S., Pelliccia said.

The model constructed by Viskin and colleagues assumed that 8.5 million high school and college athletes would be screened annually (representing 154.7 million people for 2 decades). The yearly rate would remain constant as the number of new athletes would compensate for the 2% who are disqualified each year.

The downstream tests of the 2% of disqualified athletes for the 20-year period (representing 3.4 million people) include echocardiogram (100% of those disqualified), exercise test (82%), Holter monitoring (41%), and MRI/catheterization (5%).

A total of 11.9 million athletes who are not disqualified would require an additional history and physical and ECG. Of these athletes, many will require more tests every 5 years, including echo (100%), exercise test (19%), Holter (5%), and MRI/catheterization (1%).

The investigators calculated that the sudden cardiac death rate would gradually decrease from four per 100,000 at the beginning of the screening program to 0.43 per 100,000 at 20 years.

As an alternative strategy, researchers noted that an educational campaign focusing on CPR training, effective communication systems within campuses, and the use of automated external defibrillators would result in a cost-per-life-saved of $1.5 to $3.3 million.

But Pelliccia said that it's "quite odd" the AHA recommends pre-participation screening without ECG, as ECG is better at detecting the particular cardiac abnormalities in athletes that could lead to sudden death.

"If cost is the main criterion [of the AHA's position], then the only wise decision is to abolish the current screening program [without ECG], which is costly and inefficient to the scope," he concluded.

Viskin and colleagues noted limitations to their study including some Medicare prices used in their calculations might not actually represent the cost of the test. They also said a limitation is their use of "cost-per-lives-saved" rather than "cost-per-life-year-saved," which they used mainly because cardiomyopathies are progressive.

From the American Heart Association:

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