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SAN FRANCISCO -- When screening high school athletes for cardiac abnormalities, an electrocardiogram (ECG) interpreted using athlete-specific criteria had a lower false-positive rate than a history and physical examination, researchers found.

The rate of false-positive findings was 4% with the ECG, 22% with the history alone, 15% with the physical exam alone, and 32% with the combination of a history and physical, according to , of the University of Washington in Seattle.

In addition, of the 23 abnormalities identified in the study, seven (30%) were detected only by the ECG, he reported at the Heart Rhythm Society (HRS) meeting here.

"The history and physical do have some utility to them, but our data suggests that the utility is less than an ECG alone or an ECG in combination with a history and physical and that if we use athlete-specific criteria for interpreting an ECG, we're going to have a much lower false-positive for abnormalities versus using a history and physical," Prutkin told MedPage Today.

He added that he wouldn't go so far as to advocate for a change to the recommendations from the American Heart Association (AHA), which state that a history and physical exam should be used for pre-participation screening, with an ECG used only if something turns up.

"I think we need to keep doing further research to get to that point, but I don't we should [make a blanket statement] that you shouldn't do an ECG," he said. "I think we just need to keep on finding either the right ECG criteria or even the right patient populations to screen."

Adding an ECG to pre-participation screening of young athletes has been controversial in the U.S., and opponents point to a high false-positive rate, which can lead to unnecessary testing, higher costs, and distress for athletes and their families.

But the problem with recommending only a history and physical, Prutkin said, is that there hasn't been enough research into the utility of a history and physical for detecting cardiac abnormalities.

In the current study, he and his colleagues assessed the performance of a history, physical, and ECG among 4,812 competitive athletes, ages 13 to 19, who were screened at 23 high schools in the Seattle area.

The screening protocol included a heart health questionnaire (the history), a physical exam as recommended by the AHA, a resting 12-lead ECG, and a limited echocardiogram if indicated.

The researchers used athlete-specific criteria to interpret the ECGs -- criteria from the for the first part of the study and the for the second part.

"ECG interpretation guidelines in athletes must distinguish normal, physiologic adaptations resultant from regular exercise from findings suggestive of a pathologic cardiac condition," according to Prutkin and colleagues.

Overall, 0.5% of the athletes screened had cardiac abnormalities requiring further evaluation, including the following:

• Wolff-Parkinson-White pattern (nine cases)
• Coronary artery anomaly (four cases)
• Dilated aorta (three cases)
• Long QT syndrome (three cases)
• Hypertrophic cardiomyopathy (two cases)
• Premature ventricular contraction (one case)
• Short QT syndrome (one case)

Together, the history and physical exam uncovered 61% of the abnormalities. The ECG found 70% of them.

Prutkin said that starting with an ECG would have detected 16 true abnormalities, with a false-positive rate of 4%. Starting with the history, however, would have detected fewer true abnormalities (10), with a higher false-positive rate (22%).

Although Prutkin did not have any information on the cost of adding the ECG, he noted that the way to make it more cost-effective to add the ECG would be to further refine the ECG criteria to increase detection of important abnormalities while driving down false positives.

Speaking for himself and not as a representative of the HRS, , an electrophysiologist at Intermountain Heart Rhythm Specialists in Utah and program chair for this year's meeting, said that he's in favor of adding an ECG to pre-participation screening of young athletes and that "this study supports that."

He challenged the AHA's stance that an ECG should not be added because of the potential downstream consequences of a false-positive finding.

"Information is power," Day said. "You can't turn a blind eye to information because of any potential unintended consequences of the information."

He pointed out that an ECG is one of the least expensive tests doctors perform.

"Yes, the likelihood of finding an abnormality is very low, but by appropriately managing the information, it is something that can be very helpful to the young athlete who is considering competitive sports and also very beneficial to the physician," he said.

An interesting aspect of the current study, he said, was the use of athlete-specific criteria for interpreting the ECG.

"I think that helps to bridge the gap [between the two sides of the debate]," he said. "Rather than coming out against routine screening like the American Heart Association has, I would challenge the American Heart Association to -- rather than ignore the data -- find a way to react responsibly to the data you get from an ECG, like they did in this study."

From the American Heart Association:

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