In the News: Get an EKG?

We’ve talked previously here at the blog about the general issue of pre-participation screening for cardiovascular disease for athletes at all levels. In the United States, this has been well-organized for high school and collegiate athletes, but lacking for adult athletes beyond their school days. The typical approach to pre-participation screening invovles taking a medical history and performing a physical examination with particular attention to the heart and cardiovascular system. There has been an ongoing debate about whether the addition of an electrocardiogram (EKG or ECG) and/or an echocardiogram provides additional useful information in a cost-effective manner.

I’d like to draw your attention to 2 articles and 1 editorial that appeared in the May 2 issue of the prominent medical journal, Annals of Internal Medicine.

1. Wheeler MT et al. Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med 2010; 152:276-286.

2. Baggish AL et al. Cardiovascular screening in college athletes with and without electrocardiography. Ann Intern Med 2010; 152:269-275.

3. Maron BJ. National electrocardiography screening for competitive athletes: Feasible in the United States? (Editorial) Ann Intern Med 2010; 152:324-326.

In the first study, Wheeler et al. report that the addition of an ECG to the pre-participation physical examination saves 2.06 lives per 1000 athletes screened, at a cost of $88 per athlete. This results in a cost-effectiveness ratio of $42,900 per life-year saved. For reference, most interventions with a cost-effectiveness ration of
In the second study, Baggish et al. report that, among 510 collegiate athletes who received an ECG and echocardiogram in addition to a physical examination, 11 athletes (2.2%) were identified who had a cardiac problem that was significant. Five athletes were identified on the basis of physical examination alone and 5 more were identified by the ECG. Importantly, though, screening that included an ECG resulted in a false-positive rate of 16.9%–a fair number of athletes who had an “abnormal” ECG but in whom no heart disease was actually present.

In the editorial, Dr. Barry Maron, perhaps the country’s foremost expert in this area considers the issue of mandating an ECG for school-related pre-participation screening programs. He reminds us of how rare it is for young athletes to die from sudden death: 1 per 220,000 participants. He also points out that the cost of ECG screening for all school-aged students would probably cost upwards of $2 billion. He concludes that the merits of ECG screening are not yet fully established and that there are significant logistical challenges to mandating widespread ECG screening for school-aged athletes.

So, what should my adult athlete readers take from all of this?

Here’s what I recommend to my friends…. I think that every endurance athlete should have, at least on 1 occasion, an ECG and an echocardiogram to rule out the major congenital heart conditions that predispose athletes to sudden death. This should be combined with an annual physical examination and medical history-taking that focuses on the heart and cardiovascular system. Athletes should discuss this issue with their physician, who is in the best position to help make decisions about ongoing screening for the development of heart disease as the athlete ages.

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  1. says

    I wonder what one of these machines costs to purchase. Maybe cities should buy them and conduct the tests on their own for their athletes.

  2. says

    Just curious if you recommend the ECG and echocardiogram for men AND women adult athletes.

    I can only think of one case where a woman died in the swim portion of a triathlon.

  3. says


    The cost of the machine is easily justified if it is used. That’s why most doctor’s offices have them. Similarly, University-related sports medicine departments would have them.

    Italy has been the pioneer with the use of EKG and echocardiogram as part of athlete screening. I would guess that the machines are owned by the government.

    I’m not aware of civic-oriented screening here in the U.S.

  4. says


    Great question. Yes, I do make the same recommendation for my triathlete and runner friends who are women.

    Since I know you’re a triathlete, we can focus on triathlon. I’m aware of only 1 study of sudden death in triathlons….and it has only been presented in abstract form at last year’s annual meeting of the American College of Cardiology.

    The authors reviewed all of the triathlons sanctioned by USA Triathlon from 2006-2008–events of all distances in which an amazing 922,810 athletes participated. There were 14 deaths, so ~1.5 per 100,000 participants.

    Interestingly, 13 of the 14 deaths occurred in the swimportion. The victims ranged in age from 28 to 55 years. The majority of deaths (11) occurred in men. As I recall, the 1 non-swimming death was in a man (but I could be wrong). Six of the victims had autopsies and 4 were found to have structural heart disease; the other 2 had “normal” autopsies and so arrhythmias were suspected as the cause of death.

    Since the detailed findings of the study have not yet made their way into a medical journal, all of the details are not at hand. You will already know that most triathlon participants are men….so it’s not surprising that there were more male deaths than female deaths. The male:female ratio of the deaths would seem to be greater than the typical male:female ratio at a race, so perhaps men are at greater risk.

    But obviously, women are at risk, too! And that’s why I make the same recommendations for my endurance athlete friends who are women.

    Hope that helps.

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