Miscellaneous
Lessons Learned from Preparticipation Cardiovascular Screening in a State Funded Program

Presented at the American Heart Association Scientific Sessions 2010, Chicago, Illinois.
https://doi.org/10.1016/j.amjcard.2012.05.018Get rights and content

In 2007, the Texas legislature appropriated money for a pilot study to evaluate cardiovascular screening of student athletes to identify those who might be at risk of sudden death using a questionnaire, physical examination, electrocardiography, and limited echocardiography. We sought to determine (1) the feasibility of a state-wide cardiovascular screening program, (2) the ability to reliably identify at-risk subjects, and (3) problems in implementing screening state wide. The data were analyzed using established pediatric electrocardiographic and echocardiographic criteria. Positive results were confirmed by a blinded reviewer. In 31 venues (2,506 students), the electrocardiographic findings met the criteria for cardiovascular disease in 57 (2.3%), with 33 changes suggestive of hypertrophic cardiomyopathy, 14 with long QT syndrome, 7 with Wolff–Parkinson–White syndrome, and 3 with potential ischemic findings related to a coronary anomaly. Of the 2,051 echocardiograms, 11 had findings concerning for disease (9 with hypertrophic cardiomyopathy and 1 with dilated cardiomyopathy). In patients with electrocardiographic findings consistent with hypertrophic cardiomyopathy, the limited echocardiograms were normal in 24 of 33. Of the 33 who remained at risk of sudden death on the electrocardiogram or echocardiogram, 25 (65.8%) pursued the recommended evaluation, which confirmed long QT syndrome in 4, Wolff–Parkinson–White syndrome in 7, and dilated cardiomyopathy in 1. The interobserver agreement was 100% for electrocardiography and 79% for echocardiography. The questionnaire identified 895 (35% of the total) potentially at-risk students, with disease confirmed in 11 (1.23%). In conclusion, in this large state-funded project, electrocardiographic and echocardiographic screening identified 11 of 2,506 patients potentially at risk of cardiovascular disease. The questionnaire was of limited value and had a large number of false-positive results. Interobserver variation was significant for echocardiography and might create problems with limited echocardiographic screening. Finally, many subjects with abnormal screening results declined a follow-up evaluation.

Section snippets

Methods

In 2007, the Texas State legislature approved Senate Bill 7, relating to the placement of automated external defibrillators in schools statewide. Section 38.109 of this bill allocated 1 million dollars for the Texas Education Agency to “establish a pilot program under which students are administered cardiovascular screening, including an electrocardiogram and an echocardiogram.” To implement this screening program, a collaborative group of investigators was formed with regional centers in

Results

A total of 28 events were present for model 1, averaging 72.2 students/event. On average, the ECGs were interpreted 82.5 days after the screening venue, the echocardiograms were read 28.6 days after the venue, and the study results were mailed to the participants 89.5 days after the venue. In model 2, 3 events occurred, averaging 161.3 students/venue. In this latter model, the screening results were provided immediately to the participant.

A total of 2,506 students were enrolled, with 2,022

Discussion

Although nationwide acknowledgment and agreement exists among experts regarding the importance of preventing SD in youths and adolescents, consensus is lacking regarding the methods to achieve this goal. A significant impediment is inadequate data regarding the feasibility and efficacy of a large-scale screening process. The present study is the first large, prospective and fully state-funded screening initiative to identifying the potential causes of young athlete SD. Others have reported

Acknowledgment

We appreciate Janet Smith, BA, and Ellen Suen, MS, for their assistance with the database development and organization, and Joan Reisch, PhD, MS, for her assistance with the biostatistical analysis and database development. We also thank Ben Eidem, MD (Mayo Clinic, Rochester), for his willingness to independently review the study echocardiograms.

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    This project was funded by RFP number 701-08-027 from the Texas Education Agency (Austin, Texas).

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