Athlete anxiety no excuse to skip heart test: study

After finding that student-athletes felt no more distress about heart screening with electrocardiograms, or ECGs, than they did with physical exams, a new study concludes that anxiety should not be considered a reason to avoid giving the test.

An ECG measures the electrical activity of the heart and can detect disturbances that could predispose people to rare but dangerous cardiac arrests. Sudden cardiac death is the most common cause of death during exercise, researchers note.

Italy and Israel mandate ECG screening as part of sports pre-participation examinations, while the debate over whether to require athletes to get the test has become increasingly contentious in the United States.

One of the downsides of ECGs is that they sometimes suggest a heart problem that turns out to be a false alarm upon further testing. In the interim, athletes may fear for their health or their future in sports.

“This is the first study to look at the psychological impact to athletes when they get screened,” lead author Dr. Irfan Asif told Reuters Health. “There’s nothing to indicate you shouldn’t get an ECG because of stress.”

Asif, from the University of Tennessee Graduate School of Medicine in Knoxville, and his team studied 952 high school athletes who participated in a range of sports. The students all received a medical history and physical examination to screen for underlying heart problems. All but 150, who served as a comparison group, also received an ECG.

Athlete anxiety no excuse to skip heart test Of the 802 participants who were screened with ECG, 220 had an abnormal finding at some point during the screening process. Six of those represented serious heart conditions, and the rest were false positives.

Reviews of a student’s medical history led to 127 of the false positives. An additional 50 false positives were a result of physical exams, 14 were from ECG readings and 29 were due to multiple indications.

The researchers found no difference in students’ distress levels immediately after screening based on whether their testing had included an ECG.

A 2007 American Heart Association statement on cardiovascular screening warns that false-positive results from ECGs could lead to unnecessary anxiety, the authors write in the British Journal of Sports Medicine.

But the current investigation showed no differences in distress levels based on the reason for the false-positive evaluation - the vast majority of which resulted from a review of a student’s personal and family medical history.

“The athletes we’ve interviewed are actually very grateful that someone’s tried to save their lives,” Asif said. “We’re not really seeing negative consequences. We’re seeing very positive benefits.”

But pediatric cardiologist Dr. Peter Fischbach from Children’s Healthcare of Atlanta told Reuters Health the study protocol limited its generalizability. Fischbach, who is also affiliated with Emory University School of Medicine, was not involved with the new study.

Students whose ECGs showed possible problems in the current investigation had follow-up tests on the same day at the same location. Most student-athletes have to wait for follow-up appointments with cardiologists, Fischbach said.

“If you’re not allowed to practice until you get a note from a cardiologist, and you have to go home and stew on it for three weeks, I worry that kids would become a little more stressed out,” he said. “Maybe they’d get a little more anxious and wonder if they’re ever going to be able to play again.”

The authors acknowledge that on-site, same-day tests to evaluate the abnormal ECG findings could have minimized anxiety among students.

“I imagine people having to wait for additional testing might have anxiety,” Asif said.

He and Fischbach both said there should be ways to address delays in follow-up in the real world.

But even if expected delays between tests could be shortened, Fischbach said the problem of funding to screen all U.S. student-athletes would remain. “In this era of cost-containment, this has the potential to be an explosive cost,” he said.

Some doctors have called for regular testing of U.S. student-athletes to try to prevent sudden cardiac deaths. So far, though, data have failed to show that screening could reliably weed out only the most at-risk youth at an affordable price. Based on Italian data, British researchers have calculated that close to 800 athletes would have to be benched from their sports for every death prevented (see Reuters Health story of October 11, 2012 here:

Nevertheless, Asif believes in ECG screening. He noted that reviews of family history and physical examinations are substantially flawed in their ability to detect heart defects, yet schools require them for students to participate in sports.

“People are asking for evidence. Where’s the evidence for a history and physical?” he asked.

“My message is you should do all three,” he said. “With screening with an ECG, we can save lives. Your ability to detect disease is much higher, and it looks like it doesn’t cause additional anxiety in people.”

SOURCE: British Journal of Sports Medicine, online May 13, 2014.


The psychological impact of cardiovascular screening: the athlete’s perspective Published guidelines suggest that ECG screening in US athletes may cause excessive anxiety, especially in those with false-positive findings. However, this has never been formally evaluated. Methods and study design Prospective, non-randomised controlled trial. High school athletes received a standardised history and physical examination (control) or a history and physical examination with an ECG (experimental). Prescreen and postscreen assessments for health attitudes, anxiety and impact of screening on sport were conducted. Results 952 athletes (49.7% girls, mean age 15.5 years) participated (control=150; experimental=802). 4.4% worried about having an underlying cardiac condition, and 73% wanted to learn if they had a cardiac abnormality prior to competition. In the experimental group, 576 had normal screens, 220 had an abnormal screen (by history 15.8%, physical examination 6.2% or ECG 1.7%) but normal work up (false-positive) and 6 were identified with a serious cardiac condition (true-positive, 0.75%). Compared with the control group, those who received an ECG were more likely to: (1) be significantly more satisfied with their screening (p<0.001), (2) feel safer during competition (p<0.01), (3) support that all athletes should receive cardiac screening (p<0.001) and (4) state the ECG positively impacted their training (p<0.001). False-positive athletes did not report anxiety during or after screening. Distress levels did not differ based on reason for needing further evaluation (history, physical examination or ECG, p=0.311). Compared with control participants, individuals with false-positive results: (1) reported no difference in postscreen anxiety (p=0.775), (2) felt safer during competition (p<0.001), (3) would recommend ECG screening to others (p<0.001) and (4) expressed a positive impact on training (p<0.001). Conclusions Excessive anxiety should not be used as a reason to forego ECG screening in athletes.   Irfan M Asif,   Serena Johnson,   Jason Schmieg,   Tiffany Smith,   Ashwin L Rao,   Kimberly G Harmon,   Jack C Salerno,   Jonathan A Drezner

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