Congenital Long QT Syndrome and Cardiac Arrest in a Military Tactical Athlete

We present a case of a U.S. marine who experienced cardiac arrest during military Special Forces underwater diving exercises whose evaluation revealed congenital long QT syndrome. This case highlights the expanding role for systematic electrocardiogram screening in target athletic and military populations given their stress and tactical exposures. (Level of Difficulty: Advanced.).

Screening electrocardiogram in young athletes and military members: a systematic review and meta-analysis

OBJECTIVE

To determine the effect of electrocardiogram (ECG) screening on prevention of sudden cardiac arrest and death (SCA/D) in young athletes and military members.

DATA SOURCES

MEDLINE, Embase, Cochrane CENTRAL, Web of Science, BIOSIS, Scopus, SPORT discus, PEDro, and clinicaltrials.gov were searched from inception to dates between 2/21/19 and 7/29/19.

STUDY SELECTION

Randomized and non-randomized controlled trials, where pre-participation examination including ECG was the primary intervention used to screen athletes or military 40 years of age or younger. Accepted controls were no screening, usual care, or pre-participation examination without ECG. 3 published studies , and one conference abstract were identified for inclusion.

DATA EXTRACTION

In all four studies, risk of bias was assessed with the Cochrane risk of bias tool, and found to be generally high. Two studies had data extracted for random effects meta-analysis, and the remaining study and conference abstract were included in narrative review. Overall quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Data Synthesis: Four non-randomized studies (11,689,172 participants) were included, all at high risk of bias. Pooled data from two studies (n= 3,869,274; very low quality evidence) observed an inconclusive 42% relative decrease in risk of sudden cardiac death (RR 0.58; 95% CI 0.23, 1.45), equating to an absolute risk reduction of .0016% The findings were consistent with a potential 67% relative decrease to a 45% relative increased risk in participants screened with ECG. Heterogeneity was found to be high as measured with I2 statistic (71%). Data from the remaining study and abstract were similarly inconclusive.

CONCLUSION

Existing evidence for the effect of ECG screening is inconclusive and of very low quality. Our meta-analysis observed that screening ECG may result in considerable benefit or harm to participants. Higher quality studies are needed to reduce this uncertainty. PROSPERO Registration: CRD42019125560.

Electrocardiogram in Preparticipation Athletic Evaluations among Insured Youths

OBJECTIVE

To retrospectively characterize electrocardiogram (ECG) use among preparticipation history and examinations (PPEs).

STUDY DESIGN

Using the 2005 to 2010 MarketScan insurance database, we identified subjects aged 5-21 years with either a PPE with an ECG or a PPE alone, excluding those with known cardiac diagnoses. We described cardiology referrals and subspecialty testing within 180 days and cardiac diagnoses within 1 year of the PPE, and the costs of testing in each group.

RESULTS

From 2005-2009, 503 304 PPEs occurred in 419 456 subjects, of which 8621 (2%) included an ECG. ECG use increased from 12-20 per 1000 PPEs from 2005-2009. Females, lower socioeconomic status, and rural settings were associated with fewer ECGs. Thirteen percent of PPEs with ECG and 0.5% of PPEs alone led to a cardiology referral. After PPEs with ECG, cardiac disease was identified in 18% (2% sports-limiting); after PPEs alone, cardiac disease was identified in 0.5% (0.03% sports-limiting). The PPE had a sensitivity of 44% and a specificity of 98.6% of identifying cardiac disease. The total reimbursement cost of PPEs plus testing was $80 396 464 ($160 per PPE).

CONCLUSIONS

These real-world data demonstrate that community providers selectively use the ECG as part of the PPE with a high rate of identification of cardiac disease. Mass ECG screening would need to be more efficient at identifying disease than this selective approach.