Pre-participation ECG
screening in military
recruits- the IDF
experience
Alon Grossman M.D MHA1,
2, 3,
Alex Prokupetz MHA1, 2, Igor Lipchenca MD
1.
2.
3.
IAF aero medical center, Tel Hashomer, Israel
4.
Leviev Heart Center, Sheba Medical Center and Tel Aviv University, Tel Hashomer, Israel
4
IDF medical corps
Department of Internal Medicine E, Rabin Medical Center Beilinson Campus affiliated to Tel Aviv University
Sackler Medical School, Israel
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Introduction
 Despite
the
large
numbers
of
athletes
undergoing pre-participation screening, there is
a continuing debate regarding the optimal
method of screening
 The main concern in performing mass ECG
screening in athletes is the costly additional
work up required based on resting ECG findings
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Introduction

Professional guidelines in the US do not recommend use of either ECG
or echocardiography for screening of college athletes1

On the other hand, 12-lead ECG has been supported for screening
purposes among athletes by the Sport Cardiology section of the
European society of Cardiology and Medical Commission of the
International Olympic Committee and has been shown to reduce
mortality in this population2
1.
Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to pre participation screening for
cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on
Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007; 115:1643-1655
2.
Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after
implementation of a pre-participation screening program. JAMA 2006; 296:1593–1601
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Background

Recruits to elite units in the IDF undergo pre-participation ECG prior their
enlistment

This process has been performed sporadically in the last years but all ECGS are
performed at the IAF aero medical Center since January 2010

All elite units candidates undergo a preliminary medical selection process at the
IDF recruitment center (History & PE)

Only those who are physically healthy are allowed to enlist to elite units and only
they undergo pre-participation ECG

This population consists of 17-19 years old male subjects
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Background
 All ECGS are evaluated by a single cardiologist
 Those requiring further evaluation, complete
the evaluation prior to enlistment
 A military physician from the IAF aero medical
center summarizes the medical evaluation and
decides whether the candidate is eligible to
enlist to a special unit
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Aims
 To characterize causes of referral to continued
investigation based on resting ECG findings
 To summarize the additional work-up performed
 To summarize the rate of significant findings
resulting in disqualification of military candidates in
this population
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Results
 1,455
subjects
underwent
pre-
participation ECG in the year 2010
 1,388 studies (95.39%) interpreted as
normal
 67 referred to further evaluation
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Causes for referral
Cause of referral
Definition
T wave changes
Non specific
16 (23.9%)
Pre-excitation pattern
PR segment shorter than 120
milliseconds) with or without a delta wave
14 (20.9%)
LVH
S1+R5,6 wave voltage greater than 35 mm
in precordial leads and/or R-wave greater
than 15 mm in peripheral lead I and/or 12
mm in aVL
11 (16.4%)
Sinus bradycardia
Rates slower than 50 BPM
9 (13.4%)
Blocks
AV blocks of various degree, LBBB or
RBBB, LAHB or LPHB
6 (8.9%)
Atrial or ventricular premature beats
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Number of cases (% of
total findings)
5(7.5%)
Early repolarization pattern
upward ST-segment elevation in 2 or
more peripheral or precordial leads,
beginning from an elevated J point and
continuing with an upsloping shape into
the T-wave
3 (4.5%)
Long QT interval
corrected QT interval (QTc) greater
than 440 milliseconds
3 (4.5%)
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Additional investigations
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ECG finding
Echo
Stress test
Holter
Adenosine test
T wave changes
17
8
1
0
Early repolarization
2
2
1
0
Long QT
1
2
2
0
Pre excitation
pattern
1
7
7
11
Atrial or ventricular
premature beats
2
3
2
0
LVH
16
1
0
0
Blocks
7
7
3
0
Sinus bradycardia
0
8
6
0
Total
46
38
22
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Clinical Diagnosis
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ECG finding
Final diagnosis (#)
T wave changes
BAV (1)
VSD (1)
LVH (1)
Early repolarization
LVH (1)
Atrial or ventricular premature beats
Dilated left ventricle (1)
LVH
LVH (1)
Non compacted apex (1)
Long QT, pre-excitation pattern, sinus
bradycardia, blocks
None
Total number
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example 1
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Example 2
 ICRBBB with non-specific T wave changes in inferior leads
 Echocardiography interpreted as normal
 No further w/u required
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Example 3
 Early repolarization pattern particularly in V2
 Echocardiography-normal
 No further w/u required
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Discussion
 Screening for cardiovascular disease among athletes and military
candidates is imperative as sudden death is obviously tragic and
potentially preventable
 Debate continues regarding the optimal method of screening, this
ranging from reliance solely on history and physical examination to
performance of 12-lead ECG and echocardiography

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Discussion
The total rate of ECGS defined as abnormal in this cohort was
4.6%, a percentage much lower than previously reported
Yet, even in a previous report by Pellicia et al (8) in which 11.8%
of ECGs were interpreted as abnormal, additional evaluation was
requested in only 4.8% of ECGs, disregarding some of the findings
noted on routine ECG
This rate is similar to that reported in this study and probably
represents the true rate of ECG findings requiring further
evaluation in young athletes
Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339: 364–369
Pelliccia A, Culasso F, Di Paolo FM, Accettura D, Cantore R, Castagna W, Ciacciarelli A, Costini G, Cuffari B, Drago E, Federici V, Gribaudo CG,
Iacovelli G, Landolfi L, Menichetti G, Atzeni UO, Parisi A, Pizzi1 AR, Rosa M, Santelli F, Santilio F, Vagnini A, Casasco M, and Di Luigi L. Prevalence of
abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J 2007; 28(16):
2006-2010.
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T waves
T wave changes was the most common cause for
continued investigation in the cohort
This is probably due to the non specific nature of this
finding
 Disqualifying findings were identified in 18.75% of
evaluations in these subjects
 Whether these clinical findings were associated with
the ECG findings or were incidental is unclear
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PRE EXCITATION PATTERN

Signs of pre-excitation were identified in 14 subjects who
comprised 0.96% of the study population

This is a higher percentage than previously reported (0.2%)

Probably resulted from the high awareness to this condition
among interpreting cardiologists

No cases of pre-excitation syndrome identified

This is similar to a previous report from the Israeli air force
Ferrer MF. Electrocardiographic variations, arrhythmias, pacemakers. In: Lew EA, Gajewski J. Medical Risks: Trends in
Mortality by age and time elapsed. New York, NY: Praeger 1990.
Grossman A et al Use of adenosine test for the exclusion of pre-excitation syndrome in asymptomatic individuals. Ann
Noninvasive Electrocardiol 2011 Apr 16 (2); 180-183.
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LVH criteria

Signs of LVH were identified in only 7.56% of the study
population

This is significantly lower than reported in previous studies
(up to 45%)

This is surprising given the young age of the population and
the fact that the subjects were all very physically active

Disqualifying findings were identified in 18.2% of these
subjects
Pelliccia A et al Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation
cardiovascular screening. Eur Heart J 2007; 28(16): 2006-2010
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LIMITATIONS

A selective cohort (healthy, physically active
underwent ECG during screening for athletic
activity)

Single physician interpreting all ECGS (high
inter-observer variability reported in the
literature)
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Conclusions

T wave changes, although non-specific, may
be a sign of cardiac disease

Pre-excitation pattern is of low specificity
for the diagnosis of PES, but because of
the lethal potential of this condition,
adenosine should be performed in subjects
with a suspicious pattern
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Conclusions

ECG-LVH criteria have a low sensitivity in young
subjects, but because of the fatal potential of
HOCM and because the specificity of the ECG is
very high, echocardiography should be performed to
all those with ECG criteria

Policy makers should take into account the large
number
of
echocardiographies
that
will
be
performed in order to identify subjects with true
LVH
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Conclusions
 Sinus bradycardia and conduction
disturbances (low degree AVB
and hemiblocks) probably result
from increased vagal tone and
require no additional work-up
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