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A Proposal for ECG’s in pre-participation physical examinations (PPE) for college athletes
A Proposal for ECG’s in pre-participation
physical examinations (PPE) for college athletes
Washburn University
School of Nursing
NU 670- Graduate Project
[Nov. 2, 2012]
Tracy Hill, BSN, RN, MSN Candidate
Shirley Dinkel, PhD., APRN - Instructor
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A Proposal for ECG’s in pre-participation physical examinations (PPE) for college athletes
Implementing ECG’s as part of pre-participation physical examinations (PPE) for student
athletes
Introduction
Athletes are seen as one of the healthiest segments of our society. About 400,000 students
between age 17 and 23 participate in National Collegiate Athletic Association (NCAA) sports
every year. However, each year, about one in 44,000 players in the NCAA has sudden cardiac
death (SCD) (Hendrick, 2011; Wong 2011). While still considered relatively rare, the rate of
SCD in young athletes is higher than previous estimates (American College of Cardiology
Foundation/American Heart Association Task Force [ACCF/AHA], 2011, Minneapolis Heart
Institute Foundation, 2012, NCAA, 2012, O’Connor et al., 1998, Subasic, 2010).The NCAA
reports that the incidences of sudden cardiac death have been more prevalent among AfricanAmericans (one in every 17,000 student-athletes per year) than Caucasians (one in 58,000).
Additionally, men have been shown to be at greater risk (one per 33,000) than women (one in
76,000) (NCAA, 2012). Fortunately, the incidence of sudden death in an athlete, especially a
young athlete, is a rare event, although the true incidence of SCD is unknown and probably
underestimated due to the absence of a mandatory reporting system (Casa et al., 2012, NCAA,
2012). The incidence of SCD could be as high as 110 deaths each year in young athletes or 1
death every three days in the United States (Casa et al., 2012).
Sudden cardiac death (SCD) in young athletes was first reported in the 1980s. SCD is
defined by the American Heart Association (AHA) as “death resulting within minutes of an
abrupt loss of heart function”, (Wong, 2011) or death “that is unexpected and non-traumatic and
that occurs instantaneously or within a few minutes of an abrupt change in the person's previous
clinical state” (O’Connor, Kugler, & Oriscello, 1998). SCD is the leading medical cause of
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A Proposal for ECG’s in pre-participation physical examinations (PPE) for college athletes
death for student athletes, accounting for 16 percent of college-athlete deaths (Subasic, 2010).
The overall prevalence of cardiac abnormalities responsible for SCD has been estimated to be
0.3% (3 in 1000) in the general athlete population, and while actual incidence rates of SCD are
markedly lower, relatively few cardiac abnormalities lead to a fatal event in young athletes
(O’Connor & Knoblauch, 2010). The NCAA required screenings for student athletes currently
includes a comprehensive personal and family medical history, physical examination, and
appropriate additional diagnostic testing, if warranted. Many NCAA institutions also offer an
electrocardiogram (ECG) and/or echocardiogram as part of an athlete’s heart screen, although it
is not a requirement (NCAA, 2012).
A recent study by Wong (2011) report that while it is more expensive, researchers feel
that ECGs are necessary to properly screen athletes for heart conditions. The University of
Washington is one example of an institution that now requires ECGs on incoming freshman
athletes as a result of the study, because in 2002, a woman’s basketball player on the UW team
collapsed from heart failure and survived, and in 2006, the women’s basketball coach suffered a
cardiac arrest, too. Both the former player and coach are now advocates for requiring testing
nationwide, stating "The NCAA has an opportunity to take a stand in a positive way and mandate
testing, and at the end of the day, what's a life really cost?" (Wong, 2011)
According to a study led by Thomas DeBauche, MD, of Cypress Cardiology in Cypress,
Texas, cost issues should no longer keep electrocardiograms out of most schools' efforts to
screen student athletes for potentially fatal heart problems. Researchers reported that due to
recent declines in the price of ECG machines, students can be screened for a cost of less than $3
each after an initial investment of under $500 per school (Phend, 2009).
Problem Statement
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Hypertrophic cardiomyopathy (HCM) is reported as the most common cause of
unexplained sudden cardiac death in young athletes (Minneapolis Heart Institute Foundation,
2012, NCAA, 2012, Subasic, 2010). Prevention of SCD in athletes requires early recognition of
those conditions known to cause SCD (O’Connor & Knoblauch, 2010). Adequate screening and
evaluation are important to identify and counsel persons with underlying cardiovascular disease
before they begin exercising at moderate to vigorous levels (“AHA/ACSM Joint Position
Statement“, 1998).
The purpose of this project is to apply evidence-based practice (EBP) recommendations
to 1) Discuss current evidence available to support implementing ECG screenings as part of the
pre-participation physical examination (PPE) for student athletes at WU, 2)Enhance high quality
care that is safe to all athletes by early recognition and detection of cardiac problems that may
lead to SCD, 3) In collaboration with the Department of Kinesiology Athletic Training Education
Program, it is proposed that athletic training students be trained to properly perform ECGs as
part of enhancement to their core curriculum for KN 492: Clinical Experiences in Athletic
Training- General 4) Implement ECG screening as part of PPE for all student athletes at WU.
Included will be a proposal for funding to obtain the appropriate equipment and training
necessary to perform and interpret ECG’s for student-athletes as part of the PPE and
implementation of diagnostic tools. Currently, routine ECG’s are not performed as part of the
PPE at WU.
Significance to Nursing
Health care providers, including Advanced Practice Nurses (APNs), play an important
role in correctly performing and interpreting ECG’s, and appropriately identifying and referring
those with abnormal ECGs. In 1996, pre-participation sports screenings became a joint public
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health initiative and are supported by the AHA. The guidelines are not mandated or presented as
a national standard, and their purpose is to identify risks and prevent injury in competitive
athletes. They are routinely updated, widely accepted, and endorsed as standards of care by
numerous medical and sports related associations (Subasic, 2010).
Currently, there is no standardized guideline for the performance and evaluation of ECGs
as part of student athlete physicals at Washburn University. Properly trained WU athletic
training students and faculty, along with medical providers, can increase overall safety during
athletic activities in those unknowingly vulnerable to SCD by: 1) Implementing diagnostic tools
such as ECG equipment, 2) Educating and training athletic training students to perform ECGs,
and 3) Utilizing ECG’s as part of pre-participation sports physicals for student-athletes at WU.
By increasing knowledge and awareness of evidence based guidelines and standards
about SCD and ECG’s in pre-participation sports physicals, WU is in a position to provide early
detection, recognition and treated of patients at risk for SCD. By implementing ECG screenings
for student athletes, the providers potentially improve health outcomes and potentially save lives
of student athletes, before SCD occurs. WU Department of Kinesiology Athletic Training
Education Program faculty and students, along with the WU Athletic Department and the
University have the potential to be at the forefront of implementing current European and
Olympic recommendations for ECG screenings for athletes and what may soon be “best
practice” nationally as well. It is vital that educators and practitioners recognize the need to have
a procedure to provide the most up to date evidence based care to improve patient outcomes.
This proposal, intended to reduce the potential risk of SCD in student athletes, provides the
opportunity for WU to enhance the comprehensiveness of services for student athletes and
promotes multidisciplinary collaboration in an effort to improve outcomes and facilitate prompt
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recognition and treatment of patients at risk for SCD. ECGs as part of a PPE, if implemented,
could minimize cardiovascular risk associated with sports. Health care providers, including
APRNs, play an important role in correctly performing and interpreting ECG’s, and
appropriately identifying and referring those with abnormal ECGs.
There is general consensus that within a benevolent society there is a responsibility on the
part of healthcare providers to initiate prudent efforts to identify life-threatening diseases in
athletes to minimize cardiovascular risk associated with sports (Maron et al., 1996). There also
appears to be an implied ethical and possibly legal obligation on the part of educational
institutions to implement cost-efficient strategies to ensure that their athletes are not subject to
unacceptable medical risks. ECGs as part of a PPE, if implemented, could minimize
cardiovascular risk associated with sports.
An ECG is universally acknowledged as more likely to identify serious cardiac problems,
and it has been adopted as an international standard for screening in much of the world. The
European Society of Cardiology and the International Olympic Committee have recommended
the addition of ECGs to pre-participation sports physicals for college athletes. An ECG is
required prior to sports participation in the International Olympics and is practiced by 92% of
professional sports teams in the United States (Subasic, 2010).
In collaboration with the Department of Kinesiology Athletic Training Education
Program at Washburn University, a guideline that includes ECG screening as part of the studentathlete pre-participation sports physical is suggested. It is also suggested that the a local
cardiologist review all ECG’s and be consulted for any potential abnormal ECG’s to determine if
further testing is warranted. As forerunners in the initiative, WU has the opportunity to be among
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A Proposal for ECG’s in pre-participation physical examinations (PPE) for college athletes
the first to implement the already recommended international and Olympic standards for ECG
screenings in athletes, an initiative that may soon be “best practice” nationally as well.
Project Objectives
Currently, the WU Athletic Training Education Program and the Athletic Department
does not have a guideline for including ECGs as part of the PPE. This proposal presents
implementing ECG screenings as part of the PPE for student athletes, necessary training for
athletic training faculty and students to effectively perform ECGs, and exploring funding sources
for a 12 lead ECG machine and necessary equipment and supplies. There are six objectives for
this project. They include:1) Review of literature to include current national guidelines for the
pre-participation physical examination (PPE) and ECG screening and interpretation
recommendations for student athletes; 2) Review of current practices at the WU Department of
Kinesiology Athletic Training Education Program and Athletic Department for PPE and ECG
screenings for student athletes 3) Propose a guideline for the inclusion of ECGs in PPE for
student athletes at Washburn University; 4) Educate WU athletic training faculty and staff in
proper ECG placement and performance and 5) Recommend a referral procedure for overread of
all ECG’s and follow-up of students determined to be at increased risk and 6) Explore funding
sources for 12 Lead ECG equipment and supplies for WU Department of Kinesiology Athletic
Training Education Program.
Background of the Problem
Current guidelines for pre-participation screening of competitive athletes in the US
include a comprehensive history and physical examination.
There were five objectives to this proposal, including 1)Determine the value of
electrocardiography (ECG) added to a PPE screening in college athletes, 2) Provide the
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opportunity for Washburn University to be more active in preventing SCD in student athletes, 3)
Revise and enhance the course curriculum for KN 492: Clinical Experiences in Athletic
Training- General Medical to include education and training on performing ECGs, 4) Write a
curriculum grant to help fund necessary ECG equipment and supplies for revised course,
including development of a budget, 5) Educate providers on current standards and recommend
assessment tools, including a new pre-participation physical examination (PPE) form.
Pre-participation cardiovascular screening is the systematic practice of medically
evaluating large, general populations of athletes before participation in sports for the purpose of
identifying, or raising suspicion of abnormalities that could provoke disease progression or
sudden death (American Heart Association [AHA], 2007, p. 1643). The American Heart
Association (AHA) has published guidelines for pre participation sports physicals. The
Hypertrophic Cardiomyopathy Association (HCMA) encourages each state to use these
guidelines when updating their requirements for participation in high schools and college level
programs. According to the WU Athletic Training Department, student PPEs does not currently
include an ECG.
Currently, all Big 12 Division 1 institutions, including Kansas State University and the
University of Kansas, both within 58 miles of Washburn University, include an ECG and
echocardiogram on all incoming athletes as part of their PPEs. For the purpose of collecting data
on ECG screenings from schools similar in size to Washburn, this author attempted to contact the
athletic training staff at each of the five Division II schools in Kansas. The Division II
Universities in Kansas include Emporia State University, Emporia, KS, Fort Hays State
University, Hays, KS, Newman University, Wichita, KS, Pittsburg State University, Pittsburg,
KS, and Washburn University in Topeka, KS. The athletic training staff at each of the
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universities was contacted by email, asking whether or not these schools did routine ECG
screenings as part of their PPE for their student athletes. At the time of this proposal, Washburn
University’s athletic training staff was the only school to respond to the email. Currently,
Washburn University does not conduct ECG’s on their student athletes as part of their PPE,
citing “it is very cost prohibitive to screen every athlete with the ECGs, although we do not
hesitate if it is warranted” (personal communication, Karen Garrison, MA, ATC, LAT, Clinical
Education Coordinator/Asst. Athletic Trainer, Washburn University, April 23, 2012). At this
time, the only time they order ECGs for their student athletes is if there is a family medical
history or something abnormal on their PPE (Appendix A). Officials in the athletic department
at WU also cite the National Athletic Trainers’ Association (NATA) Position Statement:
Preventing Sudden Death in Sports, quoting that "The pre-participation physical examination
(PPE) should include the completion of a standardized history form and attention to episodes of
exertional syncope or pre-syncope, chest pain, a personal or family history of sudden cardiac
arrest or a family history of sudden death, and exercise intolerance." (personal communication,
Karen Garrison, MA, ATC, LAT, Clinical Education Coordinator/Asst. Athletic Trainer,
Washburn University, April 23, 2012), (Casa et al., 2012). It is noteworthy, however, that the
NATA also reports that pre-participation screening is one strategy available to prevent SCD, and
that the best protocol to screen athletes is highly debated, and some methods lack accuracy.
Additionally, the NATA Position Statement on preventing SCD in sports reports that “As many
as 80% of patients with SCD are asymptomatic until sudden cardiac arrest occurs, suggesting
that screening by history and physical examination alone may have limited sensitivity to identify
athletes with at-risk conditions.” (Casa et al., 2012).
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Exercise-associated acute cardiac events generally occur in individuals with structural
cardiac disease. Hypertrophic cardiomyopathy (HCM) is a condition that is generally not
compatible with competitive athletics and therefore those with HCM should not participate in
most athletic programs. HCM has been proven to be the leading cardiovascular cause of SCD in
the young athlete population, accounting for about one third of events (American College of
Cardiology Foundation/American Heart Association Task Force [ACCF/AHA], 2011,
Minneapolis Heart Institute Foundation, 2012, NCAA.com, 2012, O’Connor et al.,1998, Subasic,
2010).
Theoretical Framework
The Shuler Nurse Practitioner Practice Model was used as the theoretical framework for
developing this proposal. The Model presents a holistic approach to delivery of patient care and
to evaluation of services provided. The four concepts of person, health, nursing and
environment, along with the concept of the NP role, are intrinsic to the Shuler Nurse Practitioner
Practice Model (Shuler, 2000). It is based on nursing research and scientifically supported
generalizations that are relative to the NP practice areas.
School Based Health Centers (SBHC) are in a unique position to assist with development
of positive health behaviors by providing holistic services, including ECG screenings for student
athletes, as well as all patients who receive services at SBHC. To deliver holistic services, the
SBHC must have a multidisciplinary team comprised of health care providers, mental health
counselors, health educators, nutritionists, social workers, teachers and support staff (Shuler,
2000). WUSHS onsite team leader/manager is an Advanced Practice Registered Nurse (APRN)
responsible for the coordination of SBHC services delivered, provision of primary care, and
evaluation of services rendered.
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As a result of the holistic treatment plan, patient problems related to unmet basic needs,
including underlying cardiac problems potentially uncovered by a routine ECG, can be
identified. The development and implementation of a holistic treatment plan should include
consultation and referral to multidisciplinary team members and other resource agencies. The
Shuler Nurse Practitioner Practice Model was used as the theoretical basis for the proposal
because it presents a holistic approach to patient assessment, problem identification/diagnosis
determination, treatment, and evaluation.
Review of Literature
Overview
A systematic literature review and critical analysis of available articles was completed.
The literature review utilized the following databases: PubMed, ProQuest, UpToDate, SAGE,
Cochrane, Google scholar and CINAHL databases, as well as searches of websites of relevant
organizations (e.g. AHA, ACSM, NATA, and NCAA). Key words used included ECG, college
athletes, cardiovascular screening, guidelines, pre-participation physical examination, NCAA,
sudden cardiac death, screening, hypertrophic cardiomyopathy, prevalence, incidence and
genetic cardiovascular disease. Applicable articles were limited to English language sources,
and human studies. Articles published in the last 15 years were included. Bibliographies of all
relevant articles were visually searched to retrieve additional articles. Twenty-five applicable
articles were then reviewed in full for inclusion in this proposal.
In 1996, pre-participation sports screenings became a joint public health initiative
supported by the AHA. The guidelines are not mandated or presented as a national standard, and
their purpose is to identify risks and prevent injury in competitive athletes. They are routinely
updated, widely accepted, and endorsed as standards of care by numerous medical and sports
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related associations (Subasic, 2010). The most recent update was in 2007. The moving force
behind the update was the age of the original recommendations, as well as a strong debate as to
whether a 12-lead ECG should be added to the recommended practice guidelines. The AHA
decided, despite continued debate, that an ECG was not recommended at that time due to limited
resources, cost, and the potential for false-positive results; therefore, the utilization of an ECG
for sports physicals remains optional. However, an ECG is universally acknowledged as more
likely to identify serious cardiac problems, and it has been adopted as an international standard
for screening in much of the world. The ECG is viewed at the most cost-effective
cardiovascular screening modality (Subasic, 2010).
Subasic (2010), also reports that the screening of athletes prior to participation in
competitive sports usually falls short of recommended guidelines. Currently, the NCAA requires
all student-athletes beginning their initial season of eligibility and students who are trying out for
a team to undergo a medical examination before engaging in any physical activity with the team,
and each subsequent year, an updated medical history is administered (NCAAwebsite, 2012, p.
2). Currently, the NCAA does not require ECGs on student athletes as part of their PPE, it
remains optional.
In the June 2011 issue of The American Journal of Medicine, researchers collected
electrocardiograms and echocardiograms of 964 athletes at a single university and found that
distinct ECG abnormalities were present in 10% and were more common in males as well as
black athletes. Two athletes were subsequently excluded from competition (Elsevier, 2011)
Definition
Sudden cardiac death (SCD) is the leading cause of death in exercising young athletes
(Casa et al., 2012). SCD is defined by the AHA as “death resulting within minutes of an abrupt
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loss of heart function”, and is the leading medical cause of death for student athletes, accounting
for 16 percent of college-athlete deaths (Wong, 2011). SCD is unexpected and non-traumatic and
occurs instantaneously or within a few minutes of an abrupt change in the person's previous
clinical state (O’Connor, Kugler, & Oriscello, 1998).The underlying cause of SCD is usually a
structural cardiac abnormality. HCM and coronary artery anomalies are responsible for
approximately 25% and 14% of SCD, respectively, in the United States.
Hypertrophic cardiomyopathy (HCM) is characterized by a thickened left ventricular wall
that causes an enlarged heart and while many people with HCM live a normal life and do not
experience health-related problems, HCM is currently the most common genetic heart disease
and most frequent cardiovascular cause of sudden death in young athletes (AHA, 2007, NCAA,
2012). HCM is often detectable by ECG, and in the general population may occur in as many as
one in every 500 individuals. The clinical spectrum is broad and complex, encompassing the risk
for sudden cardiac death predominantly in the young and heart failure disability at any age
(Minneapolis Heart Institute Foundation, 2012).
Pathophysiology/Clinical Manifestations
Sudden Cardiac Death is a syndrome defined by its clinical presentation rather than by a
discrete pathophysiology. SCD is a sudden state of circulatory failure due to loss of cardiac
systolic function and is the result of 4 specific cardiac rhythm disturbances: ventricular
fibrillation (VF) and pulseless ventricular tachycardia (VT), pulseless electrical activity (PEA)
and asystole (Epocrates, 2012). SCD is instantaneous and most individuals become unconscious
within seconds to minutes as a result of insufficient cerebral blood flow. SCD can occur in
patients who have no previous history of heart disease. However, underlying heart disease is
present in the vast majority of patients with SCD and identification of the patient at risk for
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sudden death or definition of the factors that result in the precipitation of the fatal arrhythmia
continues to represent a major challenge. In SCD, there are usually no predictive symptoms, but
if present, they are nonspecific and include chest discomfort, palpitations, shortness of breath and
weakness.
The “athletic heart” describes a heart that has a structural change of the heart wall,
suggestive of HCM, and is often seen in athletes who train at high levels. The AHA reports that
The American College of Cardiology Bethesda Conference No. 36, as well as the European
Society of Cardiology guidelines indicate that risk for SCD is increased during intense
competitive sports and also suggests that the removal of those individuals with HCM from the
athletic arena can diminish their risk (ACCF/AHA, 2011). Causes of sudden cardiac death in
young competitive athletes that constitute the largest percentages associated with SCD in
student-athletes are included in Figure 1(Subasic, 2010).
Epidemiology of SCD in Athletes
Sudden cardiac death (SCD) most commonly occurs in male athletes, who have estimated
death rates nearly fivefold greater than the rates of female athletes. Congenital cardiovascular
disease is the leading cause of non-traumatic sudden athletic death, with HCM being the most
common cause (O’Connor et al., 1998). Adding other heart conditions known to cause sudden
cardiac death, the prevalence of serious underlying heart disorders may approach three in every
1,000 student-athletes. A study on sudden cardiac death conducted by Harmon, K, et al (2008),
in which researchers gathered data from the NCAA, along with news reports and insurance
claims, found that college athletes across the nation suffer from sudden cardiac death up to seven
times more frequently than previously reported (Wong, 2011). The study tracked deaths from
2004-2008, and reported that about 400,000 students between age 17 and 23 participate in
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NCAA sports every year. The researchers reported that the total number of deaths from all
causes were 273, and 29%, or 80 of those athletes, died from medical causes and 56% of those
deaths were cardiovascular-related sudden deaths. Researchers have also found that among the
400,000 athletes who participate in NCAA sports every year, the incidences of SCD have been
more prevalent among African-Americans, 1: 17,000 student-athletes per year, than Caucasians,
1:58,000. Male basketball players have the highest rate of sudden cardiac death and men have
been shown to be at greater risk than women (NCAA, 2012, Wong, 2011).
The design of a screening strategy must take into account the fact that sudden cardiac
death in athletes is an infrequent event and that only a small proportion of participants in
organized sports in the United States is at risk. There are approximately 4 million competitive
high school–age athletes in addition to 500,000 collegiate and 5,000 professional athletes (Maron
et al., 1996). According to the American Heart Association, 1 in every 350 young people has an
undetected heart condition, and sudden cardiac arrest happens among exercising youth once
every three days in the United States (AHA, 2012). According to the Washburn University
Department of Institutional Research (2011), in the fall of 2011, there were 7,303 students
enrolled at Washburn University, and of those, 271 were student athletes. Therefore, it is
possible, and maybe probable, that at least one student athlete at WU has an undetected heart
condition.
The NCAA points out that many schools require only that students fill out a family
history regarding cardiac problems and have a qualified provider listen to their hearts. They also
report that heart disorders are more common than might be expected in a population group that is
perceived to be healthy, such as student athletes. Due to its sudden and often unrecognized
nature, the epidemiologic characteristics of SCD are difficult to determine with precision,
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nevertheless, estimates can be made. Survival is estimated at <20% for patients presenting outof-hospital with VF, and <10% overall for patients presenting with out-of-hospital SCD (Rhea,
Eisenberg, & Sinibaldi, 2004). An ECG can only detect 60% of those at risk for sudden cardiac
death. There are some conditions that cannot be detected with an ECG. Until further testing is
available, ECG is the best and most cost-effective tool to detect those at risk.
The Sudden Death in Athletes U.S. Registry is maintained by Dr. Barry Maron of the
Minneapolis Heart Institute Foundation. The data compiled in this important registry helps to
clearly define the causes of sudden death in U.S. Athletes. It has been proven through this
registry that the leading cause of sudden cardiac arrest and death in this population remains
HCM (Hypertrophic Cardiomyopathy Association [HCMA], 2009). The registry includes 1,866
US athletes between the ages of 8 and 39 who participated in 38 different sports and who died
suddenly or survived cardiac arrest. Of the deaths, 56% were due to cardiovascular disease.
HCM in the general population may occur in as many as one in every 500 individuals. According
to Maron (HCMA, 2009), among the 1,049 deaths due to cardiovascular disease, the highest
number of events in a single year was 76, with an average of 66 events per year during the last
six years of data collection for the registry.
Current Recommendations
Although routinely practiced in Europe, promoted by the International Olympic
Committee, and mandated in Italy, pre-participation screening including 12-lead ECG is not
commonly performed in competitive collegiate athletes in the US. Current recommendations for
cardiovascular screening call for a careful history and physical examination performed by a
knowledgeable health care provider. According to Subasic (2010), screening of athletes prior to
participation in competitive sports usually falls short of recommended guidelines. Many schools
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require only that a student fill out a family history regarding cardiac problems and have a
physician listen to their hearts. Poorly defined legislation and the absence of a national standard
for sports physicals have contributed to the inadequate health screenings of athletes. Currently,
the NCAA requires all student-athletes beginning their initial season of eligibility and students
who are trying out for a team to undergo a medical examination before engaging in any physical
activity with the team, and each subsequent year, an updated medical history is administered
(NCAA, 2012). The NCAA required screenings for student athletes currently includes a
comprehensive personal and family medical history, physical examination, and appropriate
additional diagnostic testing, if warranted. Many NCAA institutions also offer an
electrocardiogram (ECG) and/or echocardiogram as part of an athlete’s heart screen, although it
is not a requirement (NCAA, 2012).
Issues related to the methodology and justification for pre-participation screening,
including use of the 12-lead electrocardiogram (ECG), has become a complex area of debate.
Traditionally, member institutions of the NCAA have been independently responsible for their
own pre-participation evaluation process and the design of the institutional screening history and
physical examination (AHA, 2007, p. 7). Currently, the AHA panel does not believe it to be
either prudent or practical to recommend the routine use of tests such as 12-lead ECG or
echocardiography in the context of mass, universal screening (AHA, 2007). Clearly, the role of
routine ECG screening in the United States to prevent SCD is not settled and will require more
data and debate.
Effectiveness of ECG in Prevention
Broad-scale ECG screening has not been tested or implemented in the United States,
although some US studies have suggested that ECG screening may be cost-effective on the basis
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of estimated cost per year of lives saved. According to Phend (2009), the addition of a 12-lead
ECG screening would cost just $300 per year of life saved. Another study by Magalski, et al.
(2011) reported that recent data in high school and college athletes demonstrated that ECG is
associated with 2.1 life-years saved per 1000 athletes, an incremental cost of $89 per athlete, and
a cost-effectiveness ratio of $42,900 per life-year saved. Compared with no screening, use of
ECG with history and physical examination also was associated with 2.6 life-years saved per
athlete, an incremental cost of $199, and a cost-effectiveness ratio of $76,100 per life-year saved
(Magalski, 2011).
The sensitivity of ECG among elite and professional athletic populations is estimated to
range from 51% to 70%, and specificity is reported in the range of 62% to 98%. Additionally,
mandatory screening of Japanese schoolchildren since 1973 has demonstrated a greater
sensitivity of ECG versus history and physical examination. (O’Connor & Knoblauch, 2010).
Lawless, the team doctor for U.S. Figure Skating and a cardiology consultant to Major
League Soccer (MLS), said that taking a regular history and physicals of athletes may only detect
a disease such as HCM two to six percent of the time, while the ECG can pick it up 50 to 80
percent of the time (Subasic, 2010). Lawless also reports that ECG readings are abnormal in 95%
of patients with HCM and provide the ability to suspect other cardiac abnormalities associated
with sudden death. In Europe, and particularly Italy, universal ECGs are performed on athletes
and are heavily promoted as having reduced the incidence of sudden death (Subasic, 2012). Italy
pioneered nationwide screening of athletes with ECG in the late 1990s, and subsequently
revealed a 90% drop in sudden cardiac events after the screening program began (Isaacson, 2010,
Phend, 2009). Competitive Italian athletes undergo required PPE and ECG, with ECG reportedly
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demonstrating 77% greater power to detect HCM than history and physical examination alone
(O’Connor & Knoblauch, 2010).
The European Society of Cardiology and the International Olympic Committee have
recommended the addition of ECGs to pre-participation sports physicals for college athletes. An
ECG is required prior to sports participation in the International Olympics and is practiced by
92% of professional sports teams in the United States (Subasic, 2010,). In 2004, the International
Olympic Medical Committee issued a screening protocol including ECG for Olympic athletes
(American Academy of Pediatrics [AAP], 2012). In 2005, the European Society of Cardiology
(ESC) issued a consensus statement on cardiovascular pre-participation screening of all young
competitive athletes younger than 35 years, recommending a 12-lead ECG in addition to focused
history and physical examination (AAP, 2012, Malhotra et al., 2011). The AHA recommends
only history and physical without ECG (AHA, 2007, Malhotra et al., 2011).
An ECG may show QT interval, ST-segment or T-wave changes, conduction
abnormalities and ventricular hypertrophy. Lawless (2010) presented research to the AHA
supporting the AHA's belief that universal ECG tests may result in a high rate of false-positive
results, prompting unnecessary follow-up tests (Isaacson, 2010). Though ECGs are not as
thorough as imaging tests like an echocardiogram, which shows a 3-D view of the heart, they are
cheaper and easier to conduct on a wider basis.
A recent study found that although ECG screening results in many false positives
resulting in additional tests, the overall cost per diagnosis of adding ECG screening is similar to
that of history and physical screening alone (Malhotra et al., 2011). The study at the University
of Virginia, conducted over 5 years, included all 1,473 of their competitive athletes, and each
athlete was screened with a history, physical and with ECGs using European Society of
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Cardiology (ESC) guidelines with follow-up testing as dictated by clinical symptoms and ECG
findings. The authors demonstrated that adding ECGs to an athletic screening program
discovered significant pathology in college athletes (Malhotra et al., 2011). In the study, history
and physical alone uncovered five significant cardiac abnormalities. Additional testing with
ECGs confirmed eight significant cardiac abnormalities that were not found by history and
physical alone (Malhotra et al., 2011).
Consideration must also be given to the interpretation of ECGs. Computer-generated
interpretations of ECG’s are often inaccurate and can result in inappropriate treatment (Anh,
Krishnan, & Bogun, 2006) Accurate provider over-reading is necessary to avoid such errors.
Over-reading of 12 lead ECG’s is required to circumvent errors of computerized ECG
interpretation. Cardiologists as primary readers more often corrected the misinterpreted ECGs as
compared with internists, emergency physicians, or other specialists (94% vs. 71%, P < .001)
(Anh, Krishnan, & Bogun, 2006). Not only should the cardiologist review the ECG, but should
also have access to any relevant clinical information to assist in interpretation.
Recent data collection from a local hospital revealed it costs $17-$20 for a 12 lead ECG
with interpretation from a cardiologist and report (CPT 93000); the ECG charge was $44.25,
reimbursement from Medicare was $17.70, and was $20 from commercial insurance carriers
(personal communication, Sheryle D’Amico, MHA, VP Physician Division, Lawrence Memorial
Hospital, June 5, 2012). Additionally, college students are required to carry health insurance, so
the cost for the university and the student athlete could be minimal, as many insurers will cover
80 to 100 percent of the costs.
Finally, the goal of any screening effort is to identify individuals at risk; unaffected or
low-risk individuals should be cleared, and conversely, those affected should be appropriately
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restricted, counseled, and treated. No screening protocol has yet proven to be effective in their
role or validated as highly effective. The AHA has documented a 12-element recommendation
for pre-participation screening of competitive athletes (Table 1). This process will minimize
unnecessary variation.
Implementation Plan
There are many options to explore to incorporate ECG screenings as part of PPE for
student athletes at WU. The primary goal of this project will be obtaining an ECG machine and
necessary equipment to properly screen current and future student athletes as part of their PPE.
Initially, I plan to collaborate with the Washburn University Department of Kinesiology Athletic
Training Education Program to review proposed guidelines and formulate a clinical guideline
that can be applied to WU. Statistics for student athletes show that in the fall of 2011 there were
271 student athletes at WU. If WU decided to implement ECG screenings for all new or transfer
athletes, that would be about 68 athletes per year. Collaboration with the WU Athletic Training
Education Program, and other community resources such as a local hospital, and/or the medical
director for WU Athletic Department will help meet project goals. This collective effort will
facilitate establishment of a collaborative agreement for over-read of ECGs, and referrals for
those at higher risk.
Solicitation of funds for EKG equipment and necessary supplies could include a proposal
that the Washburn University Athletic Department purchase all necessary ECG equipment
necessary for initiating and implementing, as well as continuation of ECG screenings as part of
the PPE for student athletes. Another option would be to collaborate with WU Department of
Kinesiology Athletic Training Program and the WU Athletic Department, along with other
community resources such as local hospitals, to explore the possibility of a community outreach
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program with Washburn University that would include a donation of the necessary ECG
equipment and to absorb the cost of ECG screening and interpretation by their contracted
clinicians as part of community outreach endeavors. Other potential options for funding,
including, but not limited to: a Curriculum Development Grant, WU Alumni donation, WU
Endowment Association donation, WUSON alumni donation, WU Athletic Department
donation, Stormont Vail HealthCare and/or St. Francis Health Center Endowment Association
donation, personal donations, fundraising efforts, etc. Additionally, securing a donation of ECG
equipment and materials as part of a community outreach project collaboration with WU Athletic
Department could ensure screening all student athletes with an ECG as part of their PPE, and
could help reduce the risk of SCD in student athletes.
This proposal also recommends that all providers in the WU Athletic Training Education
Program obtain education and training on proper ECG placement. It is recommended that
continuing education for providers include courses related to cardiovascular issues in student
athletes. It is suggested that the WU Athletic Training Education Program students could be
required to spend at least 2 hours in the WU Athletic Training facility doing ECGs during
physical exam screenings for student- athletes. A simplified algorithm could be used, and may
help clinicians correctly identify both suspected electrode misplacements and artifacts
(Baranchuk et al., 2009, p. 67). Basic ECG interpretation course for all medical providers at WU
should be required. I have included an example of an ECG competency checklist as a potential
checklist to utilize for the WU Athletic Training Education Program course curriculum. Once
approval is given by the WU Athletic Training Education Department director, education and
training will begin for the staff on the clinical practice guidelines and associated ECG
competency training utilizing the 12 lead ECG competency check-list as a guide. WU Athletic
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Training Education Program staff and students will watch two provided videos on ECG
placement and performance (Appendix D), and will have the opportunity to practice their skills
prior to ECG competency skills check-off. A 12 lead ECG instructive poster will be placed in all
exam rooms for reference (Appendix E, cardiacscience.com, 2012).
Project Outputs
The first project output will be providing a training packet and guidelines for WU
Athletic Training Education Program faculty and students. The guidelines will include an
updated health history and physical exam form, and ECG screening and referral
recommendations.
Next, funding options for ECG equipment and supplies will be explored. Funding
requests would include ECG equipment and supplies. A proposed budget has been prepared and
it is projected that the funds would cover necessary equipment and supplies for 2 years expenses
for training athletic training students on proper ECG placement and performance, and
performing ECGs for student athletes for their PPE. (Appendix G). This information, including
the prosed budge, will be submitted with a curriculum development grant for the 2012-2013
academic year.
If approved, and funding is secured to purchase ECG equipment and supplies, WU
students enrolled in KN 492: Clinical Experiences in Athletic Training- General Medical, will be
educated on the guideline and trained on proper ECG placement and performance, with a
mandatory competency implemented. An example of an ECG placement and performance
competency is included in Appendix F; it will need slight modification for WU Athletic Training
Education Program specifics. WU Athletic Training Education Program staff will submit the
ECGs to Dr. Messmer or other appropriate clinician for final review and further
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A Proposal for ECG’s in pre-participation physical examinations (PPE) for college athletes
recommendation. It will be suggested that Dr. Messmer, the medical director for the WU
Athletic Department, be up to date and comfortable with 12 lead ECG interpretation prior to
implementing ECG screenings as part of the PPEs for student athletes, so that proper 12 lead
ECG interpretations can be attempted. The services of a local cardiologist should be secured in
order to provide accurate over-read of all ECGs to determine those individuals at higher risk and
in need of follow-up.
Conclusion
The knowledge and research about SCD and ECG screenings in student athletes remains
controversial due to cost containment limitations, and thus will warrant further research on costeffectiveness in smaller university settings before widespread implementation is initiated. This
project should help guide future research and optimally aid in the implementation of ECG
screenings for all student athletes at the college level. ECG screening of U.S. college athletes can
uncover significant cardiac pathology not discovered by history and physical alone. Although
ECG screening also results in many false positives resulting in additional tests, the overall cost
per diagnosis of adding ECG screening is similar to that of history and physical screening alone.
Early detection of clinically significant cardiovascular disease through pre-participation
screening permits timely therapeutic interventions that may prolong life. While the results of an
ECG may require additional evaluation and testing by a medical provider, this author believes
that the benefit of this potentially life-saving screening outweighs this concern. Endorsement of
required ECG screenings in college athletes is pertinent and come from organizations such as the
AHA, ACSM, NATA, and NCAA in order for collegiate institutions to implement ECGs
nationally.
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Dissemination Plan
Project defense presentation to the WU School of Nursing Faculty is planned for
December 11, 2012. In addition, if funding is secured to begin this project, a presentation will be
planned in Fall 2013 to a group of WU Athletic Training Education Program staff and students
regarding ECG screenings as part of pre-participation physical examinations for college athletes.
Discussion will include the need for further research and consideration by university institutions
to implement ECGs for SCD screening as part of PPE in all college athletes. Discussions will
also include whether the endorsement of required ECG screenings in college athletes should
come from organizations such as the AHA, ACSM, NATA, and NCAA in order for collegiate
institutions to implement ECGs nationally. Final project results with be shared with the WU
Department of Kinesiology Athletic Training Education Program, the WU Athletic Department,
and the WU School of Nursing.
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References
AHA/ACSM Joint Position Statement: Recommendations for Cardiovascular Screening,
Staffing, and Emergency Policies at Health/Fitness Facilities. (1998, June). Medicine &
Science in Sports & Exercise, 30, 1009-1018. Retrieved from
http://www.acsm.org/access-public-information/position-stands
American Academy of Pediatrics. (2012). Pediatric Sudden Cardiac Arrest. Retrieved from
http://pediatrics.aappublications.org/content/early/2012/03/21/peds.20120144.full.pdf+html
American College of Cardiology Foundation/American Heart Association Task Force . (2011).
2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic
Cardiomyopathy: Executive Summary. A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines. Retrieved
from http://circ.ahajournals.org/content/124/24/2761.full
American Heart Association. (2007). Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007
Update. A Scientific Statement from the American Heart Association Council on
Nutrition, Physical Activity, and Metabolism (Scientific Statement). Retrieved from
Hypertrophic Cardiomyopathy Association: http://www.4hcm.org
American Medical Society for Sports Medicine. (2010). Pre-participation Physical Evaluation
Form. Retrieved from http://www.amssm.org/Publications.html
American Nurses Association. (2001). Code of Ethics. In Code of Ethics for Nurses. Retrieved
from
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http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/EthicsSt
andards/CodeofEthics.aspx
Anh, D., Krishnan, S., & Bogun, F. (2006). Accuracy of electrocardiogram interpretation by
cardiologists in the setting of incorrect computer analysis. Journal of Electrocardiology,
39, 343-345. doi:
http://0dx.doi.org.topekalibraries.info/10.1016/j.jelectrocard.2006.02.002
Associated Press. (2012). D. Venkatesh collapses, dies. Retrieved from
http://espn.go.com/sports/soccer/story/_/id/7721223/d-venkatesh-bangalore-mars-diescollapsing-field
Associated Press. (2012). Fabrice Muamba facing long recovery. Retrieved March 23, 2012,
from http://espn.go.com/sports/soccer/story/_/id/7726903/bolton-fabrice-muamba-saidface-long-period-recovery
Baranchuk, A., Shaw, C., Alanazi, H., Campbell, D., Bally, K., Redfearn, D. P., Simpson, C. S.,
& Abdollah, H. (2009, February). Electrocardiography Pitfalls and Artifacts: The 10
Commandments. Critical Care Nurse, 29(1), 67-73. doi: 10.4037/ccn2009607
Casa, D. J., Guskiewicz, K. M., Anderson, S. A., Courson, R. W., Heck, J. F., Jimenez, C. C.,
McDermott, B. P., ... Walsh, K. M. (2012, February). National Athletic Trainers’
Association Position Statement: Preventing Sudden Death in Sports. Journal of Athletic
Training, 47, 96-118. Retrieved from http://www.nata.org/position-statements
Hendrick, B. (2011). Heart-Related Deaths in College Athletes: How Common? Each Year,
About One in 44,000 Collegiate Athletes Has Sudden Cardiac Death, Study Finds.
Retrieved from http://www.webmd.com/heart-disease/news/20110404/heart-relateddeaths-in-college-athletes-how-common
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Hypertrophic Cardiomyopathy Association. (2009). Sudden Death in Athletes Registry.
Retrieved from http://www.4hcm.org/hcma-outreach-events/sudden-cardiac-arrest-inathletes/40256-sudden-death-in-athletes-registry.html
Isaacson, M. (2010). Sometimes, there are no answers; Adams’ death raises issue of medical
testing. Retrieved from
http://sports.espn.go.com/chicago/nfl/columns/story?columnist=isaacson_melissa&id=48
37804
Magalski, A., McCoy, M., Zabel, M., Magee, L.M., Goeke, J., Main, M., Bunten, L., Reid, K., &
Ramza, B. (2011, June). Cardiovascular Screening with Electrocardiography and
Echocardiography in Collegiate Athletes. The American Journal of Medicine, 124, 511518. DOI: 10.1016/j.amjmed.2011.01.009
Malhotra, R., West, J., Dent, J., Luna, M., Kramer, C. M., Mounsey, J. P., Battle, R., ...
Mahapatra, S. (2011, May). Cost and yield of adding electrocardiography to history and
physical in screening Division I intercollegiate athletes: A 5-year experience. Heart
Rhythm Society, 8, 721-727. doi: 10.1016/j.hrthm.2010.12.024
Maron, B. J., Thompson, P. D., Puffer, J. C., McGrew, C. A., Strong, W. B., Douglas, P. S.,
Clark, L. T., ... Epstein, A. E. (1996). Cardiovascular Preparticipation Screening of
Competitive Athletes: A Statement for Health Professionals from the Sudden Death
Committee (Clinical Cardiology) and Congenital Cardiac Defects Committee
(Cardiovascular Disease in the Young), American Heart Association. Circulation, 94,
850-856. doi: 10.1161/01.CIR.94.4.850
Minneapolis Heart Institute Foundation. (2012 ). http://www.mplsheart.org
National Collegiate Athletic Association (NCAA) website. (2012). http://www.ncaa.org
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O’Connor, D. P., & Knoblauch, M. A. (2010). Electrocardiogram Testing During Athletic
Preparticipation Physical Examinations. Journal of Athletic Training, 45 (3), 265-272.
O’Connor, F. G., Kugler, J. P., & Oriscello, R. G. (1998). Sudden Death in Young Athletes:
Screening for the Needle in a Haystack. Retrieved from
http://www.aafp.org/afp/1998/0601/p2763.html?printable=afp
Phend, C. (2009). AHA: ECG Cost-Effective for Screening Student Athletes. Retrieved from
http://www.medpagetoday.com/MeetingCoverage/AHA/17030
Rhea, T. D., Eisenberg, M. S., & Sinibaldi, G. (2004, October). Incidence of EMS-treated out-ofhospital cardiac arrest in the United States. Resuscitation, 63(1), 17-24.
Shuler, P. A. (2000, October). Evaluating Student Services Provided by School-Based Health
Centers: Applying the Shuler Nurse Practitioner Practice Model. Journal of School
Health, 70, 348-352. Retrieved from http://0search.proquest.com.topekalibraries.info/nursing/
Subasic, K. (2010, February ). Athletes at Risk for Sudden Cardiac Death. The Journal of School
Nursing, 26(1), 18-25. doi: 10.1177/1059840509353323
Wong, B. (2011). College athletes’ risk of sudden cardiac death found higher by UW study.
Retrieved from
http://seattletimes.nwsource.com/html/localnews/2014677660_ncaacardiac04m.html
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Table 1
The 12-Element AHA Recommendations for Preparticipation Cardiovascular Screening of
Competitive Athletes
Personal History
Family History
Physical Examination
Exertional chest pain/discomfort
Premature death (sudden and Heart murmur
unexpected, or otherwise)
before age 50 years due to
heart disease, in 1 relative
Unexplained syncope/nearDisability from heart disease Femoral pulses to exclude
syncope
in a close relative <50 years
aortic coarctation.
of age
Excessive exertional and
Specific knowledge of certain Physical stigmata of
unexplained dyspnea(shortness of cardiac conditions in family
Marfan syndrome
breath)/fatigue, associated with
members*
exercise
Prior recognition of a heart
Brachial artery blood
murmur
pressure (sitting position,
preferably in both arms)
Elevated systemic blood pressure
Note: In addition the HCMA suggests that children and young adults who have been adopted or
are in any way unsure about their family history be viewed as potentially at risk and follow up
with a comprehensive cardiac evaluation.*Hypertrophic or dilated cardiomyopathy, long-QT
syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias.
At the discretion of the examiner, a positive response or finding in any 1 or more of the 12 items
may be judged sufficient to trigger a referral for cardiovascular evaluation.**Cardiovascular
screening should include ECG, echocardiogram, possible stress test, possible cardiac MRI and
follow up plan as needed. In the opinion of the HCMA, these tests should be conducted by a
cardiac professional, not a general practitioner or pediatrician (HCMA, 2009).
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Figure 1
Figure 1. Causes of sudden cardiac death in young competitive athletes (median age 17), based
on systematic tracking of 158 athletes in the United States, primarily from 1985 to 1995. Ao
indicates aorta; LAD, left anterior descending coronary artery; AS, aortic stenosis; C-M,
cardiomyopathy; ARVD, arrhythmogenic right ventricular dysplasia; MVP, mitral valve
prolapse; CAD, coronary artery disease; HCM, hypertrophic cardiomyopathy; ↑, increased.
Adapted from Maron et al with permission of the American Medical Association.
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Appendix A
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Appendix B
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Appendix C
The American Medical Society for Sports Medicine (AMSSM) PPE
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Appendix D
12 Lead ECG Placement Part I
http://www.youtube.com/watch?feature=player_detailpage&v=eA5HmQSMGHE
12 Lead ECG Placement Part II
http://www.youtube.com/watch?feature=player_detailpage&v=TFcyiCKyaZ4
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Appendix E
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Appendix F
Washburn University
Department of Kinesiology
Adult 12 LEAD ECG COMPETENCY CHECKLIST
NAME_______________________________ DATE____________________
Competent Performance
Adult 12-Lead EKG Performance

Check cable & lead wire for disconnected wires.

Position patient and identify limb sites.

Prepare skin for electrode placement to assure adequate
tracing as needed:
 Cleanse with soap & water, and/or
 Abrade skin using washcloth or 4x4, and/or
 Apply skin prep, and/or
Trim hair with clippers (no razor)
Apply electrodes to patient securely in appropriate
position; fasten lead wires per 12-Lead ECG Procedure.
Leave limb electrodes in place.
Place V leads per Right-Sided ECG Procedure:
 V1 - 4th Intercostal Space (ICS), right sternal border
 V2 - 4th ICS, left sternal border
 V4 - 5th ICS left midclavicular line
 V3 - Equidistance between V2R and V4R
 V5 - horizontal level of V4R at the left anterior
axillary line
 V6 - horizontal level of V4R at the left midaxillary
line
Turn on ECG machine









(Verbalization or Return Demonstration)
Yes (V/D) No Validator Comments
Demographic data should be entered at the top of the
ECG.
 Last Name
 First Name
 Gender
 Date of birth
 Age
Check for accuracy
Assess tracing quality by reviewing ECG monitor and
printed ECG. Perform the following steps for
troubleshooting:
 Check for negative deflection in lead 1 which
would indicate right and left arm lead reversal.
 Review ECG for missing lead(s).
Acquire (print)ECG image
Rev 12/12
Signature of Validator
Initials
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Appendix G
Proposed ECG Expense Budget
ECG Equipment/Supplies
[Fall 2012]
Budget Actual
GE Mac 1200 ECG Machine (inlcudes ECG cable & Leads, Electrodes and Operations Manual)- recertified, preowned
ECG cart
ECG Recording Paper (Chart fan fold 216x280x150 Red); $7.52/pk; $75.26/case
Difference ($) Difference (%)
1,850
1,850
undefined
300
300
undefined
75
75
undefined
105
105
undefined
85
85
undefined
206
206
undefined
*10pks/cs- Ref. 2009828-061- Graphic Controls-GE Healthcare Recording Paper
ECG Electrodes: Red Dot Rest Tab Style - EKG 100/bag; 40 bags/case ($2.62/bag); $104.80/case
Freight/Material Shipping/Handling
Taxes (8.525%) x $2,415.00
Total Expenses
Budget Actual
$
-
$ 2,621
Difference ($) Difference (%)
$
2,621
undefined
46