Electrocardiogram screening in adolescent athletes - evaluating clinical protocols, outcomes, and cost-effectiveness a systemic literature review

Table 1 Quantitative studies included in the final systematic review analysis (n = 14)

Ref.	Country	Population/region	Design	Screening modality	Sample size	Primary outcome	Key findings/quantitative result
Corrado et al[26], 2006	Italy	Competitive athletes, Veneto region	Prospective cohort	H&P + ECG (mandatory)	42386	SCD incidence	89% SCD reduction (3.6/100000 to 0.4/100000 person-years)
Papadakis et al[25], 2011	United Kingdom	Voluntary youth program	Prospective registry	H&P + ECG ± TTE	32561	Diagnostic yield	0.4% serious cardiac findings; 80% detected by ECG
Harmon et al[1], 2016	United States	HS and college athletes	Observational registry	H&P only	2046000	SCD incidence	1.21/100000 person-years; low sensitivity (< 20 %)
Drezner et al[24], 2013	United States	Collegiate athletes	Comparative	H&P vs ECG ± TTE	11168	Sensitivity/specificity	ECG 94%/93%; false positives < 5 % (Seattle criteria)
Leslie et al[30], 2012	United States	Modeled athlete cohort	Economic model	ECG ± TTE vs H&P		Cost-effectiveness	42000 dollars per life-year saved (ICER)
Malhotra and Sharma[5], 2018	United Kingdom	Elite adolescent athletes	Prospective 20-year follow-up	H&P + ECG	11168	Long-term SCD prevention	0.38/100000 person-years; 80% of SCD etiologies identified
Wheeler et al[11], 2010	United States	Modeled United State athletes	Economic simulation	H&P vs ECG ± ECHO		Cost per life saved	> 10 thousand dollars/life year saved (early); improved < 7 thousand dollars with newer criteria
Steinvil et al[22], 2011	Israel	National cohort	Retrospective trend	Mandatory ECG	National registry data over 12 years	SCD trend	No statistically significant SCD reduction
Baggish et al[15], 2017	United States	Collegiate athletes	Mixed observational	H&P ± ECG	510	Diagnostic yield	6 pathologies found only by ECG; cost per case approximately 11000 dollars
Moulson et al[33], 2021	Canada	Multicenter athletes	Prospective pilot	H&P + ECG	2120	Feasibility/FP rate	FP 3.2%; supports international criteria use
Petek and Baggish[23], 2020	United States	Sports-medicine clinicians	Survey-based quantitative	H&P ± ECG	125	Implementation feasibility	68% cited training barriers; 72% favored ECG inclusion
Hernelahti et al[36], 2008	Nordic	National registries	Policy analysis/quantitative comparison	H&P vs proposed ECG		Policy outcome	Cost-burden model > 150 thousand dollars/life year saved; ECG not adopted
Dhutia et al[12], 2021	United Kingdom	Health-policy review	Quantitative + ethical	H&P + ECG ± genetic		Cost/risk model	Supported selective screening in high-risk sports
Asif et al[38], 2014	United States	HS athletes ± parents	Mixed-methods (survey + rates)	H&P + ECG	410	Psychological/compliance data	92% reported reassurance post-ECG; FP 4%

HS: High school; H&P: History and physical examination; ECG: Electrocardiogram; TTE: Transthoracic echocardiogram; ECHO: Echocardiogram; SCD: Sudden cardiac death; FP: Feasibility probability; ICER: Incremental cost-effectiveness ratio.

Table 2 Qualitative and mixed-methods studies included in final synthesis (n = 13)

Ref.	Country	Population/region	Design/approach	Focus area	Key themes/findings
Asif et al[38], 2014	United States	High-school athletes ± parents	Survey + focus groups	Psychologic impact of ECG screening	(1) False-positive ECGs did not raise anxiety; and (2) Most athletes felt safer and more confident resuming play
Dhutia et al[12], 2021	United Kingdom	Policy experts/clinicians	Narrative review + ethical analysis	Ethical proportionality of mass screening	Advocates context-specific, risk-proportionate screening and shared decision-making
Petek and Baggish[23], 2020	United States	Sports medicine physicians/ATs	Semi-structured survey	Implementation feasibility	Training deficits, variable institutional support, and limited follow-up access identified as key barriers
Hernelahti et al[36], 2008	Nordic countries	Public-health authorities	Policy comparison/qualitative	National screening policy	Nordic taskforce declined national ECG program citing cost, limited yield, and equity concerns
Baggish et al[15], 2017	United States	Collegiate athletes	Mixed-methods observational	Clinical utility + attitudes	(1) ECG added clinical reassurance; and (2) Athletes and clinicians viewed program as acceptable and feasible
Moulson et al[33], 2021	Canada	Multicenter pilot participants	Prospective + feasibility interviews	Workflow + perception	(1) Positive reception; (2) 3.2 % false positives; and (3) Supports standardized interpretation criteria
Steinvil et al[22], 2011	Israel	Policymakers/registry review	Mixed quantitative-qualitative	Policy evaluation	(1) National mandate showed no clear SCD decline; and (2) Prompted debate about cost-benefit and implementation
Harmon et al[35], 2015	United States	Collegiate sports programs	Qualitative analysis of registries	Health-system disparities	Highlighted racial/socioeconomic inequities in SCD events and screening access
Drezner et al[34], 2017	United States	Athletic trainers + team physicians	Survey study	Knowledge and training attitudes	78% desired ECG training; 64% supported integration if cardiology follow-up available
Malhotra and Sharma[5], 2018	United Kingdom	Elite adolescent athletes	Thematic follow-up interviews	Emotional impact of disqualification	(1) Temporary disqualification caused distress; and (2) Long-term acceptance after counseling is possible unforeseen expense
Sharma et al[32], 2017	International	Consensus experts/societies	Delphi consensus process	Guideline development	Produced International ECG interpretation criteria, standardized approach reducing false positives
Roberts et al[37], 2015	United States	Sports medicine professionals	Narrative review/ethical discourse	Screening philosophy	(1) Compared ECG screening with other public-health screenings (Pap, PSA); and (2) Discussed utilitarian ethics
Corrado et al[39], 1998	Italy	Young athletes/families	Retrospective interviews	Psychosocial effects of disqualification	(1) Emotional burden significant; and (2) Counseling mitigates risk of depression/suicide in disqualified youth

AT: Athletic trainer; ECG: Electrocardiogram; SCD: Sudden cardiac death; PSA: Prostate-specific antigen.