Sports Cardiology and the Athlete's Grey-Zone Electrocardiogram: Screening, Disqualification and the Cost of Both Errors

Abstract

Preparticipation cardiac screening in athletes has converged on ECG-based interpretation criteria specifically because they
cut the false-positive rate dramatically: in one prospective study of 4,812 high-school athletes, history and physical
examination alone produced a 50% false-positive rate, versus 4% for ECG interpreted under Seattle or European Society of
Cardiology criteria, while still detecting 70% of the 23 clinically significant abnormalities present in the cohort. A separate
psychological-outcomes study of 1,192 NCAA athletes found that roughly 3% of athletes received a false-positive result and
only 0.3% had a genuine cardiac disorder, and that anxiety levels were similar between athletes with normal and
false-positive results -- though false-positive athletes reported more worry specifically about disqualification and future
cardiac risk, and 70% of all athletes surveyed said they would still rather know about a possible abnormality than compete
without that knowledge. The remaining error this review addresses is economic rather than psychological: a cost-effectiveness
analysis of the US screening model put the cost per life saved at $10.6 to $14.4 million over a 20-year program, roughly four
times the per-athlete screening cost of an established Italian programme with a materially lower per-outcome cost. This
review sets out both errors -- the false positive that disqualifies a healthy athlete, and the resource cost of avoiding the false
negative that misses a genuinely at-risk one -- as two sides of the same screening design problem.