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Screening for cardiac risk in young adults – a poor way to save lives

This one has cropped up a lot over the years. See this thread from @CRY_UK inviting people between 14-35 to get free ECG heart screenings

There’s a handy link to a website to get tested, with handy locations all over the uk.

I mostly see the red mist at this point.

I’ve also seen mass screening events being offered at football matches (heart valve disease screening with stethoscope on that occasion) and the like.

Single issue charities are going to pursue a single issue, I get this. And of course we all like to save lives and the like. What’s not to like. However as we all know screening rarely saves lives – it mostly (slightly) changes cause specific mortality. Screening always does harm in addition to the good it may do, sometimes directly sometimes indirectly.

However you look at this – screening, case finding, fishing, giving people choice….its screening. However this is spun Im struggling to see this as not screening. It is an organised process to invite people who think they are well for a test of some sort and through the results of that test give them a diagnosis.

That is screening

So to the evidence…. 

1)

My starting point is thus the NSC position on this issue.

See here for the detailed evidence review.

That ought to be enough for most.

Obviously I’d have an expectation that anyone working on promoting screening in this space has passed, with distinction, Screening 101

2)

AAC

Maron et al published the statement from AAC. The AAC recommendations are:

“4. Mandatory and universal mass screening with 12-lead ECGs in large general populations of young healthy people 12 to 25 years of age  (including on a national basis in the United States) to identify genetic/ congenital and other cardiovascular abnormalities is not recommended for athletes and nonathletes alike (Class III, no evidence of benefit; Level of Evidence C).

5. Consideration for large-scale, general population, and universal cardiovascular screening in the age group 12 to 25 years with history-taking and physical examination alone is not recommended (including on a national basis in the United States) (Class III, no evidence of benefit; Level of Evidence C).”

3)

See the references in this BMJ press release for further detail.

Analysis: Harms and benefits of screening young people to prevent sudden cardiac death

Editorial: Preventing sudden cardiac death in athletes

News: Sole data on benefits of screening for sudden cardiac death are withheld

Some immediate thoughts and questions you might ask from different perspectives….the qs you use may be dependant on the context. Different context may lead to different questions. Use your judgement.

Dealing with false negatives. A negative will reassure, if a screened person then collapse the following week, could they complain and/or sue? Who to?

Is there evidence base for this approach? Effective? Cost effective? Its screening – where and how does this fit with Wilson Jungner criteria? All screening does harm, some screening does more good than harm etc. Back to NSC

impact on local services. What cost to go and local cardiology services for clinic appts, referrals and any downstream diagnostics?

impact on local services – additional work in general practice? I don’t think they know about this?

Will someone pick up the cost of all the false positives (likely a lot, given the numbers likely to be screened – see below re context!), be responsible for any downstream harm, be responsible for all the opportunity cost and others being denied services. This just can’t be passed on to the NHS GP

4)

See this thread based on the NEJM paper, and the accompanying Medscape article.

5)

Screening ECGs in low-risk patients are associated with increased risk of downstream cardiac testing

Commentary on Bhatia RS JAMA Intern Med 2017;177:1326–33

  • 3.6m person study
  • 22% received an ECG within 30 days of index health check (2% to 76%)
  • Patients who had an ECG were five times more likely to undergo additional cardiac evaluation than those who did not

6)

Context 1. Context is important. Roberts et al considered the incidence of Sudden Cardiac Death in Minnesota High School Athletes over 10 years.

“The incidence of SCD in athletes screened every 3 years with standard PPE during MSHSL activities is 0.24 per 100,000 athlete-years in 19 academic years”

Implication- you’ll have to screen ALOT of people to pick up a case, you might need to pick up a few cases to save a life.

On the back of available evidence, seems unlikely to be beneficial in a population of athletes. Thus making the evidential case in a wider population looks to be even harder!

Context 2Maron et al provides some interesting context.

The (not very) hidden message = there are other places we might look to save more lives

So, yes of course we also want to save lives.

But proposals like this one aren’t evidence based, may do harm, will certainly burn resources and do indirect harm to others through opportunity costs. There are better ways to achieve the objective

7). English FA study

One-off cardiac screening at age 16 failed to detect most cardiomyopathies associated with sudden cardiac deaths in adolescent footballers, study finds

Study here.

  • From 1996 2016, 11,168 adolescent athletes screened.
  • 42 athletes (0.38%) were found to have cardiac disorders that are associated with sudden cardiac death.
  • 225 athletes (2%) with congenital or valvular abnormalities were identified.
  • After screening, there were 23 deaths from any cause, of which 8 (35%) were sudden deaths attributed to cardiac disease.
  • Cardiomyopathy accounted for 7 of 8 sudden cardiac deaths (88%).
  • Six athletes (75%) with sudden cardiac death had had normal cardiac screening results.
  • The mean time between screening and sudden cardiac death was 6.8 years.
  • On the basis of a total of 118,351 person-years, the incidence of sudden cardiac death among previously screened adolescent soccer players was 1 per 14,794 person-years (6.8 per 100,000 athletes)

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