Available online at www.sciencedirect.com

ScienceDirect Journal of Electrocardiology xx (2015) xxx – xxx www.jecgonline.com

Review

Best practices for ECG screening in children☆ Victoria L. Vetter, MD, MPH⁎ The Children's Hospital of Philadelphia, Philadelphia, PA, USA Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA

Abstract

Screening for conditions associated with sudden cardiac arrest in the United States (US) is aimed at high school athletes in most states and utilizes a preparticipation history and physical form that is not standardized across the US. In Italy, data have shown that their incidence of sudden cardiac arrest has decreased significantly after implementation of an electrocardiographic-based screening program including history and physical exam. The American Heart Association recommendations do not include an electrocardiogram. A recent AHA statement has suggested that those screening athletes should consider all children of similar ages in the selected venue, but still should not include an electrocardiogram. A number of models of screening are presented along with a best practice recommendation for further evaluation and study. © 2015 Elsevier Inc. All rights reserved.

Keywords:

Electrocardiography; Pediatrics; ECG screening; Sudden cardiac arrest; Sudden cardiac death

Introduction Sudden cardiac arrest (SCA) or sudden cardiac death (SCD) is often stated to be a tragic, but infrequently occurring event that does not meet the criteria for a screening program. The missing factor in all of the discussions and debates on this issue continues to be evidence [1–7]. It is estimated that SCA claims the lives of approximately 2000 children and adolescents each year in the United States (US) [8], accounting annually for approximately 5% of all childhood deaths in children aged 5–19 years, with a reported incidence of 0.6–8/100,000 [9–12]. It has been stated that between 0.2 and 0.7% of the young population has a condition associated with SCD [7]. There is no true national registry or reporting system in the US resulting in estimates often derived from media reports that have been shown to capture only half of the actual events [13]. The National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC) have just initiated a joint pilot project in 10 states that will eventually provide evidence as to the numbers and circumstances of sudden death in youth [14]. In the meantime, the apparent relative infrequency of these events does not diminish their impact upon families and communities, nor diminish the importance or relevance of this as a public health issue of importance to those who care for children. Further, SCA has a low survival rate ☆

For PPE ECG Symposium. ⁎ Cardiology Division, 8NW, The Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA 19104. E-mail address: [email protected] http://dx.doi.org/10.1016/j.jelectrocard.2015.03.004 0022-0736/© 2015 Elsevier Inc. All rights reserved.

(4–21%) that necessitates re-evaluation of our current screening and prevention practices [15]. Currently, screenings using an ECG are being performed across the country by a variety of groups, often in a non-standardized manner without evaluation of outcomes. We have evaluated a number of screening models used in the US as well as the Italian model and recommend a currently applicable best practice model for children to be considered for use in the US while additional data are being collected in an attempt to implement a preventive public health initiative that can be tested and modified going forward. An effective method to identify those at risk is a first step toward the prevention of these untimely deaths.

Etiology of sudden cardiac arrest in children In children, SCA is associated with structural cardiac abnormalities including hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, dilated and other cardiomyopathies, coronary artery anomalies, other congenital heart defects, and electrical cardiac conditions including long and short QT syndromes, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, Wolff–Parkinson–White syndrome, and others including myocarditis, Marfan syndrome, drugs, and commotio cordis [9,16]. The differences in the proportion of cases from two different datasets are shown in Fig. 1 and illustrate the issues of evidence that currently exist. In the Parent Heart Watch database, there are significantly more

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cases of electrical causes of death such as long QT syndrome compared to the US National Registry database [12,17]. Purpose of screening Discussions of screening are often confused by the issue of whether the purpose of cardiac screening is to identify those potentially at risk for SCD or to prevent SCD. It has been stated that the ultimate objective of preparticipation screening of athletes is the recognition of ‘silent’ cardiovascular abnormalities that can progress or cause sudden cardiac death [18]. Identification allows the application of clinical guidelines and surveillance for changes in symptoms or clinical status. As SCD often occurs without warning signs or symptoms, the first symptom in up to 50% of children will be the SCA [19,20]. The analytical framework of the United States Preventative Services Task Force [21], derived from the principles of Jungner and Wilson [22], is to prevent the disease either from occurring or from resulting in death. Application of these principles to SCD is complicated in that SCD is not a single disease or condition but a potential outcome of many cardiac conditions. To prevent SCD, a predisposing disease condition must be identified to allow disease specific prevention to be applied along with ongoing surveillance by the individual's physician. Current screening recommendations In 1996, the American Heart Association (AHA) recommended a 12-element preparticipation screening history and physical exam (H&P) for high school athletes [23]. An update in 2007 recommended no substantive changes, but raised concerns regarding adding an electrocardiogram (ECG) to the screening process, and did not recommend its use [24]. More recently, the AHA has published an assessment of the 12-lead ECG as a screening test and concluded that the ECG should not be used as a universal screening tool. They recommended that ECG screening could be “considered in relatively small cohorts of young healthy people 12 to 25 years of age, not necessarily limited to athletes provide that close physician involvement and sufficient quality control can be achieved.” The writers suggested that sound scientific principles should drive such programs, but offer no evidence regarding their current recommendations [25]. In 2004 and 2005, the IOC Medical Commission and European Society of Cardiology respectively recommended a screening program for young athletes based on the 12-lead ECG in addition to the H&P [26,27]. Should children be screened? Since activity increases the risk of SCA, the focus of screening youth has often been directed toward various populations of athletes [28]. Over 92% of all professional athletes in the US receive an ECG with many having echocardiograms and exercise stress testing [29]. It has been suggested that targeted screening of NCAA athletes could provide data regarding the efficacy of screening in younger ages [30], but that recommendation fails to note the high

Fig. 1. Comparison of published data from the US National Registry with the Parent Heart Watch database. This chart shows a difference in the proportion of deaths from congenital heart disease, ion channelopathies/arrhythmias, and coronary artery anomalies between the two datasets. The conditions with the greatest differences are illustrated by the vertical lines in the specific PHW bars.Ao = aortic; ARVC = arrhythmogenic right ventricular cardiomyopathy; AS/CHD = aortic stenosis/congenital heart defect; CAA = coronary artery abnormality; DCM = dilated cardiomyopathy; HCM = hypertrophic cardiomyopathy; Ion channel = ion channelopathy and other electrical conditions; MVP = mitral valve prolapse; WPW = Wolff–Parkinson–White syndrome.

rates of SCA that occur during adolescence. Most states require high school and middle school athletes to undergo cardiac screening in addition to a general evaluation before scholastic sports participation. Screening only athletes will miss millions of children who are extremely active and competitive. Additionally, SCA may occur without activity. Screening only those with symptoms is problematic as studies of youth who have experienced SCA find that approximately 50% reported antecedent symptoms and only 16% had a known positive family history [31]. Variation occurs by the condition, with 10–30% of those having long QT syndrome and 80% of those with autopsy negative SCD having SCA as the first symptom [32,33]. The specificity of SCA associated symptoms is low and they are often overlooked or dismissed. In fact, in a study of 158 athletes who underwent the current preparticipation evaluation using H&P, only 3% who subsequently experienced SCA were suspected of having cardiovascular disease and only one was correctly identified [20]. Although, the majority of SCA associated conditions have a genetic basis, most individuals are not fully aware of important aspects of their family history. In those with a positive family history, the value of family genetic or cascade screening is illustrated by Tan who found an additional 8.9 affected individuals [34]. The effectiveness of genetic screening is a complicated issue and awaits protection from discrimination in all areas, increased knowledge of genetic variants and their disease causing potential, acceptance of genetic testing by the population, as well as the development of new technology leading to lower costs. Best practices for screening of children Screening of all children at periodic intervals will result in identification of a proportion that have undiagnosed

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conditions that can be associated with sudden cardiac death and allow clinical evaluation, surveillance and treatment. The medical community will need to determine if it is justified to wait for a SCA in the 30–50% who will present in this manner or be more proactive and try to identify those in whom it is possible with an ECG or other testing. Screening methods Some screening methods are more effective for specific conditions so the search for a single solution to screening may not be logical, and should be considered from that perspective. The question remains as to whether the current system (H&P) is the best overall screening practice to identify the greatest proportion of those at risk, or if the addition of an ECG would improve the screening process when it is used. Numerous studies have shown that the ECG can be used to identify most of these conditions with coronary artery anomalies and aortic dilation associated with Marfan syndrome being the most notable exception. Conditions that can be identified using the ECG are responsible for at least two-thirds of SCA in the young [35]. An ECG suggested diagnosis should not be considered definitive in most settings as additional testing often is required for diagnostic confirmation. On the other hand, there is no evidence that current screening practice of using H&P alone is decreasing the overall occurrence of SCD [15]. Multiple clinical reports indicate that death in individuals with SCD related conditions can be prevented once treatment using standard medical practices is initiated. Any method that identifies at risk individuals would allow use of recommended interventions to prevent SCD. Prior studies on ECG screening in youth Nevada High School Athletes: In the largest US ECG screening study of 5615 high school athletes in Nevada, adding an ECG to the standard H&P, the sensitivity of the ECG to cardiac conditions was 70% vs. 6% for H&P [36,37]. North Carolina High School Athletes: in a screening of 2017 high school athletes with H&P, ECG, and echocardiogram, H&P was abnormal in 14.7% compared to 3.1% abnormal ECGs using “modern criteria.” H&P had a false-positive rate of 14.5% with ECG, 2.8% [38,39]. Chicago: ECG screening of 32,561 high school students by Young Hearts for Life identified 2.5% as needing further testing. [40] Texas Children: A screening program initiated by the Texas legislature evaluated 2506 students with H&P, ECG, and limited echocardiogram [41]. The ECG was abnormal in 2.3% with many false positive results by history. Only 0.4% received a positive final diagnosis and 66.7% failed to return for follow up, including one third of those suspected of HCM after ECG and echocardiogram. Limited echocardiography had relatively low interobserver agreement of 79%. The Children's Hospital of Philadelphia (CHOP): In 2006– 2007, 400 healthy children were screened at CHOP in a clinic-based setting using a personal medical questionnaire, physical exam, ECG and echocardiography [42].

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Ten individuals (2.5%) were found to have potentially serious conditions. Since 2006, we have screened over 4000 children in community-based settings (school or recreation centers) using personal medical questionnaire, physical exam, ECG and echocardiography (5-7%) when abnormalities were noted in the other evaluations. Additional testing has been recommended for 2–3%. There is a positive rate of 0.7% for true significant conditions from this ECG-based community screening. Japanese Students: Since 1973, mass ECG screening of school children for cardiovascular disease has been occurring in the 1st, 7th, and 10th grades [39]. In studies of Japanese school children, the greater sensitivity of ECG screening compared to H&P has been recognized [39,43]. After an ECG, 2.7% of Japanese students were reported to require additional evaluation and testing with 0.024% of students having high risk conditions identified [39]. Italian and European Athletes: The Medical Protection of Athletes Act was passed in 1979 in Italy. Corrado reported a study of athletes b 35 years of age who were screened with a history, physical and ECG from 1979 to 1996 with 1.8% of athletes disqualified from competition due to cardiovascular conditions [44]. A decreased incidence of SCA in athletes, by 89% over a 25-year period was reported with the ECG three times more likely to identify those at risk than the H&P alone [44,45]. The screening program efficacy to identify HCM or other cardiac conditions was evaluated by subsequent echocardiograms on 4450 previously screened athletes, with a low false negative rate of 1.2% [46]. Israel: A retrospective observational study of SCD from 1985 to 2009, to determine if ECGs mandated in a screening program in Israel resulted in fewer SCD, used reports in two Israeli newspapers to ascertain the outcomes [47]. There was no difference in the yearly incidence of 2.6 events/100,000 athlete years, before or after the mandate, but it is unclear if the methodology of the study has provided complete data on all deaths [48]. These reports and others suggest that screening for SCA with ECG may be more effective than the current US system [39,49,37,50,45,51]. However, a large-scale randomized control trial of an ECG screening program vs. H&P alone has not been tested to date and may be prohibitive as 4 million person-years are required to prove efficacy in prevention of SCA due to its relatively low incidence [52]. Pediatric ECGs Most US pediatric cardiologists use the criteria of Davignon derived from 2141 ECGs from white Canadian children in 1979 [53]. With the increasingly diverse US population, these normative data do not reflect the current population subgroups. Rijnbeek published normal standards for Dutch children, but these are not used commonly in the US and are not reflective of the US population [54,55]. When compared to Caucasian children, a monograph on Taiwanese children showed much lower voltage norms for left ventricular hypertrophy [53,56]. Variations in the ECG have been shown to be related to age, stage of development,

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especially puberty, gender, racial and ethnic group, type of sport, and degree and type of training. None of the current guidelines take all or even most of these characteristics into consideration.

all children at a particular age or grade level, making the process more equitable and less complicated. In the non-ECG screening years and for non-cardiac system screening, an interim H&P for children/athletes could be used. Studies should be performed to determine the best ages for intermittent screening.

Interpretation of pediatric ECGs Evaluating the accuracy of the ECG for screening purposes, Hill found little agreement among those who read a set of pediatric ECGs [57]. The misconception is that the readers were requested to make treatment decisions based only on the ECG rather than just suggesting a possible diagnosis. However, this study did indicate that “trained” individuals lacked basic recognition skills in many cases. Viskin found a low level of skill and agreement among number of practitioners regarding the reading of four ECGs [58]. Both of these studies fail to attain a level that can allow generalization of results. Drezner has illustrated that ECG reading education using predetermined standards can improve interpretation [59]. A group of experts developed standards for ECG reading, the Seattle Criteria, for athletes from age 14 years along with an educational module [60]. It is important for data to be derived to indicate if these standards are scientifically rigorous or not. Best practices for ECG interpretation Criteria for interpreting ECGs need to be developed for children by age, gender, race and ethnicity. Modern or Seattle criteria, especially for left ventricular hypertrophy (LVH) need to be evaluated as to correlation with echocardiographic or magnetic resonance images. It cannot be assumed that criteria that fit adults can be used at age 14 years, as puberty is not always on a precise chronological basis and developmental ECG changes may continue to occur into early adulthood. However, true LVH is uncommonly present in children when ST segments, T waves and Q waves are totally normal unless the R waves in the left precordial leads are excessive. The precise numbers for “excessive” need to be determined. Organization of screening that includes an ECG Timing of screening Determination of the frequency of ECG screening on an individual or the likelihood of a positive test once a negative screening ECG has been obtained has not been established. A single screening may not be adequate given the developmental changes in the cardiovascular system that occurs with growth. Best practices for screening frequency A systematic periodic screening including an ECG could be utilized. This could start with neonates to identify those at risk of an LQT mutation related to SIDS or an undiagnosed congenital heart defect; next, screening could be performed at school entry and/or in middle school; and once again in high school. Participation in a team sport will not determine eligibility for screening if one uses an ECG-based screen of

Location of screening A complete evaluation that includes an ECG can be done in an outpatient clinic office of a pediatrician, family medicine doctor, internist, a pediatric or adult cardiologist, or a sports medicine specialist. Schools are currently used for some athletic preparticipation evaluations, often on a day when the gymnasium is set up as a makeshift medical clinic. Screenings using an ECG and aimed at the school population can be conducted by using the school facility and bringing the necessary ECG equipment into the school. Schools currently screen for other health conditions including vision, hearing, and scoliosis. In Italy, a system of Screening centers exists throughout the country as part of larger polyclinic (or multispecialty clinic) center. Best practices for location of screening Incorporating the cardiovascular screening evaluation into the well child or sports clearance evaluation could become a sustainable method of screening that could include an ECG obtained at the clinic or office facility. These evaluations including obtaining an ECG could be done in the medical office with onsite or remote ECG interpretation. Screening team It is essential that the screening team have a responsible director or manager to supervise coordination of all activities. The screening team will vary somewhat depending on the site of the screening; that is, whether it is a medical facility, school site, or other. For school-aged children, the screening team composition could include a medical team of physicians, nurses, nurse practitioners and physician assistants, ECG and echocardiography technicians, and other assistants necessary to operate the office or clinic. When a school is utilized, in addition to the medical team, a school team is necessary, including school administrators and teachers, especially physical education and health teachers, athletic directors and trainers, coaches, and volunteers. If schools are the targeted screening site, communication with the school must be systematic and complete. The school leadership must be actively supportive to ensure that the majority of targeted students participate and are screened, including the parents in the process. It is important to communicate with physical education teachers, coaches, athletic trainers and others involved in athletics to emphasize the importance of screening all students. If the screening sites are to include physician offices or medical clinical sites, communication within the entire medical team is most important. Similarly, it is critical that the screening team have a mechanism for communicating with families, screened individuals depending on the age, and the individual's primary

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physician. Computer-based technologies can be used to disseminate information regarding potential screening times, to streamline administrative tasks, and to provide feedback to primary care providers and school officials when appropriate. Models for ECG screening Our group has been involved in clinic-based, and community-based screening in schools, recreation centers, churches, and in mass screening events in arenas. We have shown that it is feasible to screen a population of school-aged children using an ECG and that a methodology for use of a medical office, school, or church as a screening facility can be established [42]. Providing screening at the school or other community site requires the capacity to move personnel and equipment into the community and to develop a screening team integrating the school and medical personnel. Related to logistics, we have reserved echocardiograms for those with abnormal ECGs or with an H&P suggestive of a structural or functional cardiac condition or a positive family history of inherited cardiac conditions. Best practices for screening teams and models Table 1 contrasts the resource utilization requirements of a medical office model (e.g. pediatrician's office) with a community screening model. This will vary according to the specific screening arrangement. A screening in a clinic or medical office will be determined by the clinical issues that need to be evaluated for the visit, but addition of an ECG should not increase the time of the visit by more than 10– 15 minutes. It is recognized that “one size will not fit all” so having a multi-pronged screening capacity may be the most reasonable approach at this time. We would strongly recommend that follow-up of these individuals is key to determining future best practices along with evaluation of any screening methodology that is used, whether it includes ECG or does not. Steps toward a best practice model A best practice model should address the major barriers to applying ECG to cardiovascular screening of children including manpower considerations, the logistics of adding an ECG to a neonatal, well-child, or athletic evaluation, and the costs of the process. The ECG, similar to the H&P, is an early step in a process to establish a definitive diagnosis using additional testing

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modalities. It is a screening tool, not a definitive diagnostic tool. Every screening test requires confirmation and further evaluation. Several concerns have been raised that indicate barriers to ECG screening in the US with regard to feasibility, logistics, and costs [6,24,61–63]. Table 2 identifies concerns that have been raised and proposes solutions. The strengths and limitations of ECG screening are shown in Table 3. Recommendation of best practice model The model that is most easily applied is one that requires the least development of new infrastructure. Thus, the best practice model that we recommend for clinical application is to utilize the structure of existing offices or clinics either in conjunction with regular well child or sports clearance visits or at times that those clinics are not utilized during the day or on evenings and weekends. These clinics would already have ECG and possibly echocardiographic machines that would not normally be utilized at these times. Remote ECG interpretation or education of first line providers could be accomplished. We have provided our pediatricians with a local guideline for ECG interpretation to allow them to participate in the ECG evaluation (Table 4). We speculate that the greatest benefit is likely to result from targeting school-aged children in the age group over 10–12 years as risks of all of the SCA related conditions begin to increase beyond these ages. Insurance coverage of the 3–5% referred for echocardiograms would likely be provided by most insurance to rule out suspected cardiovascular conditions. As ECG screening becomes more common and research into normal variants and new normative values are determined, it is likely that only 2–3% of individuals will require echocardiographic and other evaluations, thus improving the cost effectiveness of screening. For communities without the resources of a pediatric cardiologist, adult cardiologist, or sports medicine physician trained to recognize cardiovascular conditions associated with SCA, a mobile school-based program could be implemented similar to that used in our community screening study. Over time, local pediatricians and family physicians, internists and others could be trained to sustain the model in the community. Community resources from community service organizations, school–parent associations, foundations, hospitals and local governments can be used to help finance these screenings. Many parents would be willing to pay a modest fee for this type of screening. At some point in the future, preventive screening may be covered by more progressive health plans.

Table 1 Resources for medical office model vs. community model of ECG screening. Location

Medical office

Community screening venue

Daily personnel

0.5 MD (for screen at well-child visits or sports clearance visit) 0.2 nurse or MA for ECG 1 ECG machine Refer for ECHO 20/day 440/month

1–2 MD 8 ECG technicians @ 8 ECGs/hour/technician 1.5 ECHO technicians @ 3–4 ECHO/hour/technician for 5% ECHO rate 8 ECG machines 2 ECHO machines 400–500/day

Equipment Number screened

ECG = Electrocardiogram; ECHO = Echocardiogram; MA = Medical assistant.

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Table 2 Screening concerns, barriers, and solutions. Concern or barrier

Solutions

Low prevalence Large numbers of youth in US Resource and manpower issues

• Conditions are more common than appreciated but need improved identification methods. • ECG screen can be performed periodically, not annually. • Multiple physician specialists and physician extenders can be utilized. • Computer technology and remote readings can be performed. • Current computer readings are not always correct. • Screening can be incorporated into current athletic preparticipation screening and well child visits. • Both a clinic-based and a community-based model can be used. • Differences in prevalence of various conditions in Europe and US may relate to differences in identification. • ECG can identify many of the common conditions. • New ECG standards including age, gender, race and ethnicity should improve sensitivity and specificity. • The ECG is a screening tool, not a definitive diagnostic tool as most screening tests require confirmation and further evaluation. • Prompt clarification of ambiguous diagnoses will relieve associated anxiety. • Long-term disqualifications are uncommon. • The presence of AEDs and personnel who can perform bystander CPR helps to ensure safe playing fields which can allow some type of athletic participation for most youth. • Families should be told the scope of screening when performed and educated that one screen is not a forever guarantee. • Variable results have been noted, but several studies suggest cost-effectiveness per life year saved.

Lack of infrastructure for screening Differences in US and European populations

ECG sensitivity and specificity, false positives

Disqualification

Liability Costs

Future studies

Conclusions

The manpower, logistics, and cost effectiveness concerns of critics of ECG screening should be addressed by scientific studies to provide evidence-based recommendations. The effects of all types of screening for SCD conditions should be carefully investigated to prevent adverse effects. With future and ongoing studies, the best ages to screen children will be identified and the best methods to find the specific conditions will be determined. A large multicenter study could be used to evaluate the method for developing a national screening infrastructure and for determining the true cost effectiveness of screening to identify those with SCA associated conditions. A very large or long-term study will be needed to determine the effectiveness of ECG screening to prevent SCA in youth. Additionally, such a study can be used to determine the comparative effectiveness of a model based on ECG screening added to the H&P to that of the current system of H&P alone.

A working group was convened by the National Heart Lung and Blood Institute (NHLBI) to discuss the prevention of sudden cardiac death in youth [52]. This working group identified a number of knowledge gaps, including [determining] the true incidence of SCD and changes associated with screening, prevalence of SCD conditions, time and frequency of screening, targeted or nontargeted screening, outcomes of those excluded from sport or accommodations to allow sport to continue, and the natural history of conditions identified by screening in asymptomatic individuals. A good first step is the recent effort by the National Institutes of Health in partnership with the US Centers for Disease Control and Prevention to fund 10 jurisdictions in a pilot project to collect information on sudden deaths in youth, including cardiovascular deaths, and to develop a national registry of these deaths as recommended by the NHLBI Working Group on SCD [52]. The goal of decreasing SCD in youth has not been realized. Support of screening efforts with sound scientific rigor should be developed to determine the best methods to identify young children before they experience an SCA or SCD. Further, effective interventions to prevent such occurrences should be established. Current screening efforts using a systematic process and standardized criteria should collect data to achieve these goals. All screened individuals, should be tracked. All screening efforts should be focused on quality, regardless of the screening methodology used. Improvement of the use of the H&P will only advance screening that adds an ECG to that process. The common goal is to decrease sudden death in the young [3]. We should continue to study cardiovascular screening of children to determine the best methods to identify at risk youth so that one day, we will have sufficient data to determine the best ways to screen, on whom, and how to do it, using best practices. We should remove obstacles and develop the evidence base that is so urgently needed.

Table 3 ECG screening. Strengths ECG has higher sensitivity than history and physical examination. ECG has lower costs with higher cost-effectiveness than other models. The ECG is the first step in diagnostic pathway. ECG interpretation can be accomplished by a wide range of health care professionals. Assistance for ECG interpretation is possible using computer measurements and algorithms. Limitations The ECG has more false positives than the history and physical examination. Additional testing for false positives adds costs. Additional testing is required to confirm most diagnoses. Current pediatric ECG standards do not recognize differences by age, gender, race or ethnicity. Current computer readings are not always correct.

V.L. Vetter / Journal of Electrocardiology xx (2015) xxx–xxx Table 4 Category of ECG interpretations. Category I. Normal or normal variant ECG readings. ECGs with the following interpretations do not require further workup unless clinical symptoms, exam or history suggest cardiac involvement. The following is a non-exhaustive list of normal or normal variant ECG readings. 1. Sinus bradycardia 2. Sinus arrhythmia 3. Sinus tachycardia 4. Isolated atrial enlargement, especially right atrial enlargement (RAE). Biventricular hypertrophy (BVH) with only mild mid-precordial voltages of 45 or 50 mm. 5. Ectopic atrial rhythms; right atrial (RA); left atrial (LA), wandering atrial pacemaker at normal rates 6. First degree AV block with PR b 300 ms and 2nd degree AV block, Mobitz I or Wenckebach 7. Right ventricular conduction delay (RVCD) or incomplete right bundle branch block (IRBBB) without right ventricular hypertrophy (RVH) and right axis deviation (RAD) 8. Isolated intraventricular conduction delay (IVCD) 9. Isolated right axis deviation or left axis deviation 10. Right ventricular hypertrophy (RVH) 11. Early repolarization 12. Nonspecific ST-T wave changes 13. Juvenile T wave pattern 14. QTc ≥0.46 by computer but normal by hand calculation 14. Premature atrial or premature junctional contractions Category II. Abnormal ECG readings and should be evaluated as they may correlate with the presence of cardiac disease, but are often false positives. As with Category I readings, the physician should correlate the ECG reading with the history, exam and any symptoms the patient might have and discuss the reading with a cardiologist to assess the need for a cardiology office visit as it is possible that a patient with these readings will need to be seen by a cardiologist. However, a cardiology office visit with examination and further testing/evaluation may not result in a diagnosis of cardiac disease. In fact, many of these patients have a low likelihood of having significant cardiac pathology. The following is a non-exhaustive list of Category II ECG readings. 1. Left ventricular hypertrophy (LVH) 2. Right atrial enlargement (RAE), right axis deviation (RAD) N 120°, and RVH. 3. 2nd (Mobitz Type II or high grade) and 3rd degree atrioventricular (AV) block 4. Right bundle branch block (RBBB) 5. Left bundle branch block (LBBB), or intraventricular conduction block 6. Prolonged QTc N0.48 s (0.46 s with family history or positive personal history) a. The prescribing physician should ask about meds that might prolong QTc, which could cause mild QTc prolongation, and can be found on Web site www.qtdrugs.org or www.crediblemeds.org. 7. Abnormal T waves with inversion V5, V6; bizarre T wave morphology, especially notched or biphasic or flat and/or ST segment depression suggesting ischemia or inflammation. T wave inversion V1–V3 after puberty. 8. Abnormal Q waves N40 ms duration or 3–4 mm depth especially with ST or T wave abnormalities 9. Ventricular tachyarrhythmias, including frequent or complex premature ventricular contractions (PVCs) 10. Supraventricular tachyarrhythmias 11. Wolff–Parkinson–White pattern (WPW) 12. Brugada pattern of coved or saddleback T wave in V1, V2 13. Epsilon wave in V1 or multiple J wave notches or elevation (not early repolarization)

Acknowledgments I would like to thank and acknowledge the following: Without the assistance of Noreen Dugan, RN, and Danielle Main Haley, MPH, Youth Heart Watch Coordinators, the ECG screenings at The Children's Hospital of Philadelphia, described in this manuscript could not have been accomplished. Similarly,

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the Screening Team of The Children's Hospital of Philadelphia has been essential to our research screening efforts. Support for the screenings has been provided by the Chair's Initiative of The Children's Hospital of Philadelphia, Simon's Fund Foundation, the Matthew Weiner Foundation, Daniel E. Rumph II Foundation, Aidan's Heart Foundation, Nicholas Ryan Over Foundation, Take It To Heart, and the Evelyn R. Tabas Chair and The Children's Hospital of Philadelphia and their Healthy Weight Research Program Award from an unrestricted donation from the American Beverage Foundation for a Healthy America. I would also like to acknowledge Parent Heart Watch for providing information from their database. References [1] Douglas PS. Saving athletes' lives a reason to find common ground? J Am Coll Cardiol 2008;52(24):1997–9. [2] Drezner J, Corrado D. Is there evidence for recommending electrocardiogram as part of the pre-participation examination? Clin J Sport Med 2011;21(1):18–24. [3] Drezner JA, Levine BD, Vetter VL. Reframing the debate: screening athletes to prevent sudden cardiac death. Heart Rhythm 2013;10(3):454–5. [4] Friedman RA. Electrocardiographic screening should not be implemented for children and adolescents between ages 1 and 19 in the United States. Circulation 2014;130(8):698–702. [5] Vetter VL. Electrocardiographic screening of all infants, children, and teenagers should be performed. Circulation 2014;130(8):688–97. [6] Maron BJ. Counterpoint/mandatory ECG screening of young competitive athletes. Heart Rhythm 2012;9(11):1897. [7] Sharma S. Point/mandatory ECG screening of young competitive athletes. Heart Rhythm 2012;9(11):1896. [8] Pediatric sudden cardiac arrest. Pediatrics 2012;129(4):e1094–102. [9] Maron BJ, Epstein SE, Roberts WC. Causes of sudden death in competitive athletes. J Am Coll Cardiol 1986;7(1):204–14. [10] Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, et al. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest. Circulation 2009;119(11):1484–91. [11] Drezner JA, Rao AL, Heistand J, Bloomingdale MK, Harmon KG. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation 2009;120(6):518–25. [12] Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980–2006. Circulation 2009;119(8):1085–92. [13] Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of sudden cardiac death in national collegiate athletic association athletes. Circulation 2011;123(15):1594–600. [14] Mitka M. US registry for sudden death in the young launched by the NIH and CDC. JAMA 2013;310(23):2495. [15] Drezner JA, Chun JS, Harmon KG, Derminer L. Survival trends in the United States following exercise-related sudden cardiac arrest in the youth: 2000–2006. Heart Rhythm 2008;5(6):794–9. [16] Berger S, Kugler JD, Thomas JA, Friedberg DZ. Sudden cardiac death in children and adolescents: introduction and overview. Pediatr Clin North Am 2004;51(5):1201–9. [17] Lopez-Anderson Martha, Michelle Snyder. Parent Heart Watch Database; 2014 [Ref Type: Personal Communication.]. [18] Maron BJ, Douglas PS, Graham TP, Nishimura RA, Thompson PD. Task Force 1: preparticipation screening and diagnosis of cardiovascular disease in athletes. J Am Coll Cardiol 2005;45(8):1322–6. [19] Corrado D, Basso C, Thiene G, McKenna WJ, Davies MJ, Fontaliran F, et al. Spectrum of clinicopathologic manifestations of arrhythmogenic right ventricular cardiomyopathy/dysplasia: a multicenter study. J Am Coll Cardiol 1997;30(6):1512–20. [20] Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA 1996;276(3):199–204.

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