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The latest international recommendations for ECG interpretation in young athletes could cut screening costs down the line, a British study suggested.

Under the new rules, abnormal ECGs would have turned up at a rate of in an analysis of previously unscreened athletes who got evaluated in 2011-2014 through mandatory sports participation screening there -- a sharp difference from the actual rate of 22.0% under the European Society of Cardiology (ESC) 2010 guidelines used at the time.

The international recommendations were even stricter than the consensus guidelines of a 2015 conference in Seattle and a subsequently refined version, which would have turned up abnormal results in 6% and 4% of ECGs, respectively (all P<0.0001), Sanjay Sharma, MD, of St. George's University of London, and colleagues reported in the August 8 issue of the Journal of the American College of Cardiology.

Theoretically, under the international recommendations, 3.8% would have gotten transthoracic echocardiography (TTE); 1.2% exercise stress testing; 1.0% Holter monitoring; 0.9% cardiac MRI; and 0.4% other tests to confirm or refute a diagnosis of cardiac disease. The old ESC guidelines led more patients to get the other tests -- 11% in the case of TTE (all P<0.0001).

It ultimately was projected to cost $80 to screen each athlete and $26,405 of testing to find one serious diagnosis with the new rules (versus $110 and $35,993, respectively, with the old ESC recommendations).

"The international recommendations are associated with a significantly lower number of abnormal ECGs and result in an impressive reduction in workload and cost of screening without compromising the ability to detect athletes with serious cardiac disease," Sharma's group concluded.

Disseminated in February 2017, these guidelines recategorize several abnormal ECG findings -- such as left axis deviation and complete right bundle branch block -- as "borderline" normal variants among athletes that only require further investigation if multiple findings are observed together.

Moreover, anterior T-wave inversion only requires further investigation in non-black athletes if it goes beyond lead V₂, according to the new document.

To validate these recommendations, Sharma and colleagues retrospectively studied 4,925 athletes (85% men, 85% white) ages 14 to 35 years. All had to fill out a health questionnaire and undergo physical exams and 12-lead ECGs.

"The evaluations were a mandatory requirement of their respective sporting associations and were facilitated nationwide through the Cardiac Risk in the Young screening program in the United Kingdom," the authors noted.

Abnormal findings resulted in referral to nearby hospital for secondary investigation. Sharma's group calculated costs based on 2014/2015 U.K. National Health Service tariffs.

Caveats of the study were the lack of sensitivity or specificity calculations and that secondary tests were ordered at the discretion of cardiologists.

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