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ECG-based cardiac screening programs: Legal, ethical, and logistical considerations
Jessica J Orchard1, Lis Neubeck2, John W Orchard3
1Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Heart Research Institute, Charles Perkins Centre, Sydney, Australia.
Insights
Screening asymptomatic individuals with electrocardiograms (ECG) may detect heart disease, but is not recommended for all. This review examines screening elite athletes for sudden cardiac death (SCD) and older adults for atrial fibrillation (AF).
Area of Science:
- Cardiology
- Preventive Medicine
- Medical Ethics
Background:
- Resting electrocardiograms (ECG) are theorized to detect latent cardiovascular disease in asymptomatic individuals.
- ECG screening is not universally recommended, particularly for sedentary middle-aged populations due to insufficient sensitivity for coronary artery disease.
- Screening programs face ethical, legal, and logistical challenges, necessitating careful consideration of implementation and oversight.
Purpose of the Study:
- To review the complexities and considerations for implementing ECG screening programs.
- To focus on two specific screening contexts: elite athletes for sudden cardiac death (SCD) and individuals aged 65+ for atrial fibrillation (AF).
- To highlight the importance of quality control, expert guidelines, and follow-up care in screening.
Main Methods:
- This is a review article, synthesizing existing knowledge and guidelines on ECG screening programs.
- The review specifically analyzes screening protocols for elite athletes and older adults.
- Considerations for legal, ethical, and logistical responsibilities are discussed.
Main Results:
- ECG screening effectiveness varies by population; it's not suitable for all asymptomatic individuals.
- Screening elite athletes for SCD and older adults for AF presents unique challenges and benefits.
- Effective screening requires robust infrastructure for interpretation, follow-up, and treatment pathways.
Conclusions:
- Screening programs must be well-executed, addressing legal, ethical, and logistical aspects from start to finish.
- Proper infrastructure, adherence to guidelines, and clear follow-up protocols are crucial for quality screening.
- Diagnosed cardiac conditions can have significant implications for insurance, employment, and mental health, necessitating careful management and communication.
Abstract:
Screening asymptomatic people with a resting electrocardiogram (ECG) has been theorized to detect latent cardiovascular disease. However, resting ECG screening is not recommended for numerous populations, such as asymptomatic middle-aged (sedentary) people, as it is not sufficiently sensitive to detect coronary artery disease. While the issues raised in this article are largely common to all screening programs, this review focuses on 2 distinct programs: (1) screening elite athletes for conditions associated with sudden cardiac death (SCD); and (2) screening people aged ≥65 years for atrial fibrillation (AF). These 2 settings have recently gained attention for their promise and concerns regarding prevention of SCD and stroke, respectively. If screening is to be done, it must be done well. Organizations conducting screening must consider a range of legal, ethical, and logistical responsibilities that arise from the beginning to the end of the process. This includes consideration of who to screen, timing of screening, whether screening is mandatory, consent issues, and auditing systems to ensure quality control. Good infrastructure for interpretation of ECG results according to expert guidelines and follow-up testing for abnormal screening results, including a pathway to treatment, are essential. Finally, there may be significant implications for those diagnosed with cardiac disease, including insurance, employment, the ability to play sport, and mental health issues. There are several legal risks, and the best protective measures are good communication systems, thorough clinical record-keeping, careful handling of eligibility questions for those diagnosed, and reference to expert guidelines as the standard of care.
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