Reevaluating the Annual ECG: Screening Tool or Waste of Resources?

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Introduction

The electrocardiogram (ECG) has been a foundational tool in cardiovascular diagnostics since its clinical adoption more than a century ago. Originating from early physiological research, the ECG quickly transitioned into widespread clinical use and remains one of the most frequently employed methods for assessing cardiac electrical activity.[6] Its enduring presence in medical practice underscores both its diagnostic utility and its accessibility across a range of healthcare settings.

In recent years, however, the role of routine ECG screening in asymptomatic populations has become a subject of growing scrutiny. As global healthcare systems contend with escalating costs and a shift toward evidence-based, value-driven care, questions have emerged about whether widespread ECG screening is a prudent investment or an unnecessary expenditure with limited clinical impact.

The debate over annual ECG screening involves a wide array of stakeholders, including primary care physicians, cardiologists, health economists, public health officials, and policymakers. Central to this discourse is the hypothesis that screening asymptomatic individuals with a resting ECG may facilitate the early detection of silent or latent cardiovascular conditions. Two particular areas have drawn significant attention: the screening of elite athletes to identify conditions associated with sudden cardiac death (SCD) and the screening of older adults, particularly those aged 65 years and above, to detect undiagnosed atrial fibrillation (AF), which is a major risk factor for stroke. [7] [8]

These targeted screening strategies reflect broader questions about the effectiveness of ECG in preventive care and the variability in its utility across different patient populations. Additionally, differences in healthcare infrastructure, resource allocation, and population health profiles across countries further complicate the standardization of screening protocols. The emergence of artificial intelligence (AI) and machine learning algorithms capable of enhancing ECG interpretation introduces another dimension to this evolving field. These technologies promise improved diagnostic accuracy, faster processing times, and the potential to uncover subtle patterns not easily recognized by human interpreters.

Given this complex landscape, a careful and balanced assessment of routine ECG screening is essential. This review aims to provide a comprehensive analysis of the current evidence supporting or opposing annual ECG screening in asymptomatic populations. We will examine the clinical effectiveness of such screening practices, explore associated healthcare costs, assess recent technological advancements, and consider the ethical and policy implications of widespread implementation.

The central research question guiding this inquiry is as follows: Does the current body of evidence support the adoption of annual ECG screening as a standard component of preventive healthcare, or do the limitations, including false positives, downstream testing, and financial burden, outweigh the anticipated benefits in reducing cardiovascular morbidity and mortality?

 

Clinical Effectiveness and Diagnostic Performance

Sensitivity and Specificity Across Populations

The diagnostic performance of ECG screening varies notably across different populations and clinical contexts. In athletic populations, meta-analysis has shown that the sensitivity and specificity of ECG screening is 94%/93%, history 20%/94%, and physical examination 9%/97% [9]. The most effective strategy for screening for cardiovascular disease in athletes is ECG, being 5 times more sensitive than history, 10 times more sensitive than physical exam, with higher positive likelihood ratio, lower negative likelihood ratio and a lower false positive rate [10].

However, the effectiveness of ECG screening in the general population presents a more complex picture. The U.S. Preventive Services Task Force recommends against screening with resting or exercise ECG for the prediction of coronary heart disease events in asymptomatic adults at low risk for CHD events (D recommendation), concluding that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events [11].

Detection Rates and Clinical Outcomes

The detection rates of major cardiac conditions through ECG screening vary considerably based on the population studied. In athletic populations, there were a total of 160 potentially lethal cardiovascular conditions detected for a rate of 0.3% or 1 in 294, with the most common pathology being Wolff-Parkinson-White (67, 42%), Long QT Syndrome (18, 11%), hypertrophic cardiomyopathy (18, 11%), dilated cardiomyopathy (11, 7%), coronary artery disease or myocardial ischemia (9, 6%) and arrhythmogenic right ventricular cardiomyopathy (4, 3%) [12].

In broader population screening programs, among 26,900 young individuals aged 14-35 years evaluated with a health questionnaire and ECG, 2,175 (8.1%) required further investigation for an abnormal ECG, with diseases associated with young sudden cardiac death identified in 88 (0.3%) individuals, of which 15 (17%) were detected with the health questionnaire, 72 (81%) with ECG and 2 (2%) with both [13].

Challenges in ECG Interpretation

One of the most common challenges in ECG screening is the variability in interpretation. Agreement on which ECGs were abnormal ranged from poor (κ = 0.297) to moderate (κ = 0.543) between observers, with the reported prevalence of abnormal ECGs ranging from 13.4% to 17.5% [14] [15]. Even when experienced physicians interpret athletes’ ECGs according to current standards, there is significant interobserver variability that results in false-positive and false-negative results, thus reducing the effectiveness and increasing the social and economic cost of screening [16].

 

Cost-Effectiveness Analysis

Economic Burden and Resource Allocation

The economic implications of ECG screening programs represent a key consideration in healthcare decision-making. The overall cost of de novo screening using 2010 ESC recommendations was $539,888 ($110 per athlete and $35,993 per serious diagnosis), with the Seattle and refined criteria reducing the cost to $92 and $87 per athlete screened and $30,251 and $28,510 per serious diagnosis, respectively [17].

For population-wide screening programs, extended screening and one-time screening were cost effective compared with no screening at a willingness-to-pay (WTP) threshold of $100,000 per QALY gained ($58,728/QALY with ECG 12-lead and $47,949/QALY with Z14 in 2016 US dollars) [18]. Screening the general population at age 75 years for non-valvular atrial fibrillation is cost effective at a WTP threshold of $100,000 [19].

Cost Variations by Screening Strategy

The cost-effectiveness of ECG screening is heavily dependent on the specific approach and population targeted. Overall, 1,072 (21.8%) athletes had an abnormal ECG on the basis of 2010 ESC recommendations, with the Seattle and refined criteria reducing the number of positive ECGs to 6.0% and 4.3%, respectively [20]. Contemporary ECG interpretation criteria decrease costs for de novo screening of athletes, which may be cost permissive for some sporting organizations [21].

False Positive Rates and Economic Impact

The economic burden of false positive results represents a major concern in ECG screening programs. False positive (F+) stress ECGs were documented in 565/3,000 tests (18.8%), with F+ stress ECGs equally prevalent in females (194/1,036, 18.7%) and males (371/1,964, 18.9%) [22]. Compared with multi-cancer early detection, single-cancer early detection tests detected 1.4× more cancers (412 vs. 298), but had 188× more diagnostic investigations in cancer-free people (93,289 vs. 497), with 3.4× the cost ($329 M vs. $98 M), demonstrating that a screening system for average-risk individuals using multiple tests has a higher rate of false positives and associated costs [23].

 

 

Technological Advances and Artificial Intelligence

AI-Enhanced ECG Interpretation

The integration of artificial intelligence in ECG interpretation represents a promising development in addressing some of the limitations of traditional screening approaches. AI is transforming electrocardiography (ECG) interpretation, with AI diagnostics reaching beyond human capabilities, facilitating automated access to nuanced ECG interpretation, and expanding the scope of cardiovascular screening in the population [24].

Rhythm classification was the first application of AI-ECG, with AI-ECG models subsequently developed for screening structural heart disease including hypertrophic cardiomyopathy, cardiac amyloidosis, aortic stenosis, pulmonary hypertension, and left ventricular systolic dysfunction [25]. An AI-ECG algorithm demonstrates high diagnostic performance in comparison to reference cardiologist interpretation of a standard 12-lead ECG, with the use of AI-ECG reading tools potentially permitting scalability as ECG acquisition becomes more ubiquitous.

Diagnostic Accuracy Improvements

Recent studies have demonstrated notable improvements in diagnostic accuracy through AI-enhanced ECG interpretation. Cardiologists determined that on average 202 (13.5%), 123 (8.2%), and 90 (6.0%) of the interpretations required major edits from the computer program, AI-ECG algorithm, and final clinical interpretations, respectively, with 958 (63.9%), 1058 (70.5%), and 1118 (74.5%) interpretations considered as ideal from the computer program, AI-ECG algorithm, and final clinical interpretations, respectively [26].

Limitations and Challenges

Despite these advances, AI-enhanced ECG interpretation faces several limitations. The effective implementation of AI-powered ECG analysis is limited by issues such as systematic bias, with biases based on age, gender, and race resulting from unbalanced datasets, and a model’s performance being impacted when diverse demographics are inadequately represented [27].

 

Population-Specific Considerations

Athletic Population Screening

The screening of athletic populations represents one of the most well-studied applications of ECG screening. The risk of sudden cardiac death may be increased up to 2.8 times in competitive athletes compared with nonathletes, with the majority of sudden cardiac death cases caused by an underlying abnormality that potentially may be identified on cardiovascular screening [28].

The ESC recommends screening consisting of personal history, physical examination, and 12-lead resting ECG, whereas recommendations from the AHA includes only personal history and physical examination, with firm scientific ground to state that the sensitivity of screening with ECG is vastly superior to, and the cost-effectiveness impressively better than, screening without ECG [29].

Elderly Population Screening

Screening for atrial fibrillation in elderly populations has gained considerable attention due to the potential for stroke prevention. Quarterly screening was associated with an increase in the detection rate of atrial fibrillation, compared with annual screening (hazard ratio 1.71; 95% CI 1.06–2.76; p=0.029), with 40 incident cases detected in quarterly screening (7.2 per 1000 person-years) compared to annual screening [30].

Pediatric Considerations

The application of ECG screening in pediatric populations remains particularly controversial. Most pediatric cardiologists do not wish to see ECG screening in infancy, disagreeing with the view that there is sufficient evidence to propose ECG screening in infancy for long QT syndrome [31]. The disagreement is based on: (1) The effectiveness of such a program has not been evaluated in terms of outcome, (2) The ECG is an unreliable diagnostic tool with unacceptable reproducibility, specificity, and sensitivity, (3) The adverse effects of overdiagnosing or underdiagnosing LQTS in thousands of individuals have not been evaluated [32].

 

 

Ethical and Legal Considerations

Implementation Challenges

The implementation of ECG screening programs raises several ethical and legal considerations. If screening is to be done, it must be done well, with organizations conducting screening needing to consider a range of legal, ethical, and logistical responsibilities that arise from the beginning to the end of the process [33]. This includes consideration of who to screen, timing of screening, whether screening is mandatory, consent issues, and auditing systems to ensure quality control, with good infrastructure for interpretation of ECG results according to expert guidelines and follow-up testing for abnormal screening results being essential [34].

Psychological and Social Impact

The psychological impact of screening programs extends beyond the immediate clinical implications. There may be critical implications for those diagnosed with cardiac disease, including insurance, employment, the ability to play sport, and mental health issues, with several legal risks best addressed through 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 [35].

 

Current Guidelines and Recommendations

Professional Organization Positions

Current professional guidelines vary in their recommendations for ECG screening. The USPSTF recommends against screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at low risk for CHD events (D recommendation) [36] [37]. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening with resting or exercise ECG for the prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events [38].

In contrast, The American Heart Association recommendations do not include an electrocardiogram, with a recent AHA statement suggesting that those screening athletes should consider all children of similar ages in the selected venue, but still should not include an electrocardiogram [39].

International Variations

International guidelines demonstrate substantial variation in their approach to ECG screening. For sporting organisations that conduct screening of athletes, there are very few consistent guidelines on the age at which to start [40] [41]. The total rate of sudden cardiac arrest or death is very low between the ages of 8–11 years (less than 1/100,000/year), increasing to 1–2/100,000/year in both elite athletes and community athletes aged 12–15 years, with the conditions associated with sudden cardiac death in paediatric athletes and young adult athletes being very similar [42].

 

Future Directions and Emerging Technologies

Wearable Technology Integration

The integration of wearable technology represents a key opportunity for ECG screening advancement. Wearable ECGs have consistently demonstrated their non-inferiority in detecting arrhythmias when compared to the current standard of care, with different studies highlighting their ability to improve patient care and reduce healthcare costs [43]. The use of wearable cardiac monitoring devices demonstrated considerable symptom-rhythm correlation in various clinical settings, often resulting in a reduction in time to diagnosis and lower rates of ED visits, though this relatively new technology raised concerns for patient accessibility and privacy [44].

Artificial Intelligence Development

The continued development of AI technologies promises to address many current limitations in ECG screening. Artificial intelligence, specifically machine learning and neural networking, involves complex algorithms that allow computers to improve the decision-making process based on repeated input of empirical data, with these elements capable of being improved with a national database, evidence-based medicine, and innovation that entails a Kurzweilian artificial intelligence infrastructure [45].

Population Health Surveillance

The potential for ECG screening to contribute to population health surveillance represents an emerging application. The findings suggest that the potential role of routine ECG screening for early prevention of cardiovascular disease events, along with the optimal follow-up strategy, should be examined in future studies [46]. Of 3,698,429 individuals enrolled in the nationwide annual health check program, 623,073 (16.8%) had 1 minor ECG abnormality, 144,535 (3.9%) had 2 or more minor ECG abnormalities, and 56,921 (1.5%) had a major abnormality [47].

 

Critical Analysis and Discussion

 

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Conclusion

The question of whether annual ECG screening represents a valuable screening tool or a waste of resources cannot be answered with a simple binary response. The evidence suggests that the value of ECG screening is highly dependent on the population being screened, the specific methodology employed, and the healthcare system context in which it is implemented.

For specific populations, particularly athletes and elderly individuals at risk for atrial fibrillation, the evidence supports the clinical utility and cost-effectiveness of ECG screening programs. The integration of artificial intelligence technologies offers promise in addressing current limitations related to interpretation variability and diagnostic accuracy.

However, for the general population, particularly low-risk individuals, the current evidence does not support routine annual ECG screening. The combination of limited diagnostic yield, high false positive rates, and substantial costs creates an unfavorable risk-benefit profile that is not justified by current evidence.

Future research should focus on refining population-specific screening strategies, developing and validating AI-enhanced interpretation systems, and conducting large-scale prospective studies to better understand the long-term health outcomes and cost-effectiveness of different screening approaches. The integration of wearable technology and the development of more sophisticated risk stratification tools may further enhance the precision and effectiveness of ECG screening programs.

Healthcare systems considering the implementation of ECG screening programs should adopt a targeted approach, focusing on high-risk populations where the evidence demonstrates clear benefit. Universal screening programs, while appealing from a public health perspective, are not currently supported by the available evidence and may represent an inefficient allocation of healthcare resources.

The ongoing evolution of ECG screening technology, particularly the integration of artificial intelligence and wearable devices, suggests that the landscape of cardiac screening will continue to evolve. As these technologies mature and evidence accumulates, the risk-benefit profile of ECG screening may shift, potentially supporting broader implementation in the future. However, current decision-making must be guided by the available evidence, which supports a targeted, population-specific approach to ECG screening rather than universal implementation.

 

 

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