Quick answer: Not straightforwardly — mandatory ECG screening only works well in the handful of countries (Italy, Israel) with the national infrastructure and specialist expertise to interpret teenage athlete ECGs correctly. Without that, false positives are common and can cause real harm — unnecessary scans, sport exclusion, psychological stress — and better CPR training plus wider defibrillator access may save more lives than mass screening without the expertise to interpret it properly.
Coughs, it seems, are a bit like buses. I hadn’t had a cold for years… and then two arrived at once.
I had one a few weeks ago, and now another has turned up this half term — sore throat, irritating cough, that heavy fatigue that doesn’t quite justify being in bed but certainly makes you feel below par. Not keeping me awake at night, but enough to be annoying. Particularly frustrating when you’ve planned a week off for family time and exercise, only to find yourself mostly resting and behaving like a slightly grumpy patient.
So while I haven’t been in clinic this week, I did come across an interesting statement from the American College of Cardiology that made me reflect on two very recent cases. The statement followed new legislation in Florida mandating ECGs for high school athletes, with other US states considering similar laws. On the surface, this sounds entirely sensible. After all, if a simple test could prevent sudden cardiac death in a young athlete, why wouldn’t we do it?
But as ever in medicine, it’s not quite that straightforward.
In fact, this is a real-world dilemma I experience not infrequently. Only last week, a colleague contacted me about his 17-year-old son — very fit, very active, lots of sport — who had undergone a cardiopulmonary exercise (VO₂) test. A perfectly reasonable thing to do for fitness and training purposes. However, the ECG (the paper tracing of the heart’s electrical activity) recorded during the test looked abnormal.
As another example, another friend’s 15-year-old son — a keen footballer — underwent cardiac screening arranged by his parents last year. Again, the ECG was reported as very abnormal.
In both cases, the question was: What do we do now?
This is where things become complicated — clinically, ethically, and practically. Even if you aren’t a teenager yourself, chances are you will have relatives who are.
Why are ECGs in teenagers so hard to interpret?
The Problem With ECGs in Teenagers – Teenage ECGs are not the same as adult ECGs. They are still evolving.
Add to that:
Endurance training itself causes ECG changes.
There are well-recognised ethnic variations, particularly in Black athletes.
Many patterns that look “abnormal” to the untrained eye are in fact entirely physiological adaptations to sport.
Interpreting athlete ECGs is a specialist skill, and here lies the issue: if you mandate ECG screening for all high school athletes, do you have enough clinicians trained to interpret them correctly?
In reality, no.
Which countries already run mandatory ECG screening?
Interestingly, mandatory ECG screening laws exist in only a few countries, notably Italy and Israel. Italy has been running a structured national programme for around 40 years, and it has been very successful in reducing sudden death in young athletes. Crucially:
There is established infrastructure.
Screening is standardised.
Costs are relatively low.
Expertise is concentrated.
That is very different from introducing legislation in a healthcare system without that framework. In England, the The Football Association has operated screening programmes since the late 1990s, and the charity Cardiac Risk in the Young provides cardiac screening with cardiology support. This is not the same as nationwide mandated mass screening. What also gets forgotten is the uncomfortable truth that screening can cause harm.
Can ECG screening actually cause harm?
False positives are common — particularly if ECGs are interpreted by clinicians without sports cardiology expertise. And false positives lead to:
Follow-up echocardiograms
Exercise stress tests
Cardiac MRI scans
Temporary exclusion from sport
Psychological stress
De-training
Potential impact on scholarships or professional pathways
There is also the financial burden — which may disproportionately affect families on lower incomes.
From a systems perspective, the workload implications are enormous. Even locally in Bournemouth, we receive large volumes of “advice and guidance” ECG queries from primary care. Scale that up to every competitive teenager in a state, and the pressure becomes obvious. Also importantly, many sudden cardiac arrests in young people occur at home — not necessarily during organised sport. An ECG mandate in schools would not address that.
Are defibrillators more important than ECG screening?
Which raises an alternative priority, are automated external defibrillators (AEDs) more important? There is strong evidence that rapid cardiopulmonary resuscitation (CPR) and access to automated external defibrillators (AEDs) save lives.
Ensuring: AEDs in sports facilities, clear emergency action plans and staff trained in CPR may, in many settings, have greater impact than mass ECG screening without adequate expertise.
Sports cardiology remains a niche subspecialty. There is no formalised training pathway for most cardiologists in this area. I regularly attend a national multidisciplinary sports cardiology meeting with some of the foremost experts in the UK. What always strikes me is how nuanced these discussions are. The decisions are rarely black and white.
We are often balancing:
Statistical risk
Career implications
Psychological wellbeing
Parental anxiety
Long-term health
For a 15- or 17-year-old whose entire identity may revolve around sport, these decisions matter enormously.
So should we mandate ECG screening? On principle, screening sounds like a good idea. In practice, without: standardised interpretation criteria, iwdespread specialist expertise, affordable infrastructure, clear pathways for managing borderline findings it risks creating anxiety, cost, and unintended harm. As with many areas of medicine, good intentions are not enough. Implementation matters, and sometimes the more important intervention is not another test — but better emergency preparedness.
As ever, medicine is about balance, and occasionally, about resisting the temptation to assume that more testing automatically means better care. This last point is of huge wider significance. In my opinion it seems in medicine doctors are increasingly incapable of making clinical decisions, whether for fear of missing something or being criticised, or simply that they don’t have the training or expertise. As a consequence, they request test after test. This is not only very expensive, but a poor use of resource. Don’t get me wrong, tests are important, but in our healthcare economy, and for good practice, they have to be used appropriately. You can’t seem to get through A&E without someone wheeling you through the CT scanner for one reason or another. Time for me to get off my soapbox and reach for another strepsil.