Cardiac screening: physician-led or a score based approach?
Authors: Abela M , Grech V 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Research innovation and development trust Beating Hearts Malta.

Introduction
Sudden cardiac death (SCD) is an important cause of morbidity in young individuals. Cardiac screening may help identify high risk subjects and enable physicians to implement various early preventive strategies. However, geographical limitations and physician related expenses hinder the feasibility of widespread screening.

Objective
The objective of this study was to compare a physician-led assessment with a score-based approach.

Methodology
Students attending Form 5 (2017/2018 scholastic year) were invited to undergo cardiac screening. The screening protocol consisted of a questionnaire, ECG and an onsite consultation with a physician (Approach 1). The questionnaire included symptomatology, family history and athletic ability. Subjects were referred based on symptoms or red flags in the family history or ECG.
Questions from the validated Sports Cardiology British Columbia (SCBC) questionnaire were also included in the questionnaire.[1] The SCBC score was calculated retrospectively and a score ≥7 would have required physician referral. Those with red flags in the family history or ECG would also have been referred (Approach 2). The referral, diagnostic rates and costs were compared for both approaches.

Results
2672 students gave consent to undergo cardiac screening (mean 15.0±0.3 years, 50.4% female, 95.85 Caucasian). Patients who were under follow-up for known heart disease were excluded (n=9). 9 subjects were diagnosed with a condition linked to SCD (n=5 WPW, n=2 coronary anomalies, n=1 HCM, n=1 LQTS).
A physician led screening method (Approach 1) led to 109 (4.1%) referrals. The commonest reason for referral was an abnormal ECG (n=99, 3.7%) in isolation or in combination with symptoms/family history (Pie Chart). ECG was far more sensitive (88.9% [95% CI, 50.7% to 99.4%]) compared to symptoms (22.2% [95% CI, 3.9% to 59.8%]). Symptoms and ECG had comparable specificity (99.3% [95% CI, 98.9% to 99.5%] vs 96.5% [95% CI 95.7% 97.2%]).
Approach 2 would have led to more referrals (14.3% (n=382), p&lt;0.001)) compared to a physician-led approach. 294 (n=11.0%) had a SCBC questionnaire score of ≥7, most (n=277, 10.4%) did not have other red flags (family history or ECG). The sensitivity of this approach was however comparable to ECG (88.9% [95% CI, 50.7% to 99.4%]). Specificity was also high (89.4% [95% CI, 88.2% to 90.5%]). One individual would have been missed, resulting in a lower diagnostic yield (2.2% vs 8.3%, p=0.005).
Having a two-tier approach (SCBC and ECG initially) led to a 49.4% cost reduction. The total cost of the screening program would drop to €70,079.95, equivalent to €26.32/individual screened. The cost per cardiac diagnosis linked to SCD would drop to €7,786.66 per cardiac diagnosis.

Conclusion
A two-tier approach leads to substantial reductions in cost, with no negative impact on sensitivity and specificity. The impact of score-based questionnaires should be evaluated in larger cohorts.