USU Initiative reexamines ECG Screening to Reduce Sudden Cardiac Death of Service Members

The Military Cardiovascular Outcomes Research (MiCOR) program at the Uniformed Services University (USU) is expanding its initiative to resume electrocardiogram (ECG) screening on basic training recruits. The screening utilizes improved ECG interpretation to reduce occurrences of sudden cardiac death (SCD) in service members through identification and prevention.

Before 2002, ECG screening was frequently added to the standard historical and physical examination for pre-enlistment screening. An ECG measures the electrical activity, the rhythm of heart beats, as well as the strength and pace of electrical impulses through areas of the heart. It is a vital tool in checking for different heart conditions.

Cardiologists combine a patient’s reported medical history, physical exam, and ancillary studies, such as an ECG, to form an opinion on a diagnosis. ECGs can detect 80-86% of conditions associated with SCD. Yet, a false positive rate of 25% for ECGs at the time meant one in four applicants didn’t qualify for service until completion of additional screening.

That additional step meant a potential loss of the applicant to another career field. When factoring in costs associated with follow-up testing and the perceived low rate of SCD occurrence in the military, the Armed Forces Epidemiologic Branch recommended ending screenings at pre-enlistment sites. ECGs continue for service members in high reliability occupations such as pilots and special forces.

However, when compared to their collegiate athlete counterparts, service members experience SCD at a higher rate. There are 2.3 sudden deaths per 100,000 for collegiate athletes as compared to 11.1 sudden deaths per 100,000 for military recruits.

Each death is devastating to the family. And when the death occurs in the operational field, it can pose a risk to the unit and the mission.

Leading the initiative to resume ECG screenings for conditions associated with SCD are Drs. M. Alaric Franzos and Mark Haigney. Franzos is director of Biomedical Research at MiCOR and associate professor of Medicine in the School of Medicine (SOM) at USU. Haigney is the director of Cardiology and professor of Medicine and Pharmacology in the SOM at USU.

Also collaborating with Franzos and Haigney is Navy Capt. (Dr.) Adam Saperstein. Saperstein was the outgoing Brigade Medical Officer at the U.S. Naval Academy when screenings began there and is now associate professor and vice chair for Education in the Department of Family Medicine at USU’s SOM.

The initial collaboration between USU and the service academies began in 2020. The superintendent of the U.S. Naval Academy in Annapolis, Md., reached out to USU following two sudden cardiac deaths and one sudden cardiac arrest of midshipmen the previous year.

During the initial year of screening, the entire Naval Academy’s 4,095 midshipmen underwent ECG screening. Of those midshipmen, 53 received positive ECG results. Following additional screening, 16 received a true positive result.

Ten midshipmen possessed a condition associated with SCD and initially received a disqualification score. However, seven of those 10 underwent treatment and subsequent approval to return to duty.

Franzos says, “100% of them were successfully treated and 100% of them were returned to duty with the ability to take on any occupation in the military including flight, special forces, or dive.”

Only three midshipmen received disqualifications for continued service. Franzos says all three identifications were identified strictly through ECG and none by history or physical exam. After reporting their data at meetings of the American College of Cardiology, the health community and Congress took notice.

Following a mandate from the National Defense Authorization Act 2022 and the House Armed Services Committee, the screening expanded to the freshmen classes of the U.S. Military Academy in West Point, New York, and the U.S. Air Force Academy in Colorado Springs, Colorado.

The second year of screening saw 3,531 cadets and midshipmen. Thirty-three received a false positive ECG result with only 10 of those being true positives. And while three of the service members continue to undergo surveillance, seven received treatment and then approval to return to duty. The false positive rate for these screenings was even lower at 0.94%.

If the initiative is funded further, the next goal is to reach out to other military sites to establish the screening process. Additionally, Franzos and his team hope to bring in additional ECG technicians to help oversee the increasing number of service members and expedite follow-up examinations.

“Our goal is to be able to have a rapid turnaround for the vast majority of people that need additional testing,” says Franzos. This is mainly to minimize the risk of a new recruit from falling behind to a later class.

“The contribution of the ECG screening from Dr. Francis O’Connor and the sports medicine fellowship at USU was very helpful, especially during the heaviest part of the screening when we were evaluating 150 [service members] a day,” says Haigney.

“It’s our major focus at MiCOR to reduce sudden cardiac deaths to the absolute lowest number possible,” says Haigney. Although some causes of sudden cardiac deaths can’t be explained, he says, “other times it’s just very straightforward hypertrophic cardiomyopathy or some other condition where the ECG is very useful.”

The broader screenings won’t occur at pre-enlistment sites since cardiologists aren’t available there to oversee the results. But Franzos hopes with future approval, recruits will receive the ECG screenings when they get to basic training. “Then we have control over their follow-up, their ability to get continued medical care. Additionally, specialists can help make a formal diagnosis or refute a false positive finding on an ECG,” says Franzos.

“We’ve known for almost 20 years that sudden death was a big problem in the recruiting populations and nothing changed,” says Haigney. “I think people just felt that it was hopeless, there was nothing that could be done. I think USU is going to play a big role in getting this problem under control,” he says.