Cardiovascular preparticipation screening of the tactical athlete

Background

A marked divergence exists between European and American cardiovascular screening protocols for competitive athletes (CAs). This gap is magnified for tactical athletes (TAs), who experience significantly higher sudden cardiac arrest (SCA) than their civilian counterparts. In 2002, the United States (US) military restricted entry-level electrocardiogram (ECG) screening to high-reliability occupations, such as pilots, citing high false-positive rates and low SCA prevalence in young populations.

However, modern interpretation standards have since reduced false-positive rates from 20% to 2%, while retrospective studies reveal that SCA rates in TAs are double those of CAs. Consequently, the ACC and AHA have elevated ECG screening from “not recommended” to “reasonable to consider” – contingent on expert interpretation and adequate resources. Given this shift, it is critical to evaluate the potential impact of adopting universal screening within tactical organizations.

Purpose

The Electrocardiogram Risk Assessment to reduce Sudden cardiac Events (ERASE) pilot program was designed to identify the prevalence of cardiovascular conditions associated with SCA. By distinguishing between disqualifying pathologies and those amenable to treatment, the program aims to assess the feasibility of reinstating universal ECG screening for entry-level US military TAs.

Methods

The ERASE program integrated standardized history questionnaires and ECGs into screenings at six entry-level training sites. Cardiologists specializing in military medical standards adjudicated all ECGs and positive history findings. Abnormalities prompted immediate physical exams and supplemental diagnostics, prioritizing echocardiography within 24 hours to minimize training downtime.

Results

In 2025, ERASE screened 9,161 military trainees for SCA-associated conditions. ECG demonstrated superior diagnostic accuracy compared to history, yielding lower false-positive (1.58% vs. 7.64%) and disqualification rates (0.14% vs. 0.10%), while maintaining a higher true-positive rate (0.26% vs. 0.08%). Notably, ECG captured the majority of true positives identified by history while requiring minimal supplemental diagnostics: exercise stress testing (0.25%), cardiac monitors (0.22%), cardiac MRI (0.13%), coronary CT angiography (0.08%), exercise stress echocardiography (0.02%), transesophageal echocardiography (0.01%), and electrophysiology study (0.01%). Subsequent analysis will detail findings for treatable conditions, such as Wolf-Parkinson-White, vs. disqualifying pathologies like hypertrophic cardiomyopathy. There was one false-negative.

Conclusions

Integrating ECG with standardized history improved diagnostic accuracy while requiring minimal supplemental testing. These findings demonstrate that universal ECG screening is both feasible and scalable for large-scale military accession.