As we noticed, the rising trend in many companies and even in governmental companies to use echocardiography as a routine assessment tool before employment for all subjects irrespective to medical history or clinical examination for fear of employing an apparently healthy person undiscovered cardiovascular disease which will lead to higher medical insurance and financial costs, beside the risk on the employee and his colleagues or general population. So we designed this study to judge this practice in the light of our country with its limited resources. Also, the previous studies studied different population age and was done in western countries with better health care system and lower incidence of rheumatic heart disease. And as we expect that the results will support our recommendations to the authorities to stop this unnecessary practice to save time and cost and to avoid unnecessary psychological stress.
In our study, the fourteen elements questionnaire only revealed 13 persons with abnormal findings and this can be attributed to the socioeconomic factor with the fear of losing the job which is so valuable for them so they tended to deny the symptoms and their personal and family history of cardiovascular diseases despite their previous orientation by physicians as regards the safety purpose of these data.
As regard time cost, the total time consumed was about 4000 h (≈166.7 day) which reflected as a significant delay on the services offered by echocardiographic unite for regular work.
And the total money spent for the examinations was 218550 Egyptian pounds which is considered a large burden in a developing country with subjects of low economic level, and in comparison with the few data added by echocardiography in the study, it looks unpractical and costly as a routine examination tool for detection of cardiovascular abnormalities in subjects without symptoms, clinical, and/or ECG abnormalities.
The study suggested that the participants suffered from various degrees of psychological stress caused by referral for echocardiography where 68% of them had severe psychological stress while 32% had mild to moderate psychological stress, which should be put into consideration while recommending this test.
From the 795 subjects who were routinely examined by echocardiography as a pre-employment test, only 9 subjects had abnormal findings; 6 of them already had abnormal clinical and/or ECG findings, so only three subjects (0.377%) had cardiac abnormalities that were detected only by echocardiography but their abnormalities were non-serious or non-significant forms (Table 5).
Lindekleiv H et al.’s study found that echocardiographic screening the general population for structural heart disease had no benefit for death or the risk of myocardial infarction and CV stroke. The prevalence of structural heart disease was 7.6%. They had a higher prevalence than our study due to the higher age of their studied group (mean age was 60 years) and their study contained a larger sample volume of 3272 subjects .
We found that 18% of the subjects had a heart rate be between 100 and 120 b/m (sinus tachycardia), which may reflect the increased psychological burden for fear of the rejection after the echocardiographic examination.
Of the seven subjects with elevated BP during screening, two were known to be hypertensive patients on medical treatment but not well controlled with evidence of LVH by ECG, and echocardiography confirmed the diagnosis of LVH in these two patients. Two of the remaining five subjects truly have grade 1 hypertension and were managed with lifestyle modifications, and their ECG and echocardiography were normal. The remaining 3 subjects had stress-induced elevated BP with normal home BP readings. In this group, echocardiography did not add new data.
Subjects with DM, family history of SCD, and family history of premature CAD were asymptomatic with normal cardiac examinations, ECGs, and echocardiography.
The two subjects with a history of single attack of syncope were diagnosed as neurogenic syncope (one of them syncopal attack occurred during hard work in hot weather and the other during prolonged fasting when he was in long-standing in a queue) without any other clinical, ECG or echocardiographic abnormalities.
As regards the 14 subjects with abnormal ECGs, five of them had abnormal echocardiographic findings (Table 4) while the others had normal echocardiography.
Despite the majority of examined subjects were from rural areas, we did not find rheumatic heart disease cases which were unexpected to the authors, but we tried to explain this by the wide empirical use of long-acting penicillin injection at a low threshold in children with symptoms mimic rheumatic fever or even just elevation in ESR or ASOT in the last few decades, but this number of subjects couldn't be enough to give such result, we think this point needs further screening with a much higher number of participants.
Also, hypertrophic cardiomyopathy (HCM) is the most common inherited heart disease; we did not find HCM cases and we attribute this to the relatively small study shamble for such disease with prevalence rates between 0.2 and 0.3%.
Data coming from the 25-year Italian experience for screening to detect HCM in young competitive athletes stated that although echocardiography is the main diagnostic test for HCM diagnosis, it is expensive and impractical as a screening test for large populations  and they recommended twelve-lead ECG (in addition to history and physical examination) as an alternative, cost-effective method for population-based screening and stated that 12-lead ECG may be as sensitive as echocardiography in detecting HCM in the young athletic population. They put in their consideration the significant socio-economic impact and need for the cultural background .
Because of the low prevalence of structural heart disease among the general population, echocardiography has traditionally not been considered justified in low-risk individuals, although it is recommended in screening asymptomatic individuals with a family history of sudden death or hereditary diseases affecting the heart or the great vessels .
Unequal gender distribution, limited age group, intra-observer variability, and the pretest bias of the examiners that young apparently healthy subjects will have normal examinations.