The NY Times gets it wrong on ECG screening of young athletes

When a news source as powerful as The NY Times publishes an article about sudden cardiac death in young people, one expects accurate information. It’s far too important a topic to write about imprecisely. This piece, entitled Should Young Athletes Be Screened for Heart Risk, included numerous inaccuracies and failed to tell important facts about the complexities of widespread screening of athletes. It was a really bad post.

I’d like to help clarify things.

Let’s state the obvious first. Few events in medicine–and life–pull at your heart more than the sudden death of a young person. As a Dad, it hurts just thinking about it. I accept that the tragic nature of the problem can cloud thinking on the matter.

As a heart rhythm doctor, I am tasked with diagnosing and treating conditions that could cause life-threatening arrhythmias. This is a tough problem. One reason is the rarity with which sudden death occurs in the young and outwardly healthy. Another is that sudden death rarely gives second chances. Its finality, therefore, motivates medical people to strive for 100% effective treatment. Again the obvious: whenever one strives for 100% efficacy, over-diagnosis and over-treatment become more likely. Never missing anything has steep costs.

Now, let’s get to the specifics of the Times’ misstatements:

On the incidence of sudden death:

As stated by author, Mr Anahad O’Connor…

“Once thought to be exceedingly rare, sudden cardiac death is far more prevalent among young athletes than previously believed, recent research has shown.”

Not exactly. The two scientific papers described as ‘recent’ were published in 2001. In fact, the lead sentence in the referenced policy statement from the American Academy of Pediatrics states, “in the [US], there is no centralized or mandatory registry for pediatric sudden cardiac arrest (SCA)…Available data generally are collected through media reports, from lay SCA advocacy groups, or from peer-reviewed publications, often from major referral medical centers.” In other words, we have no idea whether sudden cardiac death is becoming more prevalent in the young.

On who is at risk:

“While it can strike those who are sedentary, the risk is up to three times greater in competitive athletes.”

This statement makes athletics sound dangerous. Given our crisis in youth health, that seems unwise. Here’s another way of stating the known facts. The best peer-reviewed estimate available (Circulation, 2009) for sudden death incidence (US) in young people are that approximately 100 competitive athletes die suddenly per year. Considering the tens of millions participating, the actual death rate is 0.6 per 100,000 person-years. Keeping the things that threaten our youth in perspective, and even if we agreed on a three-fold increase in risk from competitive athletics, tripling the risk to 1.8 per 100,000 person-years hardly seems dangerous. The bottom line, which should have been written clearly, is that sudden death in the young is exceedingly rare—and three times rare is still rare.

At the risk of sounding unsympathetic to Ms. Varrenti, a grieving mom who started a foundation dedicated to sudden death after her teen died, I disagree strongly with her statement that…”it [sudden death] happens all the time.”

On ECG screening:

The rarity of sudden death in the young person directly impacts our ability to prevent it. Enter the debate about screening ECGs, which I have written about previously. This is where the Times gets it really wrong. First, on simple facts, they are way off on the price of an ECG. Just trust me: no one charges 1400$ for an ECG. Most often, it’s below 100$.

More importantly, the article overstates the benefits of the ECG as a screening tool. Though it is true that an expert electro-cardiographer may detect abnormalities in many of the underlying conditions (hypertrophic cardiomyopathy, Long QT syndrome and myocarditis) predisposing to sudden death, this doesn’t mean that’s what will happen in the real world. I respectfully disagree with family physician, Dr. Drezner, who stated that newer methods of ECG interpretation are better. If anything, ECG skills have worsened. The very human skill of ECG reading has gone the way of the physical exam. It’s not taught, appreciated or desired anymore. And despite what you may have read, computers cannot interpret ECGs accurately. (Not even iPhones) The under-detection of ECG abnormalities combined with the sharp rise in over-investigating normal findings will negate the rare finding of a potential abnormality.

Can we screen all athletes?

Dr. James WIllerson, the head of Texas Heart Institute, and beneficiary of a five million dollar private grant to screen 10,000 Houston-area kids, says “if we save even one life, it would be worth it.” That’s hard a statement to argue with. And it’s certainly easier to strive for such lofty goals with 5-million-dollar grants.

Here are some questions that Dr. Willerson should have been asked:

  • How would you know whether finding an ECG abnormality saved a life?
  • How do you measure the emotional costs of holding a kid out of sports?
  • Does prohibiting a kid from sanctioned athletics prevent him (or her) dying on a playground or at home?
  • Will you tell us how many extra heart tests (and complications thereof) will be done in the name of saving one life?

The Times should correct (or add too) this terribly flawed story. It’s important for the youth and parents of America to have accurate information about sports-related death.

I’m no journalist, nor a precise writer, but it’s really important that educators of the public understand what we were taught in medical school: No data is better than bad data.

JMM

P.S. I am not against the use of the ECGs in individual cases in which a doctor and patient understand the pre-test likelihood of abnormalities. Rather, these comments pertain to the widespread screening of low-risk populations.

Comments

  1. Christopher says

    Yeah, I too would like to know what this “new” ECG technique is that makes it somehow better…Usually the only things you can rely on with a computerized interpretation is the axis, voltage-criteria LVH, and measurements. Although, if you’ve got any sort of baseline wander or U-waves then the QTc will be suspect.

    No silver bullet here.

  2. Ken Grauer, MD says

    JOHN,

    I saw this NYTimes post earlier – and just shook my head. Your reply is SUPERB. I linked back to your prior posts on this subject and found them equally superb (especially the one where you display a “sample” screening ECG read as “Acute MI” by the computer – as well as your “Adult EP’s Sports Physical” in which you “passed” the athlete despite omitting the hernia exam … ). My thoughts:
    1) Your sense of perspective is enviable and 1,000% on target.
    2) You could have a 3rd career (in addition to being a biker and electrophysiologist) as a writer.
    3) Any chance you might send this post to the NYTimes as a letter?
    4) I hope it is OK that I pass on the link to this post when asked by others about the NY Times article.

    THANK YOU for writing this!

  3. Staci says

    Disclaimer: I am not a doctor, so I am not speaking from any clinical knowledge whatsoever. How can ECG screenings detect an abnormal rhythm if it is not a sustained rhythm? There are people who go undiagnosed with an abnormal heart rhythm for years (or entirely) because their hearts aren’t beating abnormally when seeing their doctor. My sinus tachycardia wasn’t determined until I wore a Holter monitor.

    Just a thought. The ECG screening just doesn’t sound effective for this purpose.

  4. Lisa says

    Great response. If nothing else the article is naive regarding the ability of family physician’s who generally perform the sports physical to recognize a prolonged QT interval or even appreciate inverted T waves. I have heard too many times from internal medicine physicians “Well, I don’t see it.” as in if they don’t see it, it must not be so; even when three well qualified Electrophysiologists have diagnosed it. The last time that happened was a month ago and the statement actually came from the mouth of an Interventional Cardiologist. What good would the test be if the reader can’t correctly interpret it?

  5. Jay says

    I echo the sentiments of others above. John, this was a wonderful and provocative post.

    As I’ve already pointed out on Twitter, real impact in the prevention of sudden cardiac death in athletes may best come from proper training of athletic staff in recognition of sudden cardiac arrest and AED use. Simple AED deployment is not enough.

    The tragic case of Wes Leonard is highlighted as the lead photo in the New York Times article. Wes collapsed on the court and died shortly after making the winning shot in a high school basketball game. Autopsy later confirmed that he had a dilated cardiomyopathy and died of a fatal arrhythmia.

    Sports Illustrated published a feature length story this past February on this tragedy http://sportsillustrated.cnn.com/vault/article/magazine/MAG1194912/index.htm

    The saddest part of the story for me was reading about what happened after he collapsed. Well meaning folks thought this was heat exhaustion and cooled him with ice packs. Only later a ER nurse working concessions came down, recognized this was a cardiac arrest and asked about an AED. The AED was located stored away in office “forgotten.” It had formerly hung on the wall, but was removed due to tampering. When the AED was finally applied, it was nonfunctional due to battery depletion.

    Imagine the same gym with a proactive training staff taught in their health class about CPRs and AEDs. Imagine a well maintained AED hanging in a public location. Things may have turned out differently.

    Jay

  6. Laura Wall, VP SADS Foundation says

    Thank you for this excellent piece. So often families, upon the loss a child or young person, call for universal ECG screenings or drop everything to raise funds for AEDs. These are very sensitive and volatile subjects, especially during the critical time after a death. The SADS (Sudden Arrhythmia Death Syndromes) Foundation’s mission is to ‘support the families and save the lives of those affected by heart rhythm disorders’, and that’s what we do, every day. The SADS Foundation’s statement on universal screening is directly in line with what you have written. http://www.sads.org/Advocacy/Actions—Alerts/screening-to-prevent-sudden-death. Thank you for bringing light to this extremely sensitive topic.

  7. Eric says

    Doc M – I’m curious what you think the proper protocol should be for diagnosing those at risk for SCA. Fact is, it isn’t often that CPR and AED’s are able to save the live of someone in arrest even if we do train all the people in the universe. And expecting the family physician to determine who should get an ECG is giving credit to a specialty that is over-worked and under appreciated. A recent AHA study shows only 6% of physicians ask the questions on a physical that can determine if someone is at risk. That percentage would indicate doing a physical at all is a complete farce. Why don’t we just smack them on the butt and put them on the field. Those that are trying to make a difference by doing something rather than nothing deserve the opportunity to see if they can make a difference without your sour attitude about peer reviewed material versus the Academy of Peds. Truth be known, no one really knows the true SCA statistics. I’m disappointed in your negativity….it doesn’t save lives.

  8. Josh Scholnick says

    While there are obvious flaws with the NY Times article, I think you are dismissing ECG screening too quickly. The data from Italy merit serious consideration, even if our two health care systems are very different. The Italian protocol includes rule-based ECG interpretation which seems to greatly reduce the rate of false positives. They reduced SCD in athletes from 3.6 per 100k person-years to 0.4 per 100k person-years. The cost per year of life saved was well below $50k.

    In our practice, we will perform a state-mandated commercial drivers license physical, including vision, hearing, blood pressure and urine testing, for under $70. I think we could complete the exam described in the ESC guidelines for about the same amount, with about 15-20 minutes of physician time. Of course, an unhealthy commercial driver risks more than his or her own life, but a young person’s death on the playing field is particularly devastating. There is no question that a few dozen young people are alive today in norther Italy because of their national approach to screening.

  9. Ken Grauer, MD says

    JOSH – I think it is a “mixed bag” with pros and cons on both sides of the ECG screening fence. ECG screening will probably pick up some abnormal tracings that lead to Echo and ultimate diagnosis of HCM (hypertrophic cardiomyopathy). Along the way will be many false positive “atypical” ECGs. ECG screening is far from perfect – and will still miss many (most) young athletes at potential risk.

    My fantasy (when I was in primary care) was for someone to promote rapid (limited view) Echo that should be able to pick up virtually all cases of HCM (with far greater sensitivity and specificity than ECG screening) – which given limited views (no more than limited views should be needed to screen for HCM) – should be quick-to-do and able to be priced at no more than a 12-lead …

  10. Josh Scholnick says

    As I understand it, the Italians have about 9% screen positive by history, physical and ECG. After echo and cardiology consult, they described 7% as false postive and 2% remained disqualified from competition. Almost all the national team athletes get a massive workup with echo and in some cases MRI, allowing calculation of the false negative rate of their screening protocol. They think it’s very low for HCM, somewhat surprisingly.

  11. Ken Grauer, MD says

    My understanding is that sensitivity of Echo for picking up HCM should be near 100% (assuming adequate visualization) – so that the false negative rate when assessing for HCM if Echos are done should be near zero. The main issue is cost.

    This clearly is an issue where Dr. John has the most expertise – so I’d love to hear his input re the Italian system of screening athletes.

    • Dr John says

      I can leave a more detailed response later, but no…the false-positive aspect of Echos is not insignificant. Not by a longshot. The swath between hypertrophic cardiomyopathy and what’s normal thickening in an athletic young person is wide. These are shadows, my friend. In US healthcare, we struggle with what is normal.

  12. Ken Grauer, MD says

    Hi John. I was referring to false negative (not false positive). My impression was that if an Echo reports normal wall thickness – that the patient does not have HCM.

    The false positive issue is entirely something else. My impressions from Barry Maron’s work (including specific interaction from patient referral to him) was that there is a HUGE spectrum of HCM with as you note struggle to distinguish between some grades of normal athletic heart vs abnormal.

    No method of screening will be perfect. My thought simply being that if a lower cost (limited view) Echo could become mainstream – that it would at least prevent overlooking HCM in young athletes at comparable cost to the much lower sensitivity/specificity provided by screening ECG. But limited view Echo (as you note) would of course not solve the problem of potential false positives ….

    THANKS again for your input. It is a LUXURY to have access to a biker/AFib doctor/EP specialist by way of your blog!