A five-minute cardiac screen for athletes?

It’s heart-wrenching when young athletes die of sudden cardiac death (SCD). This week, the death of Wes Leonard, a Michigan high school star athlete, was especially poignant since he collapsed right after hitting the game-winning shot.  This sort of tragedy occurs about one hundred times each year in America. That’s a lot of sadness.

The obvious question is: Could these deaths be prevented?

Let’s start with what actually happens.

Most cases of sudden death in young people occur as a result of either hypertrophic cardiomyopathy (HCM), an abnormal thickening of heart muscle, or long QT-Syndrome, a mostly inherited disease of the heart’s electrical system. Both HCM and Long-QT syndrome predispose the heart to ventricular fibrillation–electrical chaos of the pumping chamber of the heart. The adrenaline surges of athletic competition increase the odds of this chaos. Unfortunately, like heart disease often does, both these ailments can strike without warning.

Sudden death is sad enough by itself, but what makes it even worse for doctors (and patients) is that both these ailments are mostly detectable with two simple painless tests: the ECG and Echocardiogram (heart ultrasound).

Let’s get these kids ECGs and Echos then. Git-r-done, you might say.

On the surface the solution seems simple: implement universal cardiac screening of all young athletes. And you wouldn’t be alone in thinking this way. You could even boast the support of Dr Manny Alvarez of Fox News, and the entire country of Italy–where all athletes get ECGs and Echos before competing.

But America is not Italy and things aren’t as simple as Fox News likes to suggest.

There are three major flaws with Dr Manny’s simplistic proclamation that all (American) athletes should have pre-participation ECGs and Echocardiograms.

The Economic:

The estimated cost–in our current health care system–for adding an ECG and Echo to the sport’s exam is about $1000. That’s a bunch more than $19.99–the advertised price of the sports physical at my local grocery store’s walk-in clinic. Parents may be amendable to charging $19.99 to their credit card, but even when the safety of their teen is at stake, few can afford the current-day costs of ECGs and Echos.

Now, you could make the argument that 1000$ is ridiculously high. And you would own a valid point. But that argument goes to the heart of the healthcare debate.

Let’s consider this notion for a moment: I could listen to your teen’s heart, look at their ECG, place a hand-held ultrasound probe on their chest, and in a matter of five minutes I could clear them for competition. The ECG would exclude long-QT syndrome, and the Echo would exclude excessive thickening of the heart muscle. The reason why I could do this are threefold:

  1. My entire medical career revolves around understanding ECGs.
  2. I look at Echos nearly every day, and was schooled by one of its pioneers, Dr Harvey Feigenbaum.
  3. In general, I waffle a lot less than the average reader of subjective cardiac tests. (That trait might not be valuable at the Mayo Clinic, but it would be good for screening thousands of young people, who are normal 99.999% of the time.)

Ah, but that’s not how things work in our present health care model. Obviously.

You can’t just deliver quality care that easy. There’s got to be a certified technician and machine to do the studies–portable Echos will not work. Calling an Echo normal these days is totally insufficient, fraudulent even. There has to be a three page report documenting each section of the heart. And of course, I can’t officially read an Echo because I am not board-certified in Echocardiography, I am just board-certified in Cardiology and Electrophysiology.

It’s not just the high costs that make screening athletes problematic.

It’s the Math:

Why don’t the numbers support widespread cardiac screening of athletes?

Again, it isn’t as simple as Dr Manny suggests. He portrays ECGs and Echos as black and white, yes or no, high or low kinds of tests. That’s not even close to accurate. They are both highly subjective tests that require mastery of nuance, including the ability guts to call something “normal.”  When a young person’s life is at stake, shadows and innocent blips look much more sinister. Before guaranteeing the invincibility of a young athlete, doctors often see things on ECGs and Echos that “might be something.” Radiologists sometimes call these shadows “incidentalomas.”

That’s the rub with screening that Dr Manny omits. For every life saved by the screening test, there will be hundreds (perhaps thousands) of patients sent for more (and often highly invasive) testing. Doctors are not going to be wrong about sudden death in a young person. No way. No how. There will be more tests, not just because of defensive medicine, but also in the name of quality.

To the numbers: Rare diseases like HCM and Long-QT kill athletes at a frequency of about 0.01%. That’s the left side of the equation. On the right side of the equation are the risks of all the cardiac caths, electrophysiology (EP) studies and dye-requiring CT scans ordered as a result of the screening tests. Though an individual cardiac cath, EP-study or CT are low-risk, the cumulative risk of doing these on thousands of normal people surely approach the 0.01% chance of sudden death in an athlete. Said more simply, with made up numbers to make my point, if screening saves 50 of the 100 teens who die each year, but 50 die from complications that occur from chasing down incidentalomas, than it’s an expensive statistical wash.

The Reality of the Athletic Ethos:

The third major flaw with the idea that mandated cardiac screening will save lives is that making the diagnosis of heart disease doesn’t always equate to preventing sudden death. The athlete has to accept the treatment, which for them, like it was for Boston Celtic great Reggie Lewis, is often untenable.

Gosh, I wish we could save all the young athletes that die suddenly.

But the paradox of our present health care system is that awash in all its fury of available technology (the MRIs, the robots, the GPS-navigational-systems) is our inability to do simple things for the many.

That’s too bad.

JMM

P.S.: One thing that Dr Manny was spot on about was that more AEDs (Automatic External Defibrillator) in athletic arenas are surely a good thing. In the case of AEDs, there exists strong science to show that increasing their availability saves lives.

 

22 comments

  1. John,
    One thing you didn’t touch on was that this kid had to have a pre-participation physical. Who did it? Did the doc try to elicit the murmur of HCM? You can get these done at Kroger by a nurse. You can’t pick up long QT or a non-obstructive cardiomyopathy on physical but you get what you pay for. The old school physical of turn your head and cough is ridiculous. I think cardiologist are ideally skilled for this kind of screening.

    1. Correct. But the idea that cardiologists could screen that many kids illustrates the difficulties that I tried to point out in the post.

  2. It’s so sad that we are in 2011 and cannot prevent these sudden deaths. Hopefully they will be ways in the near future to change this.

  3. Excellent summary of the issues, JMM. So what do you suggest we do? I am a primary care pediatrician. I sign hundreds of these sports participation forms every year. In Pennsylvania where I practice, the patients and parents fill out an extensive past medical and family history form. If there are any red flags on that (dizziness with exercise, chest pain, fhx of scd before the age of 50), I send those higher risk kids for cardiology clearance. Do you think this selected screening is sufficient? One cardiologist in our area recommends doing ekgs on all at 13. This is burdensome for parents especially because I don’t have someone to read them in my office. Of course, will also result in a lot of false positives and unnecessary work ups as you described. What do you think about the value of PMHx and FHx in identifying kids at risk for SCD?

    1. DC,

      Thanks for your comment. Sorry for the delayed response.

      Your comment about the burdensome-ness of the screening ECG is exactly my point. If we (the healthcare people) decided to get serious about doing screening ECGs then the system would have to become much less burdensome. But that’s the thing, providing this service to many would mean ECGs and Echos would have to be less regulated and simpler, their reports less detailed–for all we really want to know is whether the kid has HCM or not. Same with the ECG; is it abnormal or normal? But that is not how healthcare is trending these days. Doing anything that you expect payment for is more complicated. (That’s not a complaint–just a fact.)

      On a practical note, I would say that a family history of sudden death or cardiomyopathy would warrant strong consideration for referral, as both HCM and Long QT are often heritable. On the rare occasion that I do a sport’s physical, usually for friends whose kids are leery of the inguinal hernia exam, I listen carefully in a quiet room for the murmur of outflow tract obstruction–with the usual provocative maneuvers. And I ask about the family history.

  4. IU must be progressive. In 1999 when my daughter played Soccer for IU, she had an ECG and ECHO. The Italian system has proven itself. Implement it!

  5. Why did you simply provide the lump ECG and Echo price. The EKG is $35-50 and the Echo is $300-$500 and should only come in if the EKG is abnormal. EKG is abnormal in 95% of HCM, Echo would then come in for specificity. Of course, this isn’t perfect but it’s better than what we have.

    1. Adnan,

      You make excellent points. We can quibble about prices, but both 500 or 1000 dollars far exceeds the threshold that the majority of parents would pay for a .01% chance of finding an abnormality.

      I do agree that adding an ECG to our current screening exam might identify a few more cases of life-threatening heart disease (ie, increased sensitivity.) But, and this is a big but, the issue of showing statistical benefit persists. ECGs are highly subjective. (See this post in which I show my ECG–along with the computer read “Acute MI.” ) So, as with many other screening tests, the complications from “further” testing related to the many ECG “false-positives” would negate any of its statistical benefit.

      That’s not to say I would tell a parent of a teen athlete not to have their child undergo an ECG or Echo if they were willing to pay for the tests. A normal ECG and Echo would surely confer a lower risk of sudden death to that individual. That said, though, you could also argue that if minimizing a teen’s chance of dying was the objective, the larger bang for the buck would be in investing in how to curb teen smoking rates and distracted driving–behaviors that contribute much more to overall teen health.

  6. Thanks, Dr John. Helpful! As a general pediatrician who does these sports physicals every day in the office, this is a nice summary and analysis of the rationale for no universal EKG/ECHO screening.

    I would point out that when there is ANY red flag on history or exam: new murmur, palpitation, syncope or pre-syncope with exertion, FH of early cardiac disease, etc, then of course we do expand the PE and do an EKG.

    The key is getting a well-trained pediatrician to administer the sports physical, ask the correct and necessary questions, and do a thorough exam including looking at growth, development, BP, and cardiac exam. And let me tell you, I believe THAT’S gotta be worth more than 20 bucks.

    I’ll add, one of the biggest hurdles for many families is they leave the exam until the day before try-outs! At that point, there is little availability for a PE and/or they are unable to see their regular doc who is tuned into PMH, previous exams, etc.

  7. I enjoyed your analysis and cogent discussion of universal pre-sport testing. We certainly make things difficult in the U.S. Why is this standard procedure in Italy, yet it is unaffordable and fraught with false-positives here? One answer is our insane medical liability culture but if we could get around that, I don’t see why the arguments you pose would not be an issue in Italy.

    1. Thanks, Dr Brayer,

      Thanks for asking such a relevant and hotly debated topic. It seems a lot of things are different in Italy. Though the Italians say their methods save lives, both Norwegian and US experts debate it. So, I think the issues of of mass screening for a rare disease, with a blunt, non-specific screening test is probably a highly flawed strategy–even in Italy.

    1. Thanks, Doc. You are correct. The decision on how much detail to leave in a post is something I struggle with constantly.

      I appreciate the comment, because doing just ECGs as screening simplifies the problem, but I think the gist of the three arguments persist.

  8. My daughter plays ASA Travel ball and this year she is a freshman so she needed a physical done. We are one of the many many Americans without insurance. It so happens a week before she was scheduled to have her physical she complained of chest tightening. She has been playing travel ball since 8 yrs old no asthma never a problem with breathing. She is a catcher and is required to wear gear sometimes in 90 degree weather 3 to 4 innings at a time. So being without insurance I took her to the E.R there they did an EKG and chest x-rays, blood oxygen levels etc. It turns out she had bronchitis. She was given an inhaler and steriods and days later with rest was better. While in the E.R the DR asked me if I knew she has a heart murmur which I did not, he said it was nothing to worry about. Later that week she went to the nurse who was going to admin a physical for the school Dr who would sign off on it. My daughter mentioned to the nurse that while she was in the E.R for bronchitis they found a heart murmur and the physical continued. I later received an e-mail that the Dr wanted my daughter to see a cardiologist. Having no insurance I called the E.R and asked them to fax all info EKG chest x-rays blood test (which were all good) to this DR he still insisted on a cardiologist. An incident happened with her soon to be coach and her about not having the physical done on time and my daughter is one of those children who hold things in after words were exchanged my daughter went to her homeroom and complained of chest tightening and not being able to breathe. Went to the nurse who immediately remembered heart murmur gave her oxygen and took blood pressure which was high (after her softball coach said she was a disappointment I guess it was high my daughter was upset) so neither my husband or myself got to the school in time enough for them they called an ambulance and rushed her to the same E.R where they did the same tests that came out perfect and my husband asked if this would’ve been brought on by her being upset like an anxiety attack? The Dr in the hall said looking at tests about 90% sure this was.
    Here is my question now after 2 EKG’s in 3 weeks x-rays of chests and blood work for oxygen levels why is the school Dr now insisting on an ECG? Is this necessary? After every test she had the ones for bronchitis and then the one for the anxiety attack which the E.R Dr’ s diagnosed as “inflammation” of chest walls? And prescribed Advil?

    I am so confused and upset at the coach and cannot understand this school Dr’ s insistence on a ECG for clearance. for the sport. I definitely care about my daughters health but after all these tests and her playing weekly with a fast pitch travel team I am just confused maybe you v=can shed some light on this for me.

  9. Great post on a very difficult topic! Having been a college athlete I was interested in this topic and attended a lecture on this topic(Sudden Cardiac Death in Athletes – Preventable?) at the HRS meeting in Denver a couple of years ago. The presentors were cardilogists from Italy.

    One seriously negative issue in the Italian system was brought up as a discussion point is the huge number of young athletes who are excluded from athletic participation due to an abnormal test result. The vast majority never would suffer SCD event. They also admitted there is a major problem with borderline cases that cause exclusion. In today’s unfortunate world of defensive medicine and fear of lawsuits – any athlete with borderline testing would more than likely be excluded from participation.

    Beyond participation in sports, this exclusion may negatively effect exercise habits lasting a lifetime. If an athlete is told “you may die if you exert youself physically” they are much more likely to not exercise. What negative impact does this have on their health as they grow older?

  10. I am an Athletic Trainer in Texas and I stumbled upon your blog while doing some research for my own. Thank you so much for your honest approach to this topic. We offer, but do not require unless the student-athlete’s medical history has red flags, Echo’s at our annual pre-participation physical exam. We have over 600 athletes take part in these physicals ( this is about half of our total athletic population) every year. Since we started offering the Echo, we have not had a single problem detected with the exception of the innocent murmur. For us and our doctors that perform our PPEs, the most important thing is an accurate and honest medical history.

    1. Megan,

      Thanks for sharing your experience. Your zero out of 600 positive illustrates the challenge of screening for a problem with an incidence of .01%.

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