Dr John M

cardiac electrophysiologist, cyclist, learner

A five-minute cardiac screen for athletes?

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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.

 

"Shadows" are now less valuable…

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Another huge day for cardiologists today.  CMS, or medicare or the government or whoever has decided that cardiologists who read images are making too much money. Nuclear scans and echocardiograms (ultrasound) are being arbitrarily cut by up to 40 percent. These scans form the backbone of a cardiology office.  Although they require a substantial initial investment of capital and maintaining a ‘quality’ lab requires expensive human capital these images are still lucrative.

The CEO of the American College of Cardiology says that “they are basically killing the private practice of cardiology.”  Really?

Cardiologists are so mad that their professional society, the ACC, is suing the federal government.

I guess the main question is whether cutting imaging reimbursement is good for patients?

What would my old mentor Dr Fisch think?

It is 1994. On the fourth floor outside the renal ICU in a bland room with a long table in front of a wall adorned by nothing in particular we sit surrounding the late Dr Fisch–the resident to the left, the fellow to the right and the students behind, always in that formation.  Old fashioned EKG’s are passed form left to right, the resident calling out the interpretation with a hopeful tone.  A grunt and passage to the right if correct, a peer over the impossibly thick glasses if wrong and in many cases a drawing of vectors to explain the error. Dr Fisch is a world famous expert in interpretation of these ancient, now 25 dollar EKG recordings. He is old, stern, but yet comes to work at age 75 to show us. We are tentative, except Staci, who in her short third-year medical-student white coat grins at him and he is disarmed.  But yet, on Thursdays our sessions are cut short at noon for ECHO conference.  We get antsy as the clock nears 12 noon; there is free food from drug reps – a tradition which has passed the same way of the VCR tape – and Dr Fisch says with the meekest of grins “you are off to study those shadows again, aren’t you.”  He is not a believer in shadows or nuclear scans.

So is it bad that fewer scans will be done?

There are indeed stories of non-symptomatic patients who were discovered to have terrible heart disease by nuclear scans.  Consider this though: a single nuclear stress test, ordered ubiquitously, exposes a patient to the same dose of radiation in 500 chest x-rays. Additionally, they are wrong up to 20-30 percent of time and worse yet, when wrong, they are  often “false positives,” which lead to cardiac catheterization and another 500-cxr dose of radiation and the potential risk of serious complications.

So naturally, one wonders how expensive nuclear stress tests could be reduced?  Here’s where being a master of the obvious comes in to play.  Judgment. There is a role for these tests, in certain situations with clear goals, a priori considerations and knowledge of their limitations. A common unthinking scenario is “patient Jane Doe is here with chest pain, we will just get a Nuc.”  Hopefully, the “just get a nuc” will be replaced with sound clinical judgment.  Of course, the problem herein is that a time consuming careful evaluation, examination and clinical judgment is increasingly poorly compensated and the concept of not ordering tests exposes one to potential liability.

Will suing the US government help matters? This master of the obvious is not optimistic.

My concern, maybe yours too, is whether these forthcoming changes will limit availability of access to cardiac care before a major cardiac event. Combine less access with our continually worsening lifestyle choices and it is easy to foresee rough seas ahead.

Once again, we will make due with less, as Thoreau said we should.

JMM