Every three days, a young athlete somewhere in the United States collapses and dies due to an undetected heart problem. It’s a tragedy that Gian Corrado, MD, who works in Sports Medicine at Boston Children’s Hospital, has seen unfold firsthand. He was an undergraduate playing pick-up basketball when one of his teammates died suddenly on the court.
“It’s uncommon,” he says, “but it’s not so uncommon that it may not touch you. It happens, and we have no effective, efficient way to screen for it.”
There is a lot of interest in using heart screening in young athletes to reduce sudden death risk . The NCAA’s chief medical office recently suggested that it may be useful to routinely perform electrocardiograms (EKGs) and possibly other cardiac tests on some collegiate level athletes. A January 2016 opinion piece on this issue in the New York Times drew a lot of attention. Cardiac screening has also been proposed for other groups, such as children starting certain types of medications.
But there’s widespread debate in medical circles about such broad usage of EKGs. Why is this so controversial? If it’s such a valuable test, why doesn’t everyone get routine EKGs?
A large part of the debate comes down to accuracy.
EKGs yield a notoriously high number of “false positives,” or red flags that turn out to be red herrings. For example, an EKG may appear to show an abnormal pattern that is not actually problematic. As many as one in three young, athletic individuals may have such EKG patterns, but the vast majority of them do not actually have a heart problem.
“Proponents feel strongly that the opportunity to identify young people who may be at risk for cardiac arrest could save lives,” says John Triedman, MD, a cardiac electrophysiologist at Boston Children’s Hospital’s Heart Center. “If you can identify those kids, you could keep them away from risky activities, such as competitive sports, and/or start medical treatment.”
Those who oppose widespread EKG screenings argue that frequent false positives can burden athletes and their families with unnecessary anxiety, additional testing and needless restriction from activity. This side also argues that the ‘benefits’ of restricting children from sport have not been shown. “And for many of the diseases that can be detected by screening,” adds Triedman, “benefits may not even exist.”
More data is clearly needed. To that end, the National Institutes of Health is organizing a nationwide registry to gather data on undetected heart disease in young people, which should help to answer some of the questions that have been raised. Triedman adds that Boston Children’s, in conjunction with the New England Congenital Cardiology Association, is also creating a regional database that will enhance our understanding of some of the genetic causes of cardiac arrest in the young.
For the moment, Triedman emphasizes that the debate around EKG screening is “very academic.”
“It’s informed by statistics that are difficult to interpret,” he says. “More importantly, it relates to the topic of health policy in our society — not the individual relationship between parents and their child’s pediatric provider. Although parents and caregivers want to know ‘the facts’ about EKG screening, the emotional component of their concern is equally important.
“If parents are worried about their child,” he continues, “they should talk to his or her doctor or nurse and express their concerns.”
The sports medicine physician
“The American Heart Association [AHA] has a lot of good reasons for not supporting widespread EKG screenings,” says Corrado. “But we’re debating the wrong thing.”
What we should really be talking about, he says, are ultrasounds.
An ultrasound of the heart, called an echocardiogram (echo for short), shows a picture of the heart and its structures. EKGs monitor electric conduction, but “the vast majority of conditions that cause sudden death on the court or playing field are structural,” says Corrado. “Even among the electrical problems, most have some identifiable structural component.”
A May 2016 blog from the AHA reported that as many as one in ten individuals with hypertrophic cardiomyopathy (HCM) — a disease characterized by abnormally thickened heart muscle walls and the leading cause of sudden death in athletes — will have a normal EKG. Characteristics of HCM are evident on an echocardiogram.
Corrado proposes that frontline clinicians, such as primary care physicians, nurse practitioners and athletic trainers, can use a portable echo machine to screen for conditions that predispose athletes to sudden cardiac death.
He doesn’t dispute that cardiologists are uniquely qualified to diagnose serious heart disease on echocardiogram. But for the purposes of a pre-participation physical exam, Corrado says frontline providers trained on “focused ultrasound” exams can identify markers of heart disease that warrant referral to a cardiac specialist.
Corrado investigated the utility of this approach, finding that portable echo measurements obtained by frontline physicians were not statistically different than measurements obtained by cardiologists. This model also reduced the percentage of athletes referred to cardiologists for further cardiac testing.
Corrado then tested the feasibility of this model, finding that portable echos performed by a frontline physician may actually be more cost-effective than EKG screenings. The results of this study were published in the September 2017 Clinical Journal of Sports Medicine.
Access and advocacy
To Corrado, screening athletes is more than just a public health issue; it’s a social justice issue.
“If we say, ‘Parents who make an appointment with a cardiologist can advocate for their child to be screened’,” he notes, “what we’re really saying is, ‘only kids whose parents have the resources to advocate for them will be screened.’”
In other words, disadvantaged and minority populations are sidelined.
Data are there to back him up. A 10-year retrospective study published in the Journal of the American College of Cardiology in 2014 found that African-American athletes were five times more likely than white athletes to suffer sudden cardiac death.
“I’m going to keep pushing for this,” says Corrado. “My hope is to run a larger study in a number of different primary care clinics to demonstrate that this approach is feasible, cost-effective, and equitable.”
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