Sunday, July 17, 2011
Research published this week from Stanford University has proven what most doctors had a gut feeling about, that EKGs are not helpful in screening high school athletes and finding those who are at risk for sudden death. The study’s conclusion was that there was an issue with “inappropriate sports guidance” and there could be overuse of other diagnostic tests. The question remains: how do we find kids who are at risk for dying when exercising?
The heart is a two stage electrical pump. There needs to be a coordinated electrical impulse that allows all the heart muscle cells to contract at the same time. Coordinated electricity yields coordinated squeeze and a heartbeat. Certain types of short circuits can cause electrical chaos in the ventricle, the lower pumping chamber of the heart. Ventricular fibrillation causes the ventricle to jiggle like a bowl of jello. Electrical chaos yields no heartbeat, no blood flow through the body and sudden death happens.
The most common cause of sudden cardiac death in athletes is hypertrophic cardiomyopathy (HCM), where there is thickening of the muscle wall of the ventricle. The abnormal muscle increases the potential that ventricular fibrillation will occur. HCM is relatively rare, occurring in only 2 per 1,000 but its first presentation is usually collapse or sudden death during or after exercise.
The American Heart Association has few recommendations for screening athletes. They suggest a brief history and physical examination with a 12 point questionnaire (http://circ.ahajournals.org/content/115/12/1643/T1.expansion.html). Further testing may be considered at the care provider’s discretion. In their latest policy statement from 2007 (unchanged from 1996), the AHA says that “there are no universally accepted or mandated standards for the screening of high school (and college) athletes, nor are there approved certification guidelines for those healthcare professionals who perform such screening examinations.” That is technically correct, since it would be incumbent upon an organization like the American Heart Association to take the lead and develop those accepted standards. (http://circ.ahajournals.org/content/115/12/1643.full)
In 2004, the International Olympic Committee published their pre- participation cardiovascular guidelines. They were similar to those of the AHA but included an EKG and suggestion as to what further steps should be taken if problems were found. Italy is much more aggressive when it comes to screening young athletes for sudden cardiac death. These kids are seen by a sports cardiologist who does the pre-participation exam and performs an EKG at rest and with exercise. Further testing may include an echocardiogram, an ultrasound of the heart that can detect HCM. While the Italian model has decreased sudden death in athletes by almost 90% in the last 20 years, that brought the risk to the same level as in the US.
The reluctance to better screen young athletes has to do with cost. An echocardiogram, in addition to an exercise EKG, is perhaps the best screening tests available but they cost money. An EKG costs about $100 and an echocardiogram, close to $1000. But there are alternatives. Purdue University screens all their athletes with a limited echocardiogram looking basically for HCM at a cost of $35. Georgia Tech does EKGs on all their incoming athletes, understanding that it may not be helpful, but it provides a baseline should another EKG need to be done in the future.
When organized medicine decides that it may be too difficult or too expensive to try to prevent disease, it may be necessary to put those concerns into perspective. The AHA recommends treating high cholesterol levels to decrease the risk of heart attack and stroke. A prescription for Lipitor costs about $1200 a year and that cost does not include repeated monitoring blood tests that can add hundreds more dollars. (Some high cholesterol medications are available as generics that can decrease the price). There was little discussion that these medication recommendations be withheld because they just cost too much.
The pre-participation physical exam requirement is usually glossed over by parents as just more paperwork and forms to fill. In reality, it should be taken seriously as the first step to screen for potentially life threatening heart problems. A plain EKG is likely not helpful, though the Olympic Committee thinks differently. It may be that the echocardiogram is the way to go but then schools, parents and cardiologists will need to get together to figure out the cost. Sudden death should only happen on the scoreboard.