By David Hill
David Hill is an Assistant Editor at Training & Conditioning. He can be reached at: dhill@MomentumMedia.com.
Training & Conditioning, 16.2, March 2006, http://www.momentummedia.com/articles/tc/tc1602/followinghearts.htm
When five young athletes in central South Carolina died within two years of each other, in part because of undetected heart conditions, the local sports-medicine community was asked a lot of questions. Emotions ran high, and parents, coaches, and administrators wanted to know whether enough was being done to find athletes with potentially fatal heart diseases.
In response, several high schools began holding mass screenings with echocardiograms or electrocardiograms (EKG) for their athletes. Athletic trainers and team doctors began testing athletes for signs of some of the leading causes of sudden cardiac death, in particular hypertrophic cardiomyopathy (HCM), which accounts for about a third of such cases. They had the financial and logistical backing of local hospitals, cardiologists, and non-profit foundations, and they had the support of worried parents and administrators.
It has been a year and a half since the last athlete death, and the high schools are starting to re-analyze their procedures. While some schools continue to conduct the heart screenings, others have backed off, thinking that resources are better directed at other types of preventative care. Still others are seeking a middle ground, either holding occasional screenings on an optional basis or helping arrange the tests if a physician recommends one.
What makes the circumstances in South Carolina so interesting is that they are a microcosm of the national situation regarding cardiac screening in pre-participation physicals. Prompted by tragedies involving some high-profile professional and Olympic athletes, the question of whether to subject all athletes to high-tech tests for potentially serious cardiac conditions has been heating up in the United States. New studies and recommendations from the international sports community are also fueling the debate.
The latest round of discussion has been prompted by developments in Europe. For more than a generation, Italian teenagers have been given electrocardiograms before they participate in organized athletics. Researchers at the University of Padova examined the huge database of results and determined, among other conclusions, that electrocardiograms were 77 percent more effective in finding HCM than was simply listening to the heart through a stethoscope and relying on family cardiac histories and athletes’ personal recollection of incidents—such as fainting spells, dizziness, and chest pains. The researchers, in a study published in the Journal of the American College of Cardiology in December 2003, also concluded that the electrocardiograms were effective in screening for other potentially fatal and hard-to-detect heart abnormalities that lead to sudden death in young athletes.
Then, in December 2004, the International Olympic Committee’s medical commission released a consensus statement on standards for pre-participation cardiac exams that recommends an electrocardiogram. That was followed by a similar recommendation by the European Society of Cardiology. The question arose among American cardiologists: Should we do the same?
The answer boiled down to this: It would be a good idea, but we can’t recommend the screenings as a national standard. One of the leading authorities on HCM, Barry Marone, MD, of the Minneapolis Heart Foundation Institute, wrote a commentary for the European Heart Journal, which published the Italian study, explaining that such a policy is not likely to be adopted nationally in the United States given the large number of high school-age athletes and the expertise necessary to analyze the test results. Though electrocardiograms can be conducted for under $100, only experienced cardiologists can reliably interpret the data.
Marone also argued that because abnormal results aren’t definitive, they can lead to many false positives, either needlessly denying sports participation to athletes or requiring expensive further tests that may not really be needed. Marone does endorse voluntary screening to detect HCM and certain other conditions when a school or university has the means and opportunity.
Marone’s view is basically that of the American Heart Association and the American College of Cardiology. Both organizations have not altered their consensus statements on pre-participation physicals, which do not call for electrocardiograms or echocardiograms as a matter of course but say that they are appropriate for athletes with a family or personal history of heart problems.
Where does this leave high school and college athletic departments? Michael Krauss, MD, Chair of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports and Team Physician at Purdue University, says the decision on whether to use echocardiograms and electrocardiograms in pre-participation physicals is best left to each sports-medicine department based on advice from its physicians.
“Someone wrote a letter to our committee and said they wanted every NCAA athlete to see a cardiologist before participating in college athletics,” Krauss says. “We thought, ‘Wait a second. Some of these schools are struggling to get every athlete to see a doctor before they get to athletics.’ It doesn’t make a lot of sense for an organization like the NCAA to issue mandates that are out of line with what the American Heart Association says should be done. Every school has to make its own decision.”
For the South Carolina high schools, testing practices continue to evolve. Mack Harvey, ATC, SCAT, is Head Athletic Trainer and Assistant Athletic Director at Dutch Fork High School in Irmo, S.C., where a star basketball player died suddenly of a heart condition in 2003. Though the cause was not HCM, the athlete’s parents began pushing for screenings of athletes and raised money toward it. With the help of A Heart For Sports, a Yorba Linda, Calif., non-profit foundation formed by a family who has lost several members to HCM, Dutch Fork screened 140 winter athletes in 2003-04 with echocardiograms.
“We had three or four portable machines, and A Heart For Sports had a cardiologist come and supervise everything,” Harvey says. “They saved the data and he went back later and reviewed it once more to make sure he didn’t miss anything. Luckily, everybody was negative.” Athletes were charged $50, though the fee was reduced or waived for low-income families.
Dutch Fork held another screening the following fall, this time making it optional for athletes. But response was light—15 or 20 youngsters, Harvey says—so he discussed it with his district’s health care committee. With all tests coming back negative in both sessions and the light turnout the second time, the committee decided to not continue testing at school. “Obviously, if a child wants to get tested, we’ll go through their family doctors and have it done, but we don’t sponsor it any more,” Harvey says. “If there’s a child with any symptoms—shortness of breath that’s abnormal, loss of sensation, weakness, or tingling during exercise—that would be a reason to test them, and we’d help get it done.”
Meanwhile, in a school district about 10 miles away, Brian Blackburn, ATC, SCAT, Head Athletic Trainer at Brookland-Cayce High School in Cayce, S.C., has made voluntary screenings part of the pre-participation process for about 18 months and plans to continue them. Blackburn had been contacted by the president of a company that provides portable echocardiogram equipment to doctor’s offices. Following the string of sudden deaths, the company formed a non-profit arm to screen young athletes. Blackburn investigated, consulted with school-district officials, and arranged a mass screening of athletes. They are charged $50 each, with the cost subsidized through the non-profit arm of the equipment company.
Brookland-Cayce has continued the screenings, testing about 200 athletes over four sessions, and none have shown signs of serious heart conditions so far. Student-athletes are called from class one-at-a-time to the athletic training room and screened by a technician who videotapes the examination for a cardiologist’s later review. The equipment used at Brookland-Cayce also allows for a scaled-down electrocardiogram to be conducted simultaneously through leads attached to the athlete’s chest. A report is generated and copies are sent to the family and athletic department.
“Our philosophy is there is still a lot of information to be gained from these screening echocardiograms,” Blackburn says. “We may be ahead of the curve, but we just feel, especially with what happened here in the state, that we want to be proactive and offer this.”
Because the tests don’t screen for all heart conditions and they can give false assurance to athletes, Brookland-Cayce has student-athletes and their parents read and sign extensive waivers explaining that a negative result is by no means definitive proof that they have no serious problem. “We tell them up front this is not the test to end all tests,” Blackburn says.
Blackburn also rebuts the argument that the screening is not worth the cost, at least in the case of his school. “Some of the cost-benefit studies aren’t necessarily taking into account that we’re doing them for $50 and they are voluntary,” Blackburn says. “If it gets to the point where these things can be done for $40, $20, $10, the cost-benefit argument goes right out the window.”
At Georgia Tech, team physicians agree, and have implemented extensive screenings, says Jay Shoop, LAT, ATC, Director of Sports Medicine. All incoming athletes receive an electrocardiogram, which is read by a cardiologist, and some also are screened through an echocardiogram.
The key for Georgia Tech is the availability of John Cantwell, MD, the school’s team cardiologist, and his colleagues in an Atlanta cardiology practice. Cantwell is a former college basketball player, was the head of medical operations for the Atlanta Olympics in 1996, and is a big believer in preventative medicine.
Cantwell says the electrocardiograms are used to initially screen all athletes because certain conditions are detected only through heart-voltage abnormalities or other signs that show up on the test, and because it can provide information to help doctors diagnose a condition that might arise later. “We like that it establishes a baseline,” Cantwell says. “If an athlete experiences chest pain and we did an EKG but have no earlier EKG to compare it to, and if they have variations that an athlete can have, we don’t know if that’s normal for them or if it’s related to their chest pain.
“It’s a fairly inexpensive and painless test that takes a couple of minutes,” he continues. “To do one in your athletic career is not asking a lot.”
Cantwell or colleagues from his cardiology group in Atlanta read the results and listen to the hearts of all incoming athletes at physicals. If there are abnormal readings or signs of a predisposition to cardiac conditions on the history questionnaires, the doctors may then order echocardiograms, stress EKGs, cardiac MRIs, or other tests to hone in on a diagnosis. Echocardiograms are also given to all incoming athletes in football, volleyball, and basketball because of their heavy cardiac demands, and because tall athletes are more likely to have Marfan’s syndrome, which can include a potentially dangerous deformity of the aorta near the heart.
Purdue University is another school that screens all incoming student-athletes. And like Georgia Tech, it can do so because of help from a large cardiology practice in town.
The cardiologists use scaled-down echocardiograms and technicians specially trained to take limited readings, which makes the process quicker and more affordable, costing about $35 per athlete. As at Brookland-Cayce, the tests use equipment that can also provide limited electrocardiogram information about the athletes’ heartbeats. “The technicians capture two or three views with some flow studies that take about two and a half minutes to get done,” Krauss says. “The cardiologists have worked very hard to educate the technicians on how to get it done quickly. By the time you lay the athlete down, get some jelly on their chest, place the EKG leads, and do the study, it takes about five minutes per kid.
“You need a good echo tech who understands what a screening echo is, and then you need a cardiologist who has a lot of experience in looking at echos,” Krauss continues. “It’s a fairly specialized test, no doubt.”
The limited echo doesn’t pick up all the causes of sudden death, but can uncover hypertrophic cardiomyopathy. “The arguments about more extensive screenings are really about just time and finances, and whether there is available expertise to pull it off,” Krauss says. “A full echo costs $1,000 and thus wouldn’t be feasible. At Purdue, it costs about $75 to do an EKG. We’re doing the echos for half that cost, so we figure that’s a good value.”
A MIDDLE GROUND
While many schools and universities wait for the cost of echocardiograms to fall and seek out cardiologists willing to donate or subsidize their time, some athletic trainers are finding a middle-ground approach. Spring Valley High School, another school in central South Carolina, has begun conducting echos on just some of its athletes, explains Ron Caldwell, MAT, LAT, Head Athletic Trainer. The school took up the offer of a nearby hospital’s sports-medicine outreach program to provide two portable echocardiogram machines and technicians for a one-time, voluntary heart screening event.
The tests were conducted on athletes who answered yes to one or more questions. Had they ever passed out, become dizzy, or had chest pain during or after exercise? Had they ever experienced a racing heart or a skipped heart beat? Had they ever been told they have high cholesterol or been restricted from physical activity because of a heart problem? Had a close relative died of heart disease before age 50? Thirty-five student-athletes turned out on a Saturday morning, and after the questionnaires were administered, 13 were given echocardiograms.
General-practice physicians and orthopedists were on site, but the echocardiograms were analyzed later by an off-site cardiologist. The hospital didn’t charge, but the school collected $10 from each student as a fundraiser for its sports-medicine program.
“We’re going to do it again,” Caldwell says. “The parents who came to the clinic were very impressed. I’m sure it was worth the money and time.”
The University of Nevada has begun taking a similar approach. In recent years, four Wolfpack athletes have been diagnosed with serious cardiac conditions. Two received surgical ablations to correct their heart-rhythm problems and continued to participate. Two others, however, were medically disqualified. In one case, the athlete had a fainting spell that led to the diagnosis, but the other three were caught during pre-participation physicals by doctors listening to their hearts and then prescribing further tests.
Although Nevada does not routinely give echocardiograms or electrocardiograms at physicals, it now has the equipment and cardiologists at the ready, says Marc Paul, MS, LAT, ATC, Head Athletic Trainer. “Our physical exam process starts with family practice physicians and residents, and now we have a cardiologist who comes to our physical night with a portable EKG machine,” he says. “If a physician picks up something that’s perceived as an abnormality on an athlete’s exam, they immediately send the athlete over to the EKG. The cardiologist reads it right there. If they see something and we need to do an echo, it’s arranged, and the athlete can go to the cardiologist’s office the next day.
“Before, we had the EKG machine, we’d have to call ahead and schedule the test a week or so down the road, and in the meantime this kid is sitting here with a lot of anxiety. The ideal thing would be to hook every kid to an EKG machine and go from there. But so far we can’t pull that off cost wise and time wise.”
A Nevada team physician arranged the expertise, Paul says. “She knows a lot of cardiologists from a particular group in town,” he says, “and she told them, ‘We’ve had these incidents come up. We’d really like for you to come down and be here.’ It’s such a large group that at least one of them can come to our physical nights. They volunteer their time and come down and hang out for a couple hours and read through the EKGs if we need them.”
SCARY TO THINK ABOUT
While each athletic department must ultimately decide for itself what route to take in terms of heart screenings, Paul stresses that high schools should consider the subject as seriously as colleges, since it’s in the mid-teen years that HCM typically develops. He notes that one of the Nevada student-athletes, a female who had long-QT syndrome, a malfunction of the heart’s ability to reset itself after a contraction, probably had the condition in high school.
“She was extremely lucky nothing happened to her,” he says. “Who knows how many are at the college level, but especially at the high school level. It’s scary to think about what could be going on.”
That’s basically the viewpoint Brookland-Cayce is taking. The philosophy is, yes, perhaps the school is exceeding what cardiologists collectively recommend, but the consequences can be so dire that if the screenings can be done, they should be done.
“There are a lot of doctors who feel that if there is no family history of cardiac problems you’re wasting your money,” Blackburn says. “There are a lot of questions still. But it’s good to debate them, to have some dialogue.
“It’s not that I want to find an athlete that has a heart condition,” he continues, “but when we do find one, whether it’s at our school or another school, that might help change some people’s minds as far as whether we should be screening or not.”
A small but growing number of non-profit organizations can help arrange screenings for certain heart conditions in athletes. Here are two:
Click on “Our Programs” and then “Championship Hearts - Young Athlete Heart Screening Program.”
This Southern California organization, founded by a family stricken repeatedly by sudden cardiac death, helps promote and arrange screenings.
Sidebar: Electro or Echo?
Screenings for potentially dangerous cardiac conditions rely mainly on one of two types of electronic tests, and sometimes both. The electrocardiogram, sometimes referred to as an EKG, records the electrical activity of the heart, typically in a series of wavy lines. Cardiologists read the print-out for signs of misfirings that can indicate a too-rapid or too-slow heartbeat or inconsistencies in the rhythm. The echocardiogram is a sonogram of the heart, relying on high-frequency sound waves interpreted by a computer to produce an image of the heart, which cardiologists can then examine for signs of abnormalities.
Which is better? Some cardiologists prefer screening with EKGs because they can raise a red flag about a broader range of potentially serious conditions. Others prefer echocardiograms because they offer a more direct assessment of the heart’s structure and function and are the principal diagnostic tool for detecting hypertrophic cardiomyopathy.
EKGs generally cost less, in some cases less than $100 per patient, versus several hundred to $1,000 for echocardiograms. However, some cardiologists greatly reduce the cost of echocardiograms in mass screenings by looking for only certain specific signs of heart disease most likely to occur in young athletes. Portable equipment allows cardiologists or technicians to take either type of device to schools for mass screenings.
Sidebar: Toward Better Physicals
In the debate over making high-tech screenings for heart conditions part of the pre-participation physical, one clear initiative has emerged: the importance of a clear stethoscope-based exam and a good cardiac history.
One step toward better exams is simply to make them quieter. At Dutch Fork High School, near Columbia, S.C, there is a quiet room set aside where doctors can take student-athletes to more clearly listen for murmurs or other audible indications of trouble. Dutch Fork has also beefed up its family- and personal-history questionnaire, and asks parents to go to physicals with students to help answer the eight-question form.
At the college level, Georgia Tech has developed an extensive personal- and family-history questionnaire for all incoming student-athletes that’s now a separate page in the pre-participation medical form. It includes the following 11 questions:
1. Has anyone in your family died suddenly or had a heart attack before age 55?
a) Died suddenly before age 55? Yes No
b) Had a heart attack before age 55? Yes No
2. Does your heart ever beat fast or skip a lot of beats? Yes No
3. Have you ever passed out or fainted during exercise? Yes No
4. Have you ever had chest pain, tightness, pressure, or any discomfort during exercise?
5. Have you ever been told you have high blood pressure? Yes No
6. Have you ever been told you have a heart murmur? Yes No
7. Have you or any relative been diagnosed as having:
a) Marfan’s syndrome Yes No
b) Hypertrophic Cardiomyopathy or IHSS? Yes No
8. Have you ever been told that you have a “heart problem?” Yes No
9. Have you ever been restricted from sports competition? Yes No
10. Have you ever been hospitalized for any non-orthopedic reason? Yes No
11. Please list any supplements or herbs you take other than vitamins.
Sidebar: Pro-Style Screening
In the NBA, where the health of a team depends on the health of its players, heart screens are done as a matter of course every year. But that doesn’t mean there’s no room for improvement, or that such a schedule is right for everyone.
Every NBA draft prospect gets an echocardiogram, a resting EKG, and a stress EKG—performed while exercising, typically on a treadmill—as part of a physical exam at the pre-draft camp held each summer, says Fred Tedeschi, ATC, Head Athletic Trainer for the Chicago Bulls and president of the National Basketball Athletic Trainers Association (NBATA). From there, however, screenings vary from team to team.
The Bulls conduct a resting and a stress EKG as part of each player’s end-of-season exit physical. Abnormalities are followed up with more testing, often including an echocardiogram. But the stress EKG is the key, because it can help spot changes that indicate developing conditions.
“If you play a professional sport, you want to know if there is any change in how your heart works under exercise,” Tedeschi says. “That’s why you look at it annually—to make sure there are no weird heart rhythms that have developed subtly.”
NBA physicians plan to discuss whether the league should set a minimum level of cardiological screening of players, Tedeschi says. That’s partly in light of a recent case involving former Bulls center Eddy Curry, who experienced heart arrhythmia late in the 2004-05 season. Before signing the then-free agent, the Bulls wanted him to submit to a DNA test to see if he may have the gene for a particular heart condition. He refused, and ended up signing with the New York Knicks.
An NBA-style policy isn’t necessarily best for college and high school, adds Tedeschi, who formerly worked at the University of California. “At the college level, money is an issue, and, while it may sound terrible, you want to get the most bang for your buck,” he says. “Because the NBA does screenings, does it mean people should do it at the college level? I think a reasonable person may say no. But I do think the athletic trainer and an athletic director should sit down and make a conscious decision about what is best for their athletes and their program.”