The time for pre-participation physical evaluations (PPE) for athletic participation is about to start. A PPE should be done at least 6 weeks before the start of a sports season to ensure that any abnormal finding on examination is fully evaluated. So start scheduling an appointment for your sports physicals. One portion of the PPE that has generated a lot of controversy is the cardiac examination. Sudden cardiac death is the leading medical cause of death in athletes due to participation. Studies with good academic rigor report the incidence rates (number of new cases per population at risk in a given time period) in the range of 1 in 40,000 to 1 in 80,000 athletes per year. That equates to 100 to 200 high school athletes who have either sudden cardiac arrest or sudden cardiac death each year.
Cardiac examination is a mandated part of the pre-participation physical and the goal is to identify cardiac abnormalities, with the hope to save lives. A study done in 2007 by a Dr. Baggish at Harvard (Ann Intern Med. 2010;152:269-275.) looked at 510 athletes in college and found that 11 (2%) of the athletes had a cardiac abnormality. Ten athletes with cardiac abnormalities were discovered by EKG and 86 others were thought to have a problem by EKG, but further testing revealed they did not have a cardiac problem. The EKG was better than just doing a history and physical. In exams with no EKG, only five athletes with cardiac abnormality were found, and fewer (26) other athletes were thought to have a possible problem, which further tests showed they did not.
A study by Dr. Magalski (Am J Med. 2011; 124(6):511-8) looked at 964 athletes. That study found that 9 athletes had a cardiac abnormality that needed exclusion (7 were athletes with the condition known as Wolf-Parkinson-White). The study found 86 other athletes with abnormal EKG’s, who were not found to have cardiac abnormality after further tests. This fact points out that 9 out of 10 athletes detected by screening EKG to have an abnormality were later found to be normal.
Here is the hard part: EKG obviously is more likely to detect a cardiac abnormality. If one in 50 or one in 100 athletes have a cardiac abnormality that can be found on EKG, why don’t we screen everyone? Well if every high school athlete (7.8 million) was screened, then 780,000 to 1.5 million follow-up tests would need to be done. It would overwhelm the medical system for starters, preventing other life-saving tests from being performed on patients at greater risk. Let’s look at one cardiac problem commonly found on screening tests called Wolf-Parkinson-White syndrome (an electrical problem where the person’s heart has a short circuit). It could cause a fatal problem in about 1.9 per 1000 patient years with the condition (Obeyesekere et al Circulation. 2012;125:2308). This means you will probably live life without a significant problem even if you have Wolf-Parkinson-White, but you might die earlier than necessary too. Fixing the problem by doing a procedure called radiofrequency ablation is 90% successful, but it can be fatal in 1 in 1000 people, according to Dr. Salerno, a pediatric cardiologist, during a presentation at the American Medical Society for Sports Medicine Meeting in Hollywood, FL, last month.
Dr. Barry Maron is probably the world’s expert on hypertrophic cardiomyopathy (HCM, the most common cause of sudden cardiac death in America). He reported in a study from 1995 that the rate of HCM in African-Americans was 0.24%,or 1 in 400,and in European-Americans it was 0.10%, or 1 in 1000 (Circulation. 1995; 92: 785-789). Yet only 1 in 40,000 to 1 in 60,000 a year die from HCM, meaning most athletes with HCM will not die during their athletic career. So what does the world’s expert in HCM as chair of the EKG screening committee for the American Heart Association recommend about universal EKG screening of athletes? The AHA does not support national mandatory screening ECGs of athletes.”(Circulation. 2014 Oct 7;130(15):1303-34).
Dr. Jon Drezner, a sports medicine physician for the University of Washington, Seattle Seahawks and past president of AMSSM, gave a great lecture at the AMSSM Meeting in Hollywood, FL for why we need to screen with EKG. He worked with world experts in sports medicine and cardiology including Dr. Maron. They met in Feb 2012 to define contemporary standards for EKG screening in athletes. The objective of the meeting was to develop a comprehensive training resource to help physicians distinguish normal EKG alterations in athletes from abnormal EKG findings that require additional evaluation for conditions associated with sudden cardiac death (Drezner, BJSM 2013). The Seattle criteria, a simple list of written rules to follow to distinguish those at risk from those who are safe, reduces the number of false positive (those wrongly identified as having a cardiac abnormality). But when cardiologists and/or sports medicine physicians review the same EKG done on an athlete, they agree only 85% of the time on the results (Berte, Europace 2015). As physicians get better at determining those at risk and those safe to participate in sports, we will be able to make EKG screening a better choice.
Groups like Simon’s Fund (http://www.simonsfund.org) do a great job of making people aware of the dangers of sudden cardiac death. They offer many free screenings to middle school and high school students throughout the year. I have even volunteered to help at their free cardiac screening, which includes a cardiac history, physical and EKG, with follow-up echo if determined necessary. The question of whether parents should your child get an EKG is really one for you to consider carefully and discuss with your doctor. Screening EKG has risks and benefits. It should be done at least 6 weeks before a season, preferably as part of a comprehensive sport physical. Second, a one-time cardiac screening done in middle school will not be sufficient to detect all cardiac problems through high school and college, since the heart grows and HCM may not show up until later age.
A young athlete dying from sudden cardiac death is terrible. And even though it is not common, it has a long lasting effect. EKG screening is effective at finding people at risk for sudden cardiac death. But it also identifies many people not at risk who will need follow-up testing (false positives). Work is being done by Dr. Jon Drezner to reduce the number of false positives. The hope of EKG screening would be to save lives. It makes sense that finding a cardiac abnormality will save a person’s life. Sadly, the results comparing two areas of the world – Italy, where EKG is mandatory, and Minnesota, where it is not– showed that despite different pre-participation screening strategies, athlete sudden death rates in these demographically similar regions did not differ (Maron BJ, Am J Cardiol. 2009 Jul 15;104(2):276-80). We do not know if testing people saves lives. We do know that automatic electrical defibrillator (AED) saves lives. I suggest asking your school and your child’s coach, “Where is the AED located?” and “Have you learned how to use it?” Even better would be if your school had a licensed athletic trainer, since they are trained in AED use. Many athletes have been saved by an athletic trainer with an AED.
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