John Mandrola MD is a cardiac electrophysiologist practicing in Louisville, Ky who blogs as Dr. John M. Below is his insightful discussion about why cardiac screening may not be possible to prevent sudden death in young athletes. Yet it is so distressing each time a young athlete falls dead during or after a game because he and his family did not know that he had a serious heart problem that could have been identified in a test. For some heart defects, if only the family were aware of the defect, it would be appropriate for the young athlete to wear an implanted defibrillator that would save his life either through extra pacing as the disturbance began or through electric shocks if his heart suddenly went into a wild shaking known as ventricular fibrillation.
I understand John’s concern about the high cost of making electrocardiograms and echocardiograms, heart tests that could pick up significant heart defects, a required part of sports physical in schools and colleges. Aside from the cost is the important issue that screening can pick up false positives and “shadows and innocent blips” that lead to further invasive testing. Yet, I could see parents springing for these cardiac exams themselves, but then being very cautious about doing any further testing.
It is unforgivable not to have an automatic external defibrillator at all sporting events, close to the court or the field, and more than one athletic staff member trained to use it. Every minute counts when a person’s heart stops working. Realizing what has happened, then calling an ambulance and waiting for the paramedics to arrive, may take up too much time to save a young athlete’s life. When an athlete falls to the ground and is not moving, the trainer or other staffer should immediately have the defibrillator or crash cart ready so that the shocks could be applied to the athlete’s heart within one to two minutes.
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 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:
- My entire medical career revolves around understanding ECGs.
- I look at Echos nearly every day, and was schooled by one of its pioneers, Dr Harvey Feigenbaum.
- 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.
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.