February is designated as American Heart Month to bring awareness to the fact that heart disease is still the number one killer in America. However, no one expects teens, who are athletes no less, to succumb to heart disease.
Every year we hear about cases in the media of young athletes collapsing and dying during their sporting events from sudden cardiac death. The majority of these young athletes are football or basketball players. In fact, within the last six months, we have read about three such high school athletes who have collapsed due to cardiac arrest during their games. An Oregon high school football star, Hayward Demison, and a Minnesota high school basketball star, Zach Gabbard, both luckily survived. But tragically, a star high school quarterback from Texas, Reggie Garrett, collapsed after throwing a touchdown pass and could not be revived. He was later pronounced dead at the hospital. These tragedies are refueling the debate and controversy over whether all young athletes participating in organized sports in the U.S. should be getting an electrocardiogram (EKG or ECG) to screen them for heart disease.
According to the American Orthopedic Society for Sports Medicine (AOSSM), it's estimated that about 30 million high school and middle school kids participate in competitive sports programs. There are at least 2 million injuries over all, with about 500,000 kids seen at the doctor or in an emergency room for their injuries. About 30,000 need to be hospitalized because of their injuries. It's estimated that more than 100 young athletes die each year in sports-related incidents and according to the National Athletic Trainers' Association (NATA), close to half of these deaths are attributed to sudden cardiac death.
Sudden death in young athletes is often due to some congenital abnormality of the heart that is sometimes asymptomatic, making it a silent killer. A majority of these cases are due to a condition called hypertrophic cardiomyopathy (HCM). This inherited defect causes the muscular wall of the heart (often the middle wall called the septum) to be asymmetrically or irregularly enlarged. This interferes with, or prevents, blood from flowing out of the heart when it is beating fast during exercise. Only about a quarter of patients will have symptoms such as chest pain, fainting or a heart murmur. Unfortunately, sometimes sudden death during exercise may be the first sign of this condition.
Another condition that can cause sudden death in young people is congenital abnormalities of the coronary arteries. This is when the blood vessels that supply oxygen and nutrients to the heart muscle are connected abnormally and they can become compressed or kinked during exercise. An inherited abnormal heart rhythm is another cause of sudden death. It can lead to fast and chaotic beating of the heart during exercise. Some risk factors for these conditions are a family history of an unexplained sudden cardiac death in a relative under the age of 50 or unexplained fainting during increased physical activity.
NATA reports that high school athletes suffer three times as many serious injuries as college athletes each year. This has led some to speculate that it might be related to the lower levels of sophistication in both the training and the screening of high school athletes for potential injuries and problems. All high schools in the U.S. today require sports physicals before participating in organized athletics. These are called pre-participation physical evaluations (PPE) and can be done by any physician. The exam entails listening with a stethoscope to the heart and lungs, as well as examining the musculoskeletal system. The exam also includes getting a good history of drug use, family history of heart problems, as well as asking about any symptoms during exercise.
An electrocardiogram (ECG) or referral to a heart specialist is not done unless there is an abnormality suspected from the PPE. Both the American College of Cardiology and the American Heart Association agree that the mandatory screening of all young athletes with an ECG is not warranted based on cost (due to the large number of tests that would be required), as well as the possibility of false positive results. A false positive is falsely detecting a heart abnormality when there isn't any, thus unnecessarily requiring young athletes to quit their beloved sports. However in Europe, both the European College of Cardiology and the International Olympic Committee (IOC) recommend resting electrocardiograms for all young athletes before they are allowed to compete.
Two recent studies here in the U.S. -- published in the Annals of Internal Medicine --looked at ECG testing along with the PPE sports physical exams. The first study found that adding an ECG to a routine sports physical doubled the number of cases of potential heart problems detected when compared to just a sports physical alone. The second study concluded that adding an ECG would be an additional $80 per athlete. But when the researchers did a computer model cost analysis, they found that the cost was actually feasible. It fell within the range of other accepted screening tests used today in the U.S. Thus, it was considered as cost-effective as the PAP exam for detecting cervical cancer or the mammogram for detecting breast cancer.
This begs the question, could a simple test have prevented the deaths of these young athletes? Despite the possible false positives that may detect an abnormality when there really isn't one, for me, as a mother, it is a no-brainer! An ECG is a non-invasive, relatively inexpensive test in the scheme of medical costs today. Given the fact that it could potentially save a young athlete's life, how can we even consider putting a price on that?
As a physician, though, I do understand the limitations of this test. In fact, there are also false negative test results, meaning that some abnormalities may not show up with a single resting electrocardiogram. And while no medical diagnostic test is foolproof, this is definitely a discussion we must continue. We need to ensure that organized sports are as safe as possible for our children.
My heart truly goes out to these families who have lost their children. And as both a doctor and a parent of a child who participates in school sports, I feel if we err, we should always err on the side of caution.
Dr. Leigh Vinocur is a board certified emergency physician and national spokesperson for the American College of Emergency Physicians. You can visit her website www.drleigh.com