Increasing numbers of young people participate in outdoor activities, including strenuous competitive athletics. In so doing, they subject their bodies to stresses that are more intense and prolonged than those presented by a largely sedentary life. Every story of a sudden death in a young person is a tragedy, and usually accompanied by commentary pondering the role and utility of pre-activity screening. Could the death have been prevented? What was the physiological condition of the deceased? Could the collapse, often attributed to a heart problem, have been predicted? Was there an examination or evaluation that might have indicated that the deceased was at greater risk, or should have been held out of the activity? These are all important questions, with no simple answers.
Sudden collapse and cardiac arrest in a young person seems wrong. It shouldn’t happen. It is a parent’s worst nightmare. Similar horrors occur on the freeway when a teenage driver is killed, or at the beach when a surfer is tossed in a monster wave and drowned. We know a great deal about injury prevention; much of our teaching and experience points to errors in judgment. But the situation is different when the seemingly healthy slumps to the ground without a pulse. That person has been taken by surprise in a cruel act of fate.
Sometimes we learn that the victim had a congenital or acquired heart abnormality, such as idiopathic hypertrophic subaortic stenosis, a seizure disorder, or a propensity to abnormal heart rhythms. A young person may be walking around with an inflamed heart muscle after apparently recovering from a viral infection, and not know until it is too late that his or her heart is operating at a greatly reduced capacity, such that heart failure is just around the corner. The young person with a brain aneurysm is in great shape until the dilated blood vessel bursts and leaks a lethal torrent into the confined space within the skull.
A large proportion of sudden adverse health events—whether a first serious attack of ketoacidosis associated with diabetes, a stroke in a person with a brain aneurysm, or cardiac arrest in a person with a potentially lethal heart rhythm disorder—come without any antecedent event or other warning. To what degree should apparently healthy persons be screened for the possibility of an occult problem?
To begin with, the child should receive a prompt physical examination if there is a chronic problem with any of the following:
- fainting spells
- frequent urination
- fatigue out of proportion to the activity
- weight loss
- shortness of breath
- palpitations (particularly with an irregular pulse)
- chest pain
The doctor will screen for heart problems and other abnormalities. Routine parameters of good health, such as appropriate pulse rate, blood pressure, ease of breathing and breath sounds, and ideal body mass and total weight are essential. Similarly, routine laboratory testing, such as blood counts, urinalysis, blood glucose, and essential electrolytes establish what is hopefully a normal baseline for the participant.
What is “Extra”?
An electrocardiogram (ECG, EKG – “heart tracing”) is not usually part of a basic physical examination in youth. The test will detect arrhythmias and certain structural abnormalities of the heart. An echocardiogram bounces sound waves off the heart and determines anatomy and function. Combined with the ECG, an ultrasound becomes a very reasonable heart screening regimen for persons of all ages.
Exercise-associated events, such as dizziness, fainting or chest pain, should be examined with an ECG and echocardiogram, and perhaps a stress test (“treadmill”). Further testing is guided by the results of these three examinations.
What is the Value of “Family History?”
Certain congenital conditions and many medical disorders have a basis in genetics. Knowing whether or not your father or mother had heart problems is useful to help determine your risk, but in my opinion, a “negative” family history does not rule out the need for a physical examination and proper testing. The person who collapses with a heart attack may be the first one in the family to do so.
What Are the Controversies in Testing?
False Positive Results
There is always a possibility that the results of a test deemed positive for a problem are in fact incorrect—there is not a problem, so the test is “false positive.” If the false positive rate is high, then there will be too much unnecessary follow-up testing, and, furthermore, persons may be precluded from activities when they are perfectly normal.
How many lives are saved for what total dollar amount? How much is it worth to society to save a small number of athletes who, without screening, might go on to collapse and die? Finally, what is the quality of “mass screening?” Do we rush through the exams and make mistakes with the interpretations because we don’t have a high index of suspicion combined with a hasty effort?
My recommendation, which is entirely based on opinion, is that a healthy child, who has received all the normal examinations and healthcare, should have a comprehensive physical examination prior to undertaking a new and very strenuous activity (be it on the playing field, underwater, or climbing a mountain). A baseline EKG is good for people to have in their possession for future medical reference, provided that it will be safely stored, and not misplaced or lost. If there is any suggestion of a heart problem by virtue of history or exam, or if there is a significant family history of heart abnormalities, an echocardiogram should be obtained.