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Universal Cardiac Screening For All Young Athletes?

It’s heart wrenching when young athletes die of sudden cardiac death (SCD). Last week the death of Wes Leonard, a Michigan high school star athlete, was especially poignant since he collapsed right after making 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 (LQTS), a mostly inherited disease of the heart’s electrical system. Both HCM and LQTS 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 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 ‘er dun,” 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 isn’t 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 Economics

 The estimated cost — in our current healthcare system — for adding an ECG and echo to the sport’s exam is about $1,000. 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 $1,000 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 LQTS and the echo would exclude HCM. The reason why I could do this is threefold:

  1. My entire medical career revolves around understanding ECGs.
  2. I look at echos nearly every day and was schooled by one of its pioneers, Dr. Harvey Feigenbaum.
  3. 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 percent of the time.)

Ah, but that’s not how things work in our present healthcare model. Obviously.

You can’t just deliver quality care that easily. 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.

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 -hite, 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 aren’t 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 LQTS kill athletes at a frequency of about 0.01 percent. 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 scan is low risk, the cumulative risk of doing these on thousands of normal people surely approach the 0.01 percent 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 healthcare system is that a-wash 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.

JMM

P.S.: One thing that Dr. Manny was spot on about was that more automatic external defibrillator (AEDs) 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.

*This blog post was originally published at Dr John M*


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