The tragic deaths of two high school athletes last week has reignited public debate about whether or not young people should undergo more detailed physical exams before participating in sports. Those in favor of increased testing advocate for electrocardiograms (ECG) because they’re noninvasive and could help identify heart conditions before they pose problems on the field. However, even though early identification might prevent tragedy in some cases, many in the medical field aren’t convinced blanket ECG testing for young athletes is an efficient course of action. The following blog weighs the pros and cons of blanket ECG testing among kids, written by Mark Alexander, MD, an associate in Cardiology at Children’s Hospital Boston.
Just over a year ago I wrote a blog post after a 17-year-old hockey player died in Haverhill. This weekend we learn of two high school boys, in Michigan and Colorado, both apparently with hypertrophic cardiomyopathy, who died during athletic contests. Our hearts go out to the families and with the publicity associated with these events I am revisiting that post with a few additional thoughts.
In addition to the personal and community grief, this event focuses attention on the cardiac risks athletes (or any child) face, and whether more intensive screening can prevent these tragedies. Originally, the call for increased screening gained steam after the release of a study from Texas, in which high school athletes were screened with an electrocardiogram (ECG) using a specially designed laptop. Just under 10 percent were then referred for more formal testing, with 12 of the 2,100 disqualified from sports and another dozen identified as having potentially important cardiac conditions. The authors suggest that all athletes should be screened and that using the laptop technique the ECGs can be performed for a mere 50 cents.
So is wider – even mandatory – screening of athletes warranted? The answer is complicated, but the discussion shares themes that have been discussed in recent weeks related to breast cancer screening and how we organize health care. At the core of both issues is the question: How do you prevent a very low-risk but tragic event with tests that aren’t perfect?
Do we know what causes problems like this in young athletes?
Fortunately, we have a very good sense of what causes sudden cardiac arrest in school-age children, and about half of at-risk children are identified early in childhood. Of those without a prior diagnosis, hypertrophic cardiomyopathy, Long QT syndrome and coronary problems lead the list of hidden life-long diseases, along with acute heart infections. Not all of those children will have symptoms prior to a cardiac arrest. Asthma and other non-cardiac diseases can also lead to sudden death.
Do organized athletics increase risk of cardiac arrest in children more than active play, dancing or other activities?
Many cardiac events, at every age, occur during exercise. At the same time, exercise has enormous long-term benefits that over years may actually decrease risk of coronary disease, hypertension, obesity and other long-term adult problems. In children and teens, we think that if exercise increases risk, that increase is quite small. Even for hypertrophic cardiomyopathy, the most common disease identified in the death of young athletes, most cardiac arrest occurs at rest and in non-athletes.
Do stimulants used for ADHD cause cardiac arrest?
There is little doubt that overdoses of those medications can be dangerous. There are suggestions that in rare cases, normal doses increase the risk of sudden cardiac arrest in children, but at the same time, they may decrease the risk of car accidents in teenage drivers with ADHD (which are very common).
Is there something unique about the teenage athlete that makes them appropriate for extra testing?
The death of an athlete almost always produces headlines in the local papers that make those deaths seem more common. The families of the dancer, violinist or video-gamer are just as devastated at the loss of their child, but those families typical share their grief in private. In Massachusetts, up to 70 percent of high school students participate in at least one sport, so screening athletes really means not screening 30 percent of the students. It’s very difficult to create a moral context in which we elevate any group for special care.
Is this really that common?
Most of the tragedies that take our children from us are felt in private. The young person with acute myocarditis, suicide, or the victim of a motor vehicle accident may have an appropriate column in their local paper; friends and family share their love and grief and then the news moves on to something else. The stories of the athletes, particularly during contests, are rapidly amplified. The Michigan basketball player was on the front page of the Sunday Globe sports section and the Colorado Rugby player already has more than 5000 Google results with articles in London, India and most US news sources. These news reports amplify a rare event making it seem commonplace (which it isn’t) rather than rare. Not only do we hear of each event in the US, we hear about it many times. As best we can tell there are~ 2 athletic related deaths/year for a state the size of Massachusetts, with more sudden deaths in the patients already restricted from sports for prior diagnoses, completely silent heart disease or acute infections.
Does the ECG find things?
Absolutely. ECG screening identifies important diseases on a regular basis. In the older teen, it’s pretty good at making us suspect hypertrophic cardiomyopathy, though in the younger child it may not find anything. ECGs aren’t always right, of course. They can neither identify all the patients nor all the diseases.
Would it only cost 50 cents to screen athletes? And if so, should we do it?
If it sounds too good to be true it probably is. The Texas study calculated costs using donated computers, ECGs done for free by the school trainer, read for free by the authors and probably dramatically under-estimates the costs of a careful consultation. Commercial ECG screening companies typically charge about $50 paid by the parent with a reasonably prompt report and further testing determined by the primary care physician. While ECGs alone are relatively inexpensive, careful consultation regarding abnormal findings can take several visits and be expensive.
Aren’t my child’s physical and the forms I need for sports screening tests?
Absolutely. The questionnaires ask important questions, not just about cardiac disease, but asthma, concussions and orthopedic concerns. When families and physicians pay attention to these issues during annual physicals, the primary care doctor can help get appropriate referrals or additional testing. For those children who have an important cardiac symptom or family history an ECG is almost always part of the evaluation.
I’m still worried.
As parents, we worry, that’s part of our job. As a parent of three college students and a cardiologist taking care of survivors of cardiac arrest, though, I worry more about car accidents, depression and suicide, alcohol and drug abuse (and how those relate to car accidents). We know that cardiac arrest probably happens in only two to four children per year in Massachusetts, compared to 70 deaths from car accidents and 21 from suicide.
What if a family member had a cardiac arrest or unexplained drowning?
Families who have experienced unexplained sudden cardiac arrest should start with getting evaluation of those closest (parents and siblings) to the family member who died. That may involve evaluating the parents and siblings. Autopsy is reasonable for excluding many diagnoses, but can’t find the 10 to 20 percent of those caused by Long QT.
So should we be getting ECGs on all children?
I don’t think so, at least not yet. No test is perfect at preventing rare events. Making the decision to add ECG screening for athletes, or all children (70,000 students/grade in Massachusetts) is complicated. Most of the children we are trying to identify will either have symptoms or an important family history that already deserves investigation. There are clearly physicians and families who have reached other conclusions, but choices to make a broad change in how we look for disease and what we are going to do with the findings I think need pretty cautious consideration of each part of the decision. We don’t know how often we would need to screen, how to manage borderline tests (which are very common) and what the consequences of restricting or labeling patients with borderline findings will have on their well being.
Also read a story we did a few years ago about this topic in Children’s Pediatric Views publication.