Screening young athletes for heart disease

14-point checklist evaluation preferred over mandatory testing for all


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“When one of these tragic deaths occurs, it’s understandable that everybody wants to do something. But mandated ECG screening for large populations would be chaos.”
Barry Maron, M.D., Minneapolis Heart Institute Foundation


The NCAA is developing guidelines to detect college athletes at risk for sudden cardiac death — an issue that recently riled university team physicians and is seeping into state legislatures, where lawmakers are pushing for mandated heart screenings for high school athletes.

But what will be missing from the NCAA guidelines — expected in 2016 — is a recommendation to automatically screen all college athletes with an electrocardiogram, a test that measures the heart’s electrical activity to check for a number of heart problems. Testing entire teams would pose a logistical and financial challenge for some universities. In addition, ECGs do not find every significant heart problem and can sometimes look abnormal in people with normal hearts.

“At this point in time, it doesn’t make sense for us to recommend ECG screening,” said Brian Hainline, M.D., the NCAA’s chief medical officer.

Hainline backed off an idea to recommend ECG screening for all athletes in sports such as basketball after a Wall Street Journal article in March prompted about 100 team doctors from NCAA schools to sign a petition opposing the plan. Currently, ECG screening is required for many professional athletes, but not for those in high school or college.

What schools can expect instead, Hainline said, are a set of cardiac recommendations that provide a more comprehensive approach, including emergency response plans for sudden cardiac arrest, which could require cardiopulmonary resuscitation training; and increased access on campus to automated external defibrillators, portable devices that detect abnormal heart rhythms when someone is in cardiac arrest and then shock the heart back to a normal rhythm.

What personal histories revealThe guidelines may also recommend that all of the more than 1,100 NCAA schools use the same pre-sports checkup — the one recommended last year by the AHA and American College of Cardiology.

The checklist is a 14-part evaluation for young athletes that includes questions about family and personal history, including heart-related symptoms such as fainting or chest discomfort. It also includes a physical exam in which doctors measure blood pressure and check the blood vessels and heart, including listening for heart murmurs. The evaluation is meant to flag individuals who should be referred to a cardiologist for further evaluation, which may include tests such as ECGs.

Components of the preparticipation exam currently vary from school to school, said Hainline.

“We should be moving toward a universalization of the preparticipation exam, and the best cardiac example we have right now is the AHA 14-point guidelines,” he said.

Sudden cardiac death among young athletes is very uncommon. One study estimated that roughly 66 athletes die from sudden cardiac arrest each yearThe NCAA last year started requiring member schools to report every athlete death and its cause.

“It’s troublesome, and we may just say there’s nothing we can do, but I don’t think that’s the right answer,” said Hainline.

On the high school level, some state legislatures aren’t waiting for the NCAA’s decision. New Jersey, for one, enacted a law in early May that makes a cardiac health assessment mandatory during wellness exams for children under 19.

ECGs not accurate enoughBut AHA and ACC have long suggested that careful evaluation with personal and family history and a cardiovascular exam should be done in young people — athletes and non-athletes alike. Such an evaluation can pick up some heart problems that may not be found with simple ECG screening alone, according to the AHA.

Barry Maron, M.D., led the panel that wrote the recent AHA/ACC guidelines and said mass screening of student athletes would be impractical and ineffective.

“When one of these tragic deaths occurs, it’s understandable that everybody wants to do something,” said Maron, director of the Hypertrophic Cardiomyopathy Center at Minneapolis Heart Institute Foundation. “But mandated ECG screening for large populations would be chaos.”

As many as a third of athlete ECGs may result in so-called false-positives, according to a 2014 study done in the United Kingdom.

ECGs can also miss dangerous heart problems. For those with hypertrophic cardiomyopathy, a thickening of the heart muscle and the most common cause of sudden cardiac death in young athletes, research shows that at least one in 10 will have a normal ECG. Coronary artery anomalies, the second-most common cause of death in this group, is missed at least nine out of 10 times.

Moreover, there aren’t enough experts to interpret all those additional ECGs, said Maron, who has been studying sudden cardiac deaths in young people for more than three decades.

And the overall cost of screening roughly 10 million U.S. high school and college athletes could be at least $2 billion in the first year, according to estimates by the authors of the AHA’s 2014 scientific statement.

As the debate continues, about 50 organizations in 26 states now offer ECGs to student athletes at little or no cost, according to Screen Across America, a consortium of screening groups.

“But the 14-point exam is what we believe to be most effective,” said Maron.

Source: The American Heart Association: http://blog.heart.org




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