Ticker Testing

Should heart screening be part of sports physicals for student athletes?

You may have seen the horrifying video last winter of the Michigan high school athlete sinking the game-winning shot for his basketball team one minute, only to collapse and die on the court the next. Could his death have been prevented?

Such deaths are rare — about 60 out of the 11 million competitive athletes in the United States die from Sudden Cardiac Death, or SCD, each year. It’s about the same as the number of deaths from lightning. Still, the dramatic and sudden nature of this tragedy has led to efforts to identify kids at risk. So far, studies show that requiring pre-participation sports physicals by trained professionals has had limited effectiveness, preventing perhaps two or three deaths per year.

However, the cardiac abnormalities responsible for 60 percent of the SCDs might be detected by an electrocardiogram (ECG), a relatively inexpensive and readily available test that can be performed with a simple office visit. In Italy, athletes have been required to undergo ECG testing in addition to an exam and interview for the past 30 years. The Italians believe it has reduced the number of SCDs considerably.

But the Italian approach has been controversial here and has not been adopted. At issue are the usual difficulties in detecting a very rare occurrence among a huge population. Finding the needle in the haystack, so to speak, is expensive and leads to lots of false positives, which come with their own set of issues — additional testing, needless worry.

If you crunch the numbers, even in the best case scenario of a 99 percent accurate ECG, you will find that we could possibly save 40 lives a year if, and it’s a big if, we found practitioners to accurately perform and read 11 million ECG studies. And then we would have to find a way to manage the approximately 100,000 cases of false positive results.

So researchers are looking for ways to increase our odds of identifying people truly at risk. To that end, there has recently been a very compelling study out of the University of Washington that analyzed SCDs in NCAA athletes.

The study shows that every year about one of every 44,000 NCAA athletes has experienced Sudden Cardiac Death. However, their analysis goes on to further identify groups at higher risk: Deaths are twice as likely in males (compared to females), three times more likely in African-Americans compared to Caucasians. And, of all sports, basketball players had the highest risk.

Putting it all together shows that Division I male basketball players were four times more likely than the average NCAA athlete to die of SCD.

Those results make a compelling case that screening NCAA athletes with more advanced methods would be worthwhile. For the rest, for now, it looks like we will have to settle for the marginal preparticipation sports physical and a review of the patient’s history.

Which brings me back to our current system of sports physicals. I suspect that sports physicals divert many adolescents away from the comprehensive medical care they should receive with a primary care provider. Sports physicals do not address depression, sleep disturbance, tobacco, alcohol, drugs, sexually transmitted diseases or unplanned parenthood.

There are more than 4,000 teen suicides a year in the United States, thousands of automobile fatalities, thousands of fatalities related to substance abuse, and millions of dollars spent treating the consequences of unsafe sex. Do these five-minute physicals lull parents into a false sense of security about their child’s health? They certainly won’t provide answers to many of the most important health issues young people face.

So maybe requiring an ECG, like they do in Italy, would be a good thing, because it would get these kids into my office for more comprehensive care, instead of settling for those cursory exams every other year.

I’m in. Bring on the ECG requirement!

Matt Thompson is a pediatrician at the Kids Clinic in Spokane.

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