There may be no more horrifying medical catastrophe than the sudden death of a young athlete on the playing field in front of a large crowd of friends, family, and community. But it’s also a dizzyingly complex subject with no easy solutions. Experts are divided. The American Heart Association recently reaffirmed that it does not recommend universal screening for potential cardiovascular disease in young athletes with electrocardiograms (ECGs). On the other hand, universal screening has been adopted, apparently successfully, in Italy.
According to Anahad O’Connor in the New York Times, however, the movement toward routine ECG screening for student athletes may be inexorable, as it is not just cost-effective but desirable from a medical and a societal perspective. The Times article states that sudden cardiac death (SCD) of young athletes “is far more prevalent… than previously believed.” About 2,000 children each year die from SCD, according to the American Academy of Pediatrics, as cited by the Times, but this includes all children, not just athletes. The Times quotes the mother of a young athlete who died: “this happens all the time.”
But the world’s leading expert on SCD, Barry Maron, of the Minneapolis Heart Institute, insists that there has been no noticeable change in prevalence, and that SCD in children– whether athletes or not– is a rare event. “The peer reviewed data on this topic suggests that there are about 75 sudden cardiovascular deaths in competitive atheltes every year in the US,” he told me in an interview. (The Times article is similarly dizzy about the cost of an ECG test. Although medical costs are always a byzantine topic, the $1,400 cost cited in the article is preposterous. Move the decimal point one place: $140 is a lot closer to reality.)
O’Connor acknowledges that the AHA does not recommend universal screening, but argues that the position “pivots on old data.” He cites a 2010 study from Stanford published in Annals of Internal Medicine suggesting that ECG screening may be cost-effective, but doesn’t cite an accompanying article in the same issue that reached a much less positive conclusion. Also not mentioned is an editorial accompanying the articles, written by Maron himself, offering a number of reasons why widespread ECG screening should not be widely adopted at this time. (Click here for my previous coverage of the Annals articles.)
Even the Stanford author tells the Times that “we are not advocating this as a mandatory test for all students or all athletes,” but the article moves on to quote another expert who thinks “the time has come for thorough heart screenings for all young athletes.” James Willerson, of the Texas Heart Institute, told O’Connor: “If we save even one life, it will be worth it.” But Willerson, who had a distinguished career as a cardiology thought leader, is not an expert in SCD, and has an important conflict of interest in this case. As mentioned in the Times article, Willerson has a $5 million private grant to screen 10,000 students in Houston middle schools.
In his interview with me Maron offered a far more balanced perspective. He acknowledged that “each of these deaths are greatly tragic, and it is never the intention to minimize it by citing numbers, however large and however small. Furthermore,” he continued, “no one would ever feel comfortable placing a monetary value on a young athlete’s life.”
Maron spoke about the limitations that most cardiologists, Willerson aside, understand about ECGs. The test is far from perfect. There are false negative and false positive tests, and these need to be considered when evaluating the test. The high rate of false negatives associated with the ECG means that “in a significant proportion of the screened population important diseases would be expected to be missed,” said Maron. “This limitation is not even mentioned in the [Times] article.” False positives are also important, Maron observed, “because they create the possibility of unwarranted disqualification from sports as well as substantial anxiety among the families and participants.”
Another cardiologist, electrophysiologist Wes Fisher, talked about false positives in more graphic terms:
The psychological and emotional toll of telling a young student athlete that they can no longer partiipate in sports… is huge. Anyone who thinks it’s as easy as “just get an EKG” has never had to evaluate the marginal 18-year old who’s life you’ll potentially change forever.
Maron was also highly critical of the exclusive focus on student athletes:
All this discussion about limiting preparticipation screening for the detection of potentially lethal cardiovascular disease to athlete populations does not make a lot of sense because it is exclusionary and discriminatory. More sudden deaths from these same genetic diseases occur in nonathletes, numerically speaking. Therefore it would seem most prudent to discuss screening in young people, athletes and nonathletes, for these diseases. However, the numbers involved in those projected screening programs are so large that they limit any reasonable discussion of practicality.
According to Maron, there are about 10.7 million athletes out of a total population of 63 million children and adolescents.
On the same day as the Times article appeared, the AHA issued a science advisory about screening approaches for heart disease in children and adolescents. Once again, the AHA did not endorse mandatory screening for athletic participation. As Stuart Berger, one of the authors of the AHA statement, wrote:
New screening programs, including mass ECG screening, must be based on sound and evidence-based principles rather than a reaction to catastrophic events.
The Times article appears to be one of the first articles featured in the Times new “Well” blog, which is intended to bring substantially enhanced coverage of health topics onto the Times’ website. This article does not bode well for the future of this coverage, as it falls short in so many respects.