Should young athletes be screened for heart disease?

In the wake of sudden deaths in a young athletes, the question arises – as it does after each of these tragic events – whether all young athletes should be screened for occult heart disease before participating in sports. It appears, for instance, that 16-year-old Wes Leonard had an underlying heart condition which likely could have been identified with a simple echocardiogram.

The question is controversial, and accordingly, even the professionals disagree. The European Society of Cardiology and the International Olympic Committee, for instance, recommend screening every young athlete with electrocardiograms (ECGs), and if the ECG is abnormal, following with an echocardiogram. But the American Heart Association and the American College of Cardiology do not recommend screening ECGs, and advocate only a medical history and physical examination – which will notoriously miss many if not most of the occult cardiac conditions that produce sudden death in young athletes.

To DrRich, of course, sorting through the controversy is mere child’s play. Allow him to explain.

The problem in answering this question stems solely from our failure to clearly identify what we wish to accomplish in establishing such a screening policy.

Those who advocate widespread screening stress the horrific nature of sudden death in vital young people.  They can fully articulate their argument simply by pointing to the awful video of young Wes scoring the winning basket to cap off a perfect season, then moments later, collapsing and dying. The scene is just too gut-wrenching to watch. Clearly, we should all want to do whatever we can to prevent such scenes from ever happening again. If Mr. Leonard had had an echocardiogram, it is likely that this tragedy might not have happened – and that should be argument enough for a widespread screening program.

For a good articulation of the alternative point of view we can begin by turning to DrRich’s colleague, Dr. Wes. Wes points to the experience of a Detroit area hospital that screened 5200 young student athletes, and identified three who had cardiac abnormalities which placed them at risk for sudden death. In finding these three individuals, the screeners not only performed ECGs on all 5200 students, but also performed nearly 1000 echocardiograms on students with suspicious ECGs, and in the process identified at least 30 students who needed even further evaluation (and possibly treatment). Evaluating these other, possibly false-positive cases not only cost money, but also subjected these young students to medical risk. Dr. Wes estimates the overall cost of this screening process at well over $600,000, and Wes is being very conservative in his assumptions.  As a result of this well-intentioned effort, it appears that several kids were told not to participate in sports any more; it is not clear that any lives were actually saved.

As it happens, a report from Israel this week in the Journal of the American College of Cardiology substantiates Wes’ suspicions. According to this study, the national mandatory cardiac screening program for athletes, instituted in Israel in 1997, seems not to have reduced the incidence of sudden death in young athletes at all. The incidence of sudden death was 2.6 per 100,000 athlete-years both before and after the mandatory screening was instituted.

Does this mean that screening does not save any lives? No. It is certain that some individuals are spared sudden death thanks to this aggressive type of screening program – just not enough to affect the overall statistics. This result illustrates that when you are dealing with an event that has such a low incidence of occurrence, it is extraordinarily difficult to prove that your intervention is producing a statistically significant reduction in that incidence.

Furthermore, by definition, screening programs of any type (whether it’s screening for sudden death in athletes or screening for breast cancer) don’t change outcomes. All they do is identify people at some degree of increased risk. To change the outcomes, you have to find a way of treating the at-risk individuals you’ve identified with some process that is sufficiently effective, that itself does not worsen outcomes, and that the at-risk individual is willing and able to employ.

In the case of screening young athletes, to effect a reduction in the rate of sudden death you must either convince the young person to give up sports (not only organized sports, but all athletic activities), or find a way to make the underlying heart condition go away. DrRich understands that some of his readers might not have experience in trying to convince dedicated young athletes to stop what they’re doing and become bookkeepers, but the fact is that informing them of the risk is not always perfectly effective in changing their behavior. And while most of the cardiac conditions that produce a risk of sudden death in these young people can be managed to one degree or another, they generally are not “cured” or mitigated to the extent that athletic activity becomes risk-free.

So, while occasional individuals are likely to benefit substantially from these screening programs, if you look at it from the collective point of view these programs appear to do little or no measurable overall good, despite the high cost.

So this brings us back to the original question – should routine cardiac screening of athletes be performed? It seems clear, to DrRich at least, that the answer is: It depends on what you are trying to accomplish.

If you are asking the question from a collective viewpoint, wherein “society” will be paying the bills for the screening procedures, and thus will not have that money any longer to spend on other healthcare services that might yield a more substantial result, it is obvious (since there is no measurable benefit but a high cost) that such screening should not be done.

But if you are one of the individuals – or the loved one of such an individual – who is concerned about having a readily identifiable cardiac condition which places you at risk for sudden death, and would be willing to change your behavior if you are found to be at high risk, it would be entirely reasonable for you to want cardiac screening, and furthermore you should have every opportunity to avail yourself of that screening.

So what we have here is that very common circumstance, which modern medical ethicists insist never ever occur, wherein what is clearly best for an individual is equally clearly not best for the collective.

This situation, DrRich thinks, is analogous to the situation with smoke detectors. Smoke detectors clearly save lives here and there – we have all heard anecdotes about a family being aroused to safety by a smoke detector. But proving that the overall incidence of death from fire has been significantly reduced in the era of smoke detectors seems difficult if not impossible. And if it were society’s job to buy smoke detectors for every individual, then society would – rightly – determine that the cost is not worth the insubstantial benefit.

Yet, everybody has smoke detectors. Why?

Simply, everybody has smoke detectors because it is NOT society’s job to pay for them. The individual does. And the individual does not care that smoke detectors cost $1.2 million per life saved. They only care that the life saved, potentially, is theirs, and that owning the smoke detector that might just save their life does not cost them $1.2 million, it only costs them $19.99.

The issue of screening young athletes would be resolved if we made screening ECGs readily available to individuals for $10 at Walmart, and a follow-up echo (if needed) for $50, also at Walmart. Then individuals who decide that they wanted to know if they’re at risk for sudden death could do their own cost-benefit analysis, and if the potential benefit is worth a few dollars to them, they could buy the screening for themselves.

So screening young athletes for underlying cardiac conditions seems like a pretty good idea, just like smoke detectors seem like a pretty good idea. Where we go wrong is by making such screening a medical service, and therefore making it the responsibility of the collective to pay for it (if indeed it is to be purchased), and furthermore, making it next to impossible – and soon illegal – for individuals to pay for it themselves.

From the collective point of view, paying for the screening of young athletes makes no more sense than would collectively purchasing smoke detectors, carbon monoxide detectors, fog lights, back-up cameras, home security systems, and a host of other personal safety-enhancers that people will happily pay for themselves, but which would be ridiculously wasteful to pay for collectively.

Which just goes to illustrate a general rule: The more stuff we collectivize, the less stuff we’ll have.

Richard Fogoros is a cardiologist who blogs at The Covert Rationing Blog.  He is the author of Fixing American Healthcare – Wonkonians, Gekkonians, and the Grand Unification Theory of Healthcare.

 

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  • Camilla

    Another cost: potential athletes declining to enter sports programs due to cost/availability/convenience of test.

  • Michelle

    Why must everyone else be screened with an ECG because a very small number of their fellow athletes died? Because one man’s video is hard to watch?

    His death is tragic, but stop a think about something. These are young *athletes*. You know, people who participate in sports and fitness activities. Lots of them are probably the healthiest members of their age group.

    Stick to a physical exam and questionnaire.

  • http://www.drdarrellwhite.com drdarrellwhite

    Ah, and in this particular example of the challenges of screening tests the answer is even easier (and more difficult) because the overwhelming majority of deaths in young athletes from cardiac events have occurred in one particular cohort, and even in that cohort the majority of deaths occurred in children in who’s family there is a history of the exact cardiac problem responsible for those deaths.

    REAL screening first identifies an at-risk group, automatically increasing the “yield” of positives, before embarking on screening tests. Easier to screen? Of course: simply screen within this group, with or without taking family histories. Harder? Sudden athletic cardiac deaths occur almost exclusively in males of a certain genetic heritage that has a history of being on the receiving end of discrimination.

    Good medicine, unfortunately, cannot escape not-so-good history and its sequelae.

  • http://www.jamesloganmd.com James

    “So what we have here is that very common circumstance, which modern medical ethicists insist never ever occur, wherein what is clearly best for an individual is equally clearly not best for the collective.”

    No, no, no! Your outline of the controversy was excellent but the kind of thinking expressed in the above quote is exactly why our society is so confused about screening – why, for example, women’s health advocates get so up in arms when we changed the recommendation for breast cancer screening from starting at age 40 to age 50. Screening is either beneficial on the whole or it isn’t. How many prostate biopsies and radical proctectomies do you have to do, for example, to prevent one prostate cancer death in a patient with a positive psa? Answer: TOO MANY. How many kids who screen postive for HOCM would we need to keep from playing sports in order to prevent one death? Anser: it’s not clear that we’re preventing any deaths at all no matter how many we keep from playing! Therefore, on balance, screening in this case is harmful. There’s no such thing as a screening test that is helpful for some members of an identified population and harmful to others. Screening someone for something is either more likely to benefit that person or it is more likely to harm that person. And, in the absence of clear and convincing evidence of benefit, we should err on the side of doing no harm.

  • http://www.livewellthy.org Stewart Segal, MD

    This is a brilliant commentary. I plan on sharing it with my patients and on my blog. Thanks!

  • Kristin

    …you’re talking about yourself in the third person? Okay.

    The problem with making it cost money to do these kinds of screenings is that they will be done unequally. Rich kids will get them; poor kids won’t. If parents are working and making nine or ten bucks an hour, there isn’t a lot of money left over–not much for the ten-dollar test, and definitely not enough for a fifty-dollar follow-up, let alone any kind of additional care. (In a capitalistic society, parents making ten bucks an hour probably don’t have health insurance, either. If they’re lucky, their kids do, but since Medicaid is on the chopping block and medical literacy isn’t taught in schools, they might not even know how to navigate the system to get it.)

    Monetary burdens are not equal across social classes. The same 60 bucks that to you is ridiculously trivial is somebody’s grocery money for this entire week. It’s the same reason why food isn’t taxed: it’s a much bigger burden on people living below the poverty line than it is on people living above the poverty line. (Which is already set ridiculously low, in the US.)

    So you see the middle-class mom who takes her free day, which she can afford because the other parent has a solid job, and takes her kid to Walmart, and saves him, or reassures him, or leads him down the scary path of a false positive. I see the single parent struggling below the poverty line who doesn’t take their kid in because they’re working a job that’s minimum wage or maybe below if they’re illegal immigrants and they don’t have the time or the money, watches their kid die, and blames themselves.

    The really horrific thing here is that, in focusing on the privileges of the rich, we lose sight of the almost unimaginable burdens on people living in poverty. This is why a waiting period before an abortion is a tremendous imposition; a woman might not be able to take two days off, in the same week, from her one or two minimum-wage jobs to travel for hours to get to the clinic. Making her do it is tantamount to making her either bear the child or seek an illegal abortion closer to home.

    The relentless exercise of privilege is what has made this country what it is–a rich country, yes, but one with a huge class of people who are starving, homeless, and receiving no medical help, many of them children.

  • buzzkillersmith

    It’s not as complicated as this guy says. Figure out how much it costs per life saved with screening young athletes, and compare that with how much it costs for other standard things we do, like colon cancer screening. If the costs are roughly comparable, do it. If it is much much more expensive to screen young athletes, don’t do it. Next case.
    This “collectivization” nonsense reveals the author’s crypto-reactionary bent, a bent not uncommon in subspecialists, I might add.

  • Carrie

    1) I’m not sure it is clear that it is better for the individual (I’m not saying it’s not, I just don’t think that we know). The risk of these conditions is very low, the treatment is not necessarily effective, and extensive evaluation involves risks.

    2) Smoke detectors affect the health of nearby people more than cardiac screening — if my neighbor’s house is very close to mine, I could definitely be affected if that neighbor doesn’t have a smoke detector. That is probably one reason why, at least in some cities, there are programs to provide free or reduced-cost smoke detectors to people who cannot afford them.

    3) I have a hard time imagining an echo with interpretation costing $50, even at WalMart.

    4) You didn’t mention one of the purposes of screening – avoiding liability.

    5) Thank you for mentioning the ineffectiveness of screening with history.

  • Tim M

    Instead of screening every student athlete, I think communities would be better served through mandatory AED placement in schools and coaches/teachers/staff being certified in CPR.

  • http://patientprivacyreview.blogspot.com/ Joel Sherman MD

    You don’t mention the Italian experience. All athletes are screened in Italy by specifically trained personnel and this has made a significant reduction in unexpected death.

  • doc rock

    My question that the author alludes to is the most serious. Because hypertrophic obstructive cardiomyoapthy is not balc and white but a range, how many gray zone kids or even kids with bad HOCM that never in their lives would have known or been affected by HOCM, will be rendered disabled by this diagnosis? Set to a life of misery without physical activity, and doomed to obesity, type 2 diabetes, heart attacks and strokes, not to mention the burden of knowing there chest is a ticking time bomb (perhaps) and may kill them at anytime… Would all those kids get internal defibrillators and be allowed to be active? That certainly would be cumbersome as well.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    This is an outstanding essay with equally outstanding commentary and opinions. A thought provoking piece. I am sure the cost of an EKG and interpretation and the cost of an echocardiogram would be significantly lower if we didnt have to factor in the medical malpractice defensive medicine cost of the overall procedure.

  • Laura R., MD

    Similar to what Tim M. said above: Perhaps the best use of taxpayer dollars would be in increasing comfort with basic life support and the use of automatic external defibrillators (AEDs) in the public schools. While I am not familiar with all the particulars of this athlete’s situation, I would imagine that the immediate cause of his death was from vfib arrest. The use of timely CPR – accompanied by AED use – would have offered the best chance of his surviving such a tragedy.

  • Richard GK

    I think we’re commonly overlooking that the nominal cost of the screening method (our $10 at WalMart) doesn’t even begin to get at the overall costs, both direct and indirect. If WalMart has to cover all the sequelae of a screening test $10 won’t be too attractive.

    A local vignette may be illustrative: A well off older person had some screening CT scan, I think for coronary calcifications and about $300, which showed an adrenal mass. The adrenal came out but the screening CT guys and person didn’t pay, rather Medicare/insurance so a signifcant cross subsidy and society decision now for a person not a sick patient even. Not too bad except there was no mass in the adrenal and next the kidney had to come out which proved to have a benign cyst. We (Medicare/insurance which we participate in) are probably out $50,000. Now our person is a patient and has been non-productive and out of work for a month or more which is the indirect cost to the person but also society.

    So I do think athlete screening is a societal decision. I’m personally not so concerned about the direct dollars involved in the follow-up and interventions rather am more concerned about the people who uncessarily have their lives changed and the kid who now is not allowed to become an athlete and a complete member of society.

  • Brenda, RN

    Wes’ family recognizes that the lack of an AED was most important factor here in his death- not the lack of screening.They have established a foundation to that end and are focused on getting AED’s in as many schools as possible.

    As a school RN, I have found that most schools either don’t have one at all, or may not be functional, i.e. expired patches, battery dead, or not accessible. There are rare, but amazing stories of students revived by classmates, and coaches who could get the AED, and use it.

    Our focus should be on educating our communities on the value of the AED, CPR, and being trained and having a action plan is what will save lives of not just HOCM, but potentially anyone at risk for a cardiac event.

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