A Closer Look- Athletic screening: A delicate balancing act

When Hank Gathers collapsed on court during a college basketball game against Portland State on March 4, 1990, and later died, the event both jolted the national consciousness and set into motion changes in the athletic preparticipation screening process. Although another collapse had occurred just 4 months before, and an irregular heartbeat was detected at that time, Gathers was not compliant with the prescribed beta blocker and continued to play. An autopsy revealed that the 23-year-old Gathers suffered from cardiomyopathy.

Now, 16 years after his death, and 10 years after the American Heart Association’s (AHA) 1996 release of Cardiovascular Preparticipation Screening of Competitive Athletes, has screening for athletic participation improved? Should preparticipation screening routinely include 12-lead electrocardiograms (ECGs)? Are conditions such as cardiomyopathy more likely to be detected, and can sudden cardiac deaths be prevented?

Screening Practices

If the case of Maggie Dixon is representative, the answers to these last questions are disturbingly negative. Dixon, the 28-year-old coach of the Army women’s basketball team, died suddenly April 6, 2006, following an arrhythmic episode. According to the medical examiner’s office, the cause of death was cardiomegaly with a mitral valve prolapse, a condition that had not been detected throughout her athletic careers in high school and the University of San Diego.

The cases of these 2 athletes point out a major issue in preparticipation screening-how much is enough, and how much is too much, given cost-benefit tradeoffs? (In both cases, it is possible that ECGs would have indicated a problem; a more expensive echocardiography would likely have identified the specific problem.) The AHA considered these questions back in 1996, noting that cardiac death in athletes is an infrequent event and that screening programs involve cost-efficiency considerations, practical limitations, and the need for specific tests to uncover particular conditions.

A discussion with physicians at major athletic programs suggests that these organizations both want to apply the AHA standards and do better than them.

At the University of Iowa, athletic screening hews closely to AHA recommendations. “We currently use a detailed history, which includes individual and family history and genetics and a detailed physical exam,” says Ned Amendola, MD, director of the University of Iowa Sports Medicine Center. “If anything is noted on these, such as a fainting spell or family history of sudden death, we will investigate with other tests including ECG and/or an echocardiogram.”

Twelve-lead ECG is not part of the regular preparticipation screening process, says Dr Amendola, “because it has not been shown to be effective as a screening tool, and the history and exam is as detailed.”

At Rutgers University in New Brunswick, NJ, athletic preparticipation evaluations include a complete medical and orthopedic history, with emphasis placed on cardiovascular screening questions, and a full physical exam. All athletes undergo repeat screening evaluation every other year.

Here as well, ECGs “are only performed if medically indicated on a case-by-case basis,” said Robert Monaco, MD, director of sports medicine. Other tests, including echocardiography and stress testing, are conducted if deemed medically appropriate. For the past several years, however, Rutgers has had a pilot program in which screening ECGs are performed on all incoming football and basketball players (both men and women).

“We plan to review the results of our pilot screening program, and evaluate it for effectiveness and costs,” said Dr Monaco. “We strongly recommend that team physicians thoroughly weigh the pros and cons before implementing a new screening technique.”

The National Football League (NFL) does include an ECG as part of the routine screening of athletes, along with a complete physical exam and health history. Because of controversy over the value of echocardiograms for routine screening, NFL athletes would “get an echocardiogram if they fail their initial screening and their ECG suggests there might be a problem,” says Anthony Magalski, MD, consulting cardiologist to the Kansas City Chiefs. “In more than 95% of hypertrophic cardiomyopathy cases, the player’s ECG was abnormal.”

Limitations to Screening

Of course, in the larger universe of high school and college athletic programs, with their lesser financial resources, universal ECG screening is precluded. As Dr Monaco points out, the costs of ECG screening are potentially significant (ie, the costs of the ECG machine itself; the time and reimbursement costs of the technician, nurse, or physician who performs the ECG; and the time and reimbursement costs for the team physician and/or cardiologist who reads the ECGs). At the University of Iowa the cost of an individual athletic exam can range from $0 to $100, depending on the location and physician; an ECG at the University’s Hospitals & Clinics can add $175 to the costs, says Dr Amendola. There is no question, says Dr Magalski, that “the pro player gets a better, more comprehensive screening than do most collegiate or high-school athletes.”

In addition, despite the prevalence of hypertrophic cardiomyopathy (1 in 500) in the United States, the rate of sudden cardiac death among young athletes is extremely low, says Dr Monaco. Using lower national risk estimates, and assuming that ECG screening would indeed detect the person at risk, the Rutgers Sports Medicine group calculated that an institution that brings in 250 new student-athletes per year would identify 1 potential victim of sudden cardiac death every 400 years.

Finally, another common type of sudden cardiac death in athletes—commotio cordis—results from impact to the chest wall at a precise point in the cardiac cycle, and this is a treatment rather than a screening issue. To ensure that treatment can occur, Dr Magalski recommends that automatic external defibrillators be made available at all practices and games at all levels of play, from youth leagues to professionals. (A study just released in the July 2006 issue of Heart Rhythm, however, also calls into question the value of this strategy. A study of 9 cases of intercollegiate athletes with sudden cardiac arrest found that even though defibrillation was deployed in an average of 3.1 minutes, 8 of the 9 athletes died.)

What is to be done, then, in terms of cardiac screening? The University of Iowa’s Dr Amendola says “all we can do is be thorough in evaluating these kids and if there are any warning signs, like a positive family history, symptoms like shortness of breath, fainting, chest pain, irregular heart beat, they should be prevented from participating until proven normal.”