This article contains arguments for and against heart screenings for athletes.  For once, I would like for the adversaries to substantiate their costly claims.  It is easy to throw out high dollar amounts. 

Two studies published yesterday are expected to reignite an emotionally charged debate about whether young athletes should be screened with a heart test to reduce the small risk of sudden death from an undiagnosed heart problem.

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In the first, researchers at Massachusetts General Hospital and Harvard University added an electrocardiogram, known as an ECG, to a routine physical for students. This strategy doubled the number of students with heart disease who were detected, compared with those who did not receive an ECG with their physical.

The vast majority of athletes who die suddenly are felled by an abnormal heart rhythm, which can often be detected with an ECG, a test of the heart’s electrical activity. However, the Harvard study also found a large number of “false positives’’ – tests indicating a problem when there is none – that would subject athletes to additional costly testing to rule out a heart ailment. Still, based on the findings, Harvard is routinely giving ECGs to all its athletic recruits.

In the second study, scientists at Stanford University School of Medicine concluded that adding an ECG to the traditional sports physical would tack on roughly $89 per athlete, a cost that is considered feasible compared with other routine medical interventions. Both studies were published in the Annals of Internal Medicine.

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by Whitney Harding
Jan 27, 2010

Doctors point out that not all athletes with enlarged hearts are at risk of heart failure, the unexpected cause of death of Chicago Bears defensive end Gaines Adams earlier this month.

But as a result, the NFL Cardiovascular Committee is considering the possibility of making echocardiogram heart scans mandatory for all players, starting with potential draft picks this year.

“NFL [Players Association] medical director Thomas Meyer told ESPN that the medical examiner who performed an autopsy on Adams stated the enlarged heart that led to his death could have been detected by an echocardiogram,” said Chris Mortensen, reporting for ESPN.

But just because someone has an enlarged heart, it does not mean they have a fatal heart condition, emphasized Dr. Mark Hutchinson, professor of orthopaedics and director of sports medicine at the University of Illinois at Chicago.

Any athlete in any sport could have an enlarged heart from their conditioning and endurance training. The heart, in common with any other muscle, is going to get bigger if you give it a constant workout, doctors said.

The most common heart condition seen in these sudden deaths of athletes is called hypertrophic cardiomyopothy (HCM) – a condition where the walls of the heart are too thick. This causes the heart to pump less efficiently and work harder. When the effort is too great, young, healthy people can have heart attacks or go into cardiac arrest.

“While HCM does lead to an enlarged heart, an enlarged heart by itself is not HCM,” Hutchinson said. “It is like the flawed logic that poodles are dogs; therefore all dogs are poodles. One does not imply the other.”

The echo is “the most sensitive, non invasive test we have” for detecting HCM, said Dr. Kousik Krishnan, a board certified cardiac electrophysiologist and assistant professor of medicine at Rush University Medical Center. However, just because it is the best scan available does not mean it is fool-proof.

With athletes, pictures can be deceiving and then things get complicated.

“It’s like lifting weights makes your biceps bigger,” said Dr. Robert Bonow, chief of cardiology at Northwestern Memorial Hospital. “So if you’re a super athlete, your heart is going to get bigger.”

The fact that professional athletes may already have larger hearts than the normal population is what makes detecting HCM tricky.

“A number of those patients are going to not have a problem,” but they may be considered at risk as a result of the screening, Hutchinson said. “Then, they do a cardiac injection – they put dye into the heart and see how it works. So now, you’re more invasive for a false positive.”

Another problem with detecting HCM is the symptoms. A few of those clues are chest pain, shortness of breath, unexplained dizzy spells or passing out. While the more serious end of the symptoms may seem more obvious, the less obvious symptoms could be construed as something else. For instance, a coach may think the athlete isn’t in good enough shape.

“These people don’t have a lot of symptoms,” Krishnan said. “I mean, Gaines Adams was at the highest condition – how could he have anything wrong? Symptoms are subtle, so people blow them off.”

An example of this was seen in marathon runner Ryan Shay at the 2008 Olympic trials in New York. Shay collapsed five miles into the race and died. His condition was slightly different than HCM – he suffered from an irregular heartbeat caused by an enlarged heart and had scar tissue in his heart. He had shown symptoms but those were attributed to the flu. Sorting out symptoms related to several conditions is another challenge.

So where to go from here? Should all professional athletes have to undergo full screening? What about college and high school athletes? The answers are varied.

“This has been a debate for a long time and I would be cautious saying one answer is the right answer,” Hutchinson said. “The best recommendation is a strong screening history, and that is what everyone does across the NCAA. Once positive, if those people have symptoms, then they go for further testing.”

Krishnan said the screening process as it is, does not do enough and more echoes need to be done.

“Clearly at the highest levels, spending money on these screens shouldn’t be a problem,” he said.

But then, there’s the legal issue of athletes’ rights to refuse testing to protect their careers.

“You may have an enlarged heart from being an athlete and not have a problem,” Krishnan said. “But if it comes back enlarged, no one will want to sign you. So there may be some legal issues where these pro organizations can’t screen anyone, because athletes want the right to be screened or not.”

HCM is not a disease that is growing in the United States. Krishnan said that simply, when a healthy athlete dies, it gets a lot of publicity. But nothing about the disease itself has gotten worse over the years.

Hutchinson said to look at the bottom line, that very few athletes have this condition and the cost of echocardiograms for all athletes at this point is over the top. He believes that more research is needed and not a hasty decision.

“The key here is we can’t really in all honesty say one football player dies and jump in and say everyone needs this,” he said. “What I would say is when these things happen, that should alert us to go look at the science and not make a dropkick decision.”

By Judy Peterson

Los Gatos Weekly-Times

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When 17-year-old Mikey Halpin collapsed at Los Gatos High School on Dec. 2, 2008, it sent shock waves through the community. Everyone, family included, thought the strapping senior was healthy. After all, he had recently passed the physical that was necessary for him to play football.

But Mikey suffered from a hereditary heart condition known as mitral valve prolapse, which proved to be fatal.

Now, his father, Tim Halpin, is working with local hospitals to encourage young athletes to undergo testing for heart anomalies.

“I don’t want other parents to go through the heartache I have — and still have,” Halpin said. “It’s been a year, but I don’t think it ever goes away.” Halpin was on hand Jan. 9 when El Camino Hospital Los Gatos sponsored a free heart screening clinic for young athletes.

“These conditions of heart disease in athletes are more serious because they often die,” Dr. Bing Liem said. “That’s why screening is so important.” Liem, a cardiologist at El Camino who organized the heart-screening clinic, said that the incidence of sudden death among athletes is one in 100,000.

The free tests he performed are relatively simple, but important life-saving analyses. “The first step is a good cardiac history and an EKG — an electrical recording of heart rhythms, which also reflects heart disease,” Liem said. “If we aren’t comfortable with what we see, we may recommend an ultrasound of the heart, which takes a picture of the heart. Other steps may include a stress test or other electrical tests.”

The Jan. 9 clinic was focused solely on taking an athlete’s heart history and providing an EKG.  Liem said high school athletes are of particular concern.

“Usually when they reach high school, they become very competitive. They’re going for scholarships and participating in marathons,” he said. So, that is when previously undetected problems may begin to affect otherwise functioning people. “Sudden death is made more common when athletes exert themselves,” Liem said. “Physical activity is part of the risk factor in people born with heart anomalies.”

While Liem singled out strenuous sports such as basketball, football and swimming as being particularly dangerous for young athletes with undetected heart problems, he also said endurance sports like sprinting and extreme jumping can be just as dangerous.

“Over-exertion can trigger sudden death,” he said.  He views awareness as key to preventing sudden death from heart disease.  “There was a recent publication whereby programs that mandate better screening can reduce the sudden death rate. Some countries that mandate screening found it reduces sudden death rates threefold.” There has been some pushback, Liem said, to making cardiac screening mandatory in the U.S. because of cost and manpower concerns.

“So I just wanted to do it for free to improve awareness,” he said. “Perhaps later it will become something that people embrace.”

That is exactly why Halpin is behind an effort to make cardiac screening mandatory for young athletes in California. He is working with Fresno Assemblyman Mike Villines. “We’re working to submit a bill this year to make it mandatory for kids to be tested for heart defects,” Halpin said.

Halpin is also starting a nonprofit organization in Mikey’s name to raise money to put defibrillators in all schools. In addition, Halpin is working with Good Samaritan Hospital to start a heart-screening program for all Los Gatos High School athletes.

“I would love to see all children tested, whether they’re in sports or not,” Halpin said. “It’s important for the knowledge to get out there that tests are available.”

While Halpin’s focus now is on Los Gatos, he plans to reach out to surrounding communities so that other parents are aware of the risks involved in youth sports.