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Thursday, September 1, 2011

Is Heart Screening for Teen Athletes a Good Idea?

The sudden death of a student athlete is a horrible tragedy. It’s rare—among college level athletes, a recent review estimated a death rate of 1 in about 44,000 per year—but not as rare as we’d like. In many communities, parents are hearing about advanced, high tech tests to protect their children by identifying those at risk for deaths. Sounds like a good idea, right?

It turns out that those tests are far from perfect. There are simpler and more-effective ways to keep your children safe.

The American Academy of Pediatrics recommends a careful physical exam and review of the child’s personal and family health history before sports participation, without any further routine testing. Parents should keep in mind that only a few short questions can very effectively identify many children at risk:

  • Has any immediate family member suffered a sudden, unexpected death at a young age?
  • Does your child experience chest pain, shortness of breath, or fainting during exercise?

These and a few other questions should be accompanied by a physical exam, which should include a careful, correct blood pressure measurement (with the correct sized cuff) and an unhurried heart and circulation exam. This is best done at your child’s regular doctor, so any changes can be compared with previous exams. Your child’s whole health history, growth charts, and immunization record should be reviewed. The sports exam isn’t only to screen for cardiac conditions—it should be an opportunity improve a child’s entire health status.

But is this sort of low-tech screening good enough? Studies looking at the effectiveness of adding an EKG to this history and physical have been mixed; in Italy, a large study showed that more testing saved more lives, but this wasn’t confirmed in an Israeli study.

It turns out that EKG screening is far from perfect. There are many false-positives (that is, most kids who “fail” the EKG turn out to be normal on expensive follow-up testing), and even under the best circumstances EKGs will probably only identify about half of the children at risk of death. EKGs are not simple to read and interpret, and there is a shortage of people in the USA qualified to read them correctly.

New criteria for athletes’ EKGs has just been published, which may reduce the false-positive rate and simplify EKG interpretation. Meanwhile, thousands of children who fail their EKG screen are being further tested with expensive echocardiograms and stress tests, which themselves are imperfect and require advanced training to administer and interpret.

Ironically, the anxiety surrounding media reports, testing, and false positives may be discouraging teens from participating. In the long run, less exercise is going to lead to far more heart disease than the rare events that these testing programs are meant to prevent.

Until effective and accurate testing is proven and widely available, I do not think that parents and communities should jump on the high-tech bandwagon. Instead:

  • Have your student-athletes get their yearly sports physicals with their own physicians. Bring up any concerns from symptoms that may have occurred during exercise, and be ready to discuss any concerning family history, especially information about family members who died young and unexpectedly.
  • Schedule these sports evaluations well before the season starts, so if any further evaluation is needed there is plenty of time to get it done correctly.
  • Parents, coaches, and everyone else who works with student athletes should learn CPR and how to use a life-saving “Automated External Defibrillator.” These devices should be readily available at all sporting events and facilities.
  • Parents and coaches should actively discourage and monitor for the use of both street and so-called “performance-enhancing” drugs including steroids. These dramatically increase the risk of death. There should be no tolerance for any of these in any locker room, and student athletes should know that they can save a friend’s life by speaking up.

There is no way to prevent 100% of cardiac deaths—even the most intensely expensive high-tech strategy will not keep everyone safe. For the vast majority of young athletes, sports participation will help keep bodies and minds healthy. Mass high-tech screening isn’t quite ready for prime-time, though advances in technique, training, and automation may make these strategies more reliable in the future. For now, a good history and physical is the best way to keep your kids safe.

Posted by: Roy Benaroch, MD, FAAP at 8:57 am

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