Screening to Prevent Sudden Death in Young Athletes
Is Recommended Screening Enough?
Sudden death in a young athlete, while rare, is always a tragic event. The impact on the family and loved ones is devastating.
Even those who only know the victim peripherally, or who just hear about the tragedy on the news, often feel almost personally affected.
The mere thought of a vibrant young person struck down suddenly, for no apparent reason, strikes all of us as profoundly unfair. Isn't there
something somebody could have done to prevent this?
What Causes Sudden Death in Young Athletes?
Most young athletes who die suddenly during exercise turn out to have had underlying heart disease of one type or another that had not been
previously diagnosed. Several cardiac problems can be seen in young people who appear entirely healthy, and, unfortunately, the very first sign
of a problem may be a sudden, fatal cardiac arrhythmia (usually, ventricular fibrillation). Heart problems associated with sudden death in young
athletes include hypertrophic cardiomyopathy, Marfan syndrome, and congenital abnormalities in the coronary arteries—but there are several others.
Can Athletes at Risk Be Identified Ahead of Time?
Many of the cardiac conditions that cause sudden death in young people can be diagnosed if careful testing is performed. An electrocardiogram
(ECG) plus an echocardiogram—or even an ECG alone—would often give important clues regarding which young people are at risk so that further
testing could be done. Those who turn out to be truly at increased risk for sudden death could be treated for their underlying condition, or at least told
to avoid exertion, perhaps saving their lives.
So it makes sense to many people that all young athletes ought to be screened for heart problems before they are permitted to participate in sports.
If you have a young athlete in your family, you probably have noticed that no such screening was done, or even recommended. The fact that cardiac
screening is not routinely done in young athletes, at least in the U.S., is not an oversight—it is the result of careful deliberation by cardiac experts.
Digging a bit into the data behind the decision not to do extensive screening may help shed some light on this decision.
Rationale for Current Screening Guidelines
The question of whether all young athletes should be screened for heart disease turns out not to be all that simple. Several factors make rigorous
screening difficult, expensive, and perhaps risky.
First, there are several heart diseases that can increase the risk of sudden death in young people, and each of them have different criteria and require
different testing procedures for making the diagnosis. Not all of these cardiac disorders would be detected by a few non-invasive screening tests.
Then there is the fact that a huge number of young people participate in organised sports, and thus a huge number would have to be screened—
probably between 4 and 5 million young people each year in the United States alone. Of this large number, only a tiny fraction (about 3 in 1000)
have underlying cardiac disease that increases their risk.
Any time medical screening is done for a disorder that has a very low prevalence, there will be many more false-positive test results (in which the
test suggests the disease may be present when it is not) than true-positive results. All these false positive tests would require that more testing be done
to get to the bottom of the suspected problem (although, in most cases, there isn't one). These follow-up tests would sometimes include invasive testing,
such as a heart catheterisation, that not only increases the personal risk to the young athlete but also increases overall medical costs to society.
Because of these considerations, professional societies have tried to establish guidelines for screening young athletes that will be reasonably effective
in detecting many of the more common heart conditions that increase risk, without generating a large number of unnecessary follow-up tests.
Do these recommended screening examinations miss some young athletes with potentially fatal cardiac disorders? Unfortunately, yes, and these are the
young athletes we hear about in the news from time to time.
What Are the Current Recommendations?
The American Heart Association (AHA) recommends that all high school and college athletes have a screening medical history and physical examination.
The medical history should specifically bring to light any of the following symptoms:
- chest pain or discomfort during exercise
- episodes of syncope (loss of consciousness)
- dyspnoea (shortness of breath) with exertion
- a history of a heart murmur or hypertension
The doctor should ask carefully about family history (since several of the conditions that cause sudden death are genetic), and should also focus
on premature (before age 50) death or disability from heart disease in close family members, and whether there is a family history of the more
common genetic-related heart problems such as hypertrophic cardiomyopathy, long-QT syndrome, serious cardiac arrhythmias, or Marfan syndrome.
The physical examination should concentrate on the cardiac examination, pulmonary examination, the examination of the pulses, and looking for
signs of Marfan syndrome.
The AHA specifically does not recommend an ECG, echocardiography, or stress test. These tests are reserved for young people in whom there is a
suspicion of a cardiac problem after doing the medical history and physical examination.
Is This Enough?
While the AHA experts believe that the screening program just outlined is adequate, European experts disagree. In Europe, an ECG is also recommended
as a routine screening test in all young athletes.
There is little objective evidence that routine ECG screening makes a substantial difference. However, a study looking at the impact of screening was
conducted in Italy, where routine screening of athletes with an ECG began in 1984. Between the years 1979 and 2004, the annual incidence of sudden
death in athletes decreased from 3.6 per 100,000 person years to 0.4 per 100,000 person years. This study suggests that ECG screening is effective,
but that the overall impact of ECG screening on the whole population is small.
Still, if even one young athlete's life can be saved, wouldn't screening be worth it?
Well, to be blunt, it depends on who is paying for the screening. If we expect "society" to pick up the cost (though, collective health insurance
premiums or taxes), the cost of screening (along with the follow-up tests it would generate) appears prohibitive. At least, it does to the people who
write the AHA guidelines, who have insurance executives and government officials carefully scrutinising their work.
Consider: Nobody argues whether smoke detectors save lives. They do. But if a panel of government experts had to decide whether tax dollars should
be spent to buy everyone smoke detectors, they would quickly conclude that, at a cost to society of ten million dollars per life saved, smoke detectors
are cost-prohibitive. Fortunately, we do not collectivise the purchase of smoke detectors. For us, the lives potentially saved are ours and our loved ones'
, and the cost for those lives potentially saved is only $19.95. Seems like a bargain.
If individuals paid for their own screening ECGs instead of relying on society to do so, the screening recommendations for young athletes might be very different.
The Bottom Line
Sudden death in young athletes is fortunately very rare, and the relatively simple screening recommended by the AHA will catch many—but not all
—of the young people who are at risk. So the AHA recommendations, which take a rare event and make it even rarer, make good sense.
Still, as a parent, you may not be happy skipping more definitive screening procedures. If you are particularly concerned about your child, discuss
your concerns with your child's doctor. More testing, if you want it, is your right as a patient. However, it may also be your financial responsibility.
And remember: While it may uncover problems that recommended testing does not, it also potentially exposes your child to additional risks.
Speak frankly with your child's doctor so that you can get the information you need to balance the potential risks and benefits of additional screening.