[HEADLINE: Cardiac screening before exercise may not pay off]

Author: Tim Stewart (67.39.31.---)

Date: 11-15-02 04:22

Copyright 2002 Gale Group, Inc.


Copyright 2002 International Medical News Group

Family Practice News

July 15, 2002

SECTION: No. 14, Vol. 32; Pg. 9; ISSN: 0300-7073

IAC-ACC-NO: 90301688

LENGTH: 839 words

HEADLINE: Cardiac screening before exercise may not pay off; A Boondoggle for


BYLINE: Boschert, Sherry


ST. Louis -- It's "a waste of time" to use cardiac stress tests and

electrocardiograms to screen for cardiac abnormalities before people start

sports or exercise programs, sports medicine specialists said at a symposium on

the risks of exercise.

Such screening amounts to "a boondoggle for cardiologists," they maintained

at the annual meeting of the American College of Sports Medicine.

Panelists and a speaker in a separate presentation dismissed suggestions

that all athletes get an ECG at least once in their lives, or that middle-aged,

sedentary adults need stress testing before joining a gym.

The ACSM and American Heart Association in 1998 recommended cardiovascular

screening for children, adolescents, and adults before starting exercise at a

health club or another fitness program, aimed at preventing sudden cardiac death

or myocardial infarction. The statement did not call for stress tests or ECGs,

but endorsed the use of questionnaires to identify people with risk factors that

merit further study (Circulation 97[22]:2283-93, 1998).

A 2000 study suggested that history and physical examination have a

sensitivity of just 6% and a specificity of 98% in detecting cardiovascular

abnormalities. That is "the exact opposite of what you want in a screening

test," which should be very sensitive, said Dr. Robert B. Kiningham of the

University of Michigan, Ann Arbor.

Some clinicians favor a screening ECG, but it still is nor an adequate test,

he said. A 1997 study evaluated 3-year follow-up data on 5,615 high-school

athletes who were screened by history, cardiac auscultation, blood pressure

test, resting 12-lead ECG and--when abnormalities were detected-resting

echocardiography. Such screening was 50% sensitive and 97% specific for

cardiovascular abnormalities.

The problem is that sudden cardiac death is so rare. Screening 6 million

athletes with a hypothetical test that has 100% sensitivity and 98% specificity

would yield 30 true positives and 60,000 false positives, which would not be

cost effective, he said.

The same could be said for cardiac stress tests, said Dr. Paul D. Thompson,

director of preventive cardiology at Hartford (Conn.) Hospital. Sudden cardiac

death occurs in only 1 of 15,000-18,000 apparently healthy, exercising adults

each year. "To predict one sudden death you've got to do a lot of stress tests.

With that comes costs and false positives." In a study often cited by advocates

of screening ECG, 33,735 Italian athletes younger than age 35 were examined and

followed for 17 years. Among the 9% who were referred for echocardiography, 22

athletes were found to have hypertrophic cardiomyopathy; none of those athletes

died (N. Engl. J. Med 339[6]:364-69, 1998).

But Dr. Kiningham noted that sudden cardiac death rates after screening were

1.6 per 100,000 Italian athletes per year. That is triple the estimated annual

rate of 1 per 200,000 U.s. athletes, who are screened mainly by history and

physical exam.

Despite the evidence that such cardiovascular screening is ineffective,

physicians feel compelled to do such screening because of recommendations from

major medical organizations, he said.

Several speakers criticized ACSM's suggestion to focus cardiovascular

testing before exercise on men older than 45 years and women older than 55

years. Those cutoffs are arbitrary with no data to support them, said Barry A.

Franklin, Ph.D., director of the cardiac rehabilitation and exercise

laboratories at the William Beaumont Hospital in Royal. Oak, Mich.

Selective use of stress tests based on cardiovascular risk factors makes

more sense, several speakers said. "I base it on the overall clinical picture,"

said Dr. Murray A. Mittleman, of Beth Israel Deaconess Medical Center, Boston.

"I also tell patients to start exercising slowly to build up gradually, and if

they have any symptoms, to rest.

RELATED ARTICLE: Steps to Reduce Exercise Risk

What can you do to help patients avoid cardiac complications with exercise?

Dr. Franklin cited these recommendations from the American College of Sports


* Ensure appropriate medical clearance and follow-up, although

cardiovascular screening is controversial.

* Establish an emergency plan, so patients know what to do in a crisis.

* Emphasize a warm-up period and a cool-down period before and after

exercise to patients.

* Advocate mild to moderate exercise, especially for sporadic exercisers.

* Educate patients about the warning signs and symptoms of cardiovascular


* Advise exercisers to adjust for environmental conditions. Higher

temperatures boost heart rate and oxygen requirements.

* Use continuous or instantaneous ECG monitoring during exercise in patients

with documented cardiovascular disease and in those at high risk for it.

* Advise selected patients to modify recreational games to lower energy use

and heart rate. In volleyball, for example, players might be allowed one, two,

or three bounces on the floor per side.

IAC-CREATE-DATE: November 13, 2002


[Re: HEADLINE: Cardiac screening before exercise may not pay off]

Author: Sarah B. Board Moderator (12.144.99.---)

Date: 11-15-02 08:03

Well, see, this article entirely misses the POINT.

It is well established that ECGs are not a good test for HCM as most of us have normal ECGs for a long time --or only small irregularities that may not flag you.

This article does NOT mention echos except as a secondary screening. If you simply did and echo and an ECG and cut out the stress test, you cut the costs substantially. Stress tests are just not useful that early in the game, so to speak.

It will take some time, but I think we will get these people to come around. They just aren't thinking about it from the right angle --the traditional screening methods for heart attack and heart disease just don't apply here.



[Re: HEADLINE: Cardiac screening before exercise may not pay off]

Author: mary Sharp (---.net193.fl.sprint-hsd.net)

Date: 11-16-02 05:54

Well I guess if you're the one in 15,000 you can take the hit so they can cut their costs. I guess in a bad sense you are really "taking one for the team". I find it so amazing that people can put a price on a life. Did you know that there actually is a calculation to tell how much someone's life is worth? They used the formula to pay families of 9-11 . So the families of CEOs got 100,000 a year and the families of the fire fighters only got like 25,000 a year until they reached I think it was the national life expectancy average. I just found that a bit scary.

Mary S.


[Re: HEADLINE: Cardiac screening before exercise may not pay off]

Author: Brody (211.218.19.---)

Date: 11-18-02 12:02

Your point is well made. My son had his annual sports physical and was given a clean bill to participate in cross-country running. Only last month after complaining of chest pain and shortness of breath was he given a echo which revealed the HCM.

I for one would not accept the cost of my son's life more important than the dollar cost of performing a test that could have found his condition.


[Re: HEADLINE: Cardiac screening before exercise may not pay off]

Author: Board Moderator (Sarah Beckley (---.client.attbi.com)

Date: 11-19-02 03:38

Hi guys,

No one wants to put a price on a human's life, but it is done everyday and sadly the economics of the US make it so that when policies are made, cost rather than saving lives is often the deciding factor. Look at Pinto cars, or the radios of the NY fire fighters, for example.

But we'll keep on fighting and technology will continue to get better and cheaper.