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more to think about... SCREENINGS


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  • more to think about... SCREENINGS

    Copyright 2005 The McGraw-Hill Companies, Inc. http://www.mcgrawhill.com
    All Rights Reserved
    Physician and Sportsmedicine

    SECTION: News Briefs; Pg. 12 Vol. 33 No. 3

    LENGTH: 1628 words

    HEADLINE: Groups Endorse ECG Screening for Athletes

    BYLINE: Lisa Schnirring.

       Barry J. Maron, MD, an international expert on sudden cardiac death in
    athletes, wrote that the Un


       Obstacles such as cost, staffing, and the likelihood of false-positives have
    prevented cardiac diagnostic tests such as 12-lead electrocardiography (ECG)
    from becoming a routine part of the preparticipation examination (PPE) in most
    countries, including the United States. Two international medical groups,
    however, have recently endorsed the inclusion of the 12-lead ECG in the PPE.

       In December 2004, the International Olympic Committee (IOC) medical
    commission released a consensus statement that outlines standards for the
    cardiac PPE, which includes 12-lead ECG testing. (Reference)1 Soon after, in
    February, study groups of the European Society of Cardiology published a
    consensus statement proposing a European standard for cardiac evaluation of
    athletes that includes the 12-lead ECG. (Reference)2

       The Scope of the Problem

       Estimates of sudden death in high school athletes range from 1 in 100,000 to
    1 in 300,000, and sudden death is disproportionately higher in male athletes.
    (Reference)3,4 An Italian study (Reference)5 projected that adolescents and
    young adults who compete in sports are more than twice as likely to die as their
    nonathletic peers.

        In 1996, the American Heart Association (AHA) released guidelines for the
    cardiac PPE that are still in use. (Reference)6 Since then, sports cardiologists
    and PPE experts have pushed for the adoption of a national standardized cardiac
    PPE, because the cardiac component of the PPE forms used by several states do
    not conform to AHA recommendations. The recently updated PPE monograph
    (Reference)7 incorporates the AHA guidelines and provides further guidance about
    the cardiac component of the exam.

        The AHA recommendations state that ECG testing is not cost-effective for
    screening large numbers of athletes because of its low specificity. Italians,
    however, have been doing ECG screening of athletes for 25 years as part of a
    government-mandated PPE policy. High-profile sudden deaths in athletes combined
    with high hopes that technologic advances will make noninvasive cardiac tests
    more cost efficient still fuel discussions about adding the ECG to the PPE.

       IOC Advances Care for its Athletes

       The IOC statement, commonly referred to as the Lausanne recommendations,
    advises that participants in competitive sports who are younger than age 35
    undergo a preparticipation cardiovascular screening at least every other year
    that includes:

        -- A detailed personal history to rule out any potentially detectable
    cardiovascular condition,

        -- A detailed family history to detect inherited cardiomyopathies, heart
    rhythm problems such as long QT syndrome, and connective tissue disorders such
    as Marfan syndrome,

        -- A physical examination, and

        -- 12-lead resting ECG after the onset of puberty to detect rhythm,
    conduction, or repolarization abnormalities.

        The Lausanne recommendations also suggest that athletes who have a
    positive personal history, have a family history of an inherited cardiac
    disease, or have positive findings on the physical exam or ECG be refereed to an
    age-appropriate cardiologist for further evaluation.

        Joel I. Brenner, MD, director of pediatric cardiology at Johns Hopkins
    University in Baltimore, was part of the group that drafted the consensus
    statement. Brenner says the IOC's statement isn't intended to influence global
    cardiac PPE policies. ``They're clearly making this recommendation for their own
    constituents: the Olympic medical community and the sports federations,'' he
    says. Brenner says the statement signals that the IOC medical commission is
    shifting its focus back to its original mission of safeguarding the health and
    safety of athletes. Doping responsibilities are now maintained by the World
    Anti-Doping Agency.

        The consensus group realizes that not all countries have the resources to
    cover the cost of ECG testing their athletes. ``Some can't even buy shoes for
    their athletes,'' he says.

       Europeans Seek a Common Standard

       Italy's 25-year history of ECG screening of athletes, and the contributions
    to the medical literature that have followed, are a central theme in the
    European recommendations that advocate inclusion of ECG testing to increase the
    sensitivity for conditions that increase the risk of sudden cardiac death.

        In advocating for the inclusion of the ECG in the PPE, the European group
    states that, based on Italian findings, the 12-lead ECG may be as sensitive as
    echocardiography in detecting hypertrophic cardiomopathy, the leading cause of
    sudden death in young competitive athletes. The authors wrote: ``These findings
    indicate that the Italian screening modality has 77 percent greater power for
    detecting HCM and expected to result in a corresponding additional number of
    lives saved.'' They estimated that the increased diagnostic power triples the
    cost effectiveness of the Italian strategy as compared with the US screening

        The group proposes that a cardiac PPE that combines a thorough history,
    physical exam, and ECG screening be adopted as a European standard for medical
    evaluation of competitive athletes. It suggests that screening should start at
    the beginning of an athlete's competitive career (at about ages 12 to 14) and be
    repeated at least every 2 years.

        Though the group recognizes that different socioeconomic and cultural
    conditions across Europe may make standardizing the 12-lead ECG difficult, they
    believe the increased cost is reasonable. They estimate that mass ECG screenings
    would add 10 Euros ($13.25 US) to the cost of the cardiac PPE. They add that
    costs are generally covered by the athlete or the sports team, and that national
    health systems often cover the exam for athletes who are younger than 18.

       Will Statements Influence North American Policies?

       In an editorial (Reference)8 in the European Heart Journal that accompanied
    the European group's consensus statement, Barry J. Maron, MD, an expert on
    sudden cardiac death in athletes who directs the Hypertrophic Cardiomyopathy
    Center at the Minneapolis Heart Institute Foundation in Minneapolis, lauded the
    idea of a common European protocol and praised the group's efforts to increase
    awareness and interest in sudden cardiac death across Europe. Maron writes:
    ``Extending this Italian programme to other European countries would certainly
    be a laudable enterprise, for it has the potential to save young lives.
    Nevertheless, the central challenge is one of practicality, feasibility, and
    implementation--with the primary potential obstacle being adequate resources and
    economic support.

        Maron believes that it's highly unlikely that the US could adopt a cardiac
    PPE policy that includes mass 12-lead ECG screening. With a population of 284
    million people and 12 to 15 million widely dispersed sports participants,
    ``There are simply too many competing healthcare priorities and special
    interests and anticipated difficulties in cost control, as well as heightened
    concerns for medicolegal liability, to warrant serious consideration for such an
    undertaking in the United States,'' Maron wrote.

        Though Maron says the suggestions by the European group and the IOC would
    be superior to the current US cardiac PPE strategies, adding ECG screening would
    present serious problems. ``It could also be expected to be fraught with the
    major limitation of many false-positive test results and reevaluations, which
    would negatively impact available resources and increase the psychological
    burden on the athletes, families, coaches, and institutions.''

        In Canada, the obstacles are similar, despite the fact that Canadian
    healthcare is partially nationalized, says Andrew Pipe, MD, chair of the
    Canadian Centre for Ethics in Sport and a physician at the University of Ottawa
    Heart Institute. He says the examinations by third parties such as insurance
    companies or athletic organizations are not covered by provincial health
    services. ``Thus, they would become the responsibility of the athlete or the
    athletic organizations requesting the test. As a consequence, it is unlikely
    that such testing will be formalized,'' Pipe says.

        Pipe, like Maron, is concerned about the technical comfort levels of those
    who would be interpreting ECGs if widespread screening for athletes were
    instituted. ``Our experience in addressing the concerns raised by clinicians who
    are unfamiliar with the ECG changes that commonly occur in athletes serves to
    underscore Dr Maron's point, in this regard,'' he says. While the public might
    perceive that adding an extra screening step to the cardiac PPE as a manageable
    change, physicians who perform PPE exams know how complex the process really is,
    Pipe says.

        Public health would be better served if clinicians worried less about the
    small minority of individuals for whom exercise may be hazardous and focus more
    on the number of young people who are sedentary, Pipe says. ``A cynic might
    suggest that they need a medical exam to determine whether they are able to
    withstand the `rigors' and risks of a sedentary, obesogenic lifestyle!'' he

        Brenner emphasizes that there is no perfect system for the cardiac PPE,
    but that the current systems can always be improved, even for Olympic-level
    athletes. Within the United States Olympic Committee (USOC), Brenner says he's
    aware of two athlete deaths during training in the last two decades. ``One
    clearly might have been avoided if a better history had been taken, because
    there was evidence of syncope with activity,'' he says, ``So it's safe to say
    that 50 percent of deaths could have been avoided.'' While mass ECG screening
    might not be realistic, clinicians can still improve the process by taking a
    thorough approach to the patient and family histories, Brenner says, adding that
    the USOC has already adopted a more rigorous cardiac history form.

    LOAD-DATE: March 28, 2005
    Knowledge is power ... Stay informed!
    YOU can make a difference - all you have to do is try!

    Dx age 12 current age 46 and counting!
    lost: 5 family members to HCM (SCD, Stroke, CHF)
    Others diagnosed living with HCM (or gene +) include - daughter, niece, nephew, cousin, sister and many many friends!
    Therapy - ICD (implanted 97, 01, 04 and 11, medication
    Currently not obstructed
    Complications - unnecessary pacemaker and stroke (unrelated to each other)

  • #2
    Hi all,
    Maybe I’m crazy, but it seems to me that there may be a simple test developed to identify HCM. Now I am very far from being informed on this subject, but then why can’t we ---

    We now can and do perform DNA testing to identify a particular set of identifiable genes don’t we – and HCM is a genetic disease isn’t it – so why can’t we take a blood sample and determine if that individual has the particular configuration of DNA associated with HCM? It seems to me, with that configuration (or sets of configurations) identified, the positive identification of HCM could be reduced to a simple blood test.

    Actually, I expect this is a wild oversimplification, but why won’t it work – specifically?
    Anybody out there have any ideas?


    • #3
      Not so easy my dear -
      1. We do not know ALL mutations at this point.
      2. Having a gene does not mean you will have the clinical form of HCM.
      3. The cost of a full genetic screening -for the known HCM genes is currently about $5000.00 US.
      4. Genetic protections have yet to be written into law (Federal) - we need better protection to ensure equal rights under the law and that ones genetic information can not be held against them in employment, insurance or education.

      That is but the tip of the iceburg!

      Knowledge is power ... Stay informed!
      YOU can make a difference - all you have to do is try!

      Dx age 12 current age 46 and counting!
      lost: 5 family members to HCM (SCD, Stroke, CHF)
      Others diagnosed living with HCM (or gene +) include - daughter, niece, nephew, cousin, sister and many many friends!
      Therapy - ICD (implanted 97, 01, 04 and 11, medication
      Currently not obstructed
      Complications - unnecessary pacemaker and stroke (unrelated to each other)


      • #4
        Thank you for sharing this article! I appreciate the in-depth information. The slant I get from this article is that the people of Europe seem to care more about their children than the people/big businesses of the US. Do we really put the mighty dollar ahead of human life?

        I have forwarded the article to the NCAA and the Education Outreach within the NCAA for help with screenings. We have been having some "discussions" on the matter.

        More later,


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