The Dark Side of EKG Screening in Athletes

They sat nervously with their son in the doctor's office, wondering why they were there.  John was, after all, the picture of health and had just received a scholarship to Stanford University to play soccer.  His mother and father had been to every soccer match through his formative years, enduring the travel schedule with its weekends away from home, long hours, horrible weather.  John was staring at his iPhone, his mother clutching a Kleenex.  John's father stared out the window.  It was raining.

The door opened.

"Hello, I'm Dr. Kiljoy.  They asked me to see your son about a finding on his EKG."

"Hello," they said back.

"As you know, we've been looking into EKG's in athletes because we have suspected for some time that an EKG will help us better detect students who might be at risk for sudden cardiac death while participating in sports.  You know, even if we can prevent one death in these young people, it would be worth it.  None of us want a young person to die.  That New York Times article yesterday... dang... with that crying family and all right there at the top... poor boy collapsed, people had no clue what happened at first, people thought he overheated, then waited... only later did they find that AED.  Then it didn't work 'cause the battery was dead.  So sad!  We really are trying to prevent that from ever happening.  Seriously.  Sad as hell.  And to think we could have caught this if that teenager had just had an EKG..."

"Yes, of course!" said John's mother.  "I'm SO glad you did this!  We'll be so reassured to know that John's going to be okay. "

A pause filled the room...

"He IS going to be okay, isn't he?" she asked.

"Well, Mrs Smith, we're not sure, we have to run some other tests.  You see he had a slight elevation to his ST segments in these leads here, see?  Then look at his heart rate, it's so slow!  And that voltage here, it's more than we usually see...  It's probably okay, but I'm going to order an echo to look at his chamber sizes."

"Okay..."

"And a then I'm going to have one of our EP people see him to make sure he doesn't have a congenital ion channel disorder..."

"A what?"

"A channelopathy - a genetic defect of some ion channels in his heart - the most common form is called Brudaga Syndrome..."

"How do you spell that?" She waited with pen and paper to jot it down...

"B-R-U-G-A-D-A.  Look, he's probably okay, be we want to be absolutely sure, especially with that ST segment elevation in those leads...  We'll also check a stress test to make sure his heart rate comes up appropriately with exercise and that there aren't any funny EKG changes with exercise that might suggest an anomalous coronary artery - I've seen three people die like a dog with that one!"

"How often does that happen?" she asked.

"Well, it's pretty uncommon, but if it's there, sometimes we have to do open heart surgery to reimplant it so that it won't get pinched between the pulmonary artery and aorta when he exercises."

"But he's never had a problem!  And no one has ever died suddenly in our family - ever!"

"Mrs. Smith.  Remember why we're doing this: John's safety.  This is all about John's safety."

"And if you find something in all these tests, then what?"

"Well, he wouldn't be able to play soccer."

John's eyes suddenly lift from his cell phone.  "What did you say?" he asked.

"You won't be able to play soccer," Dr. Kiljoy repeated.

"Mom, what the f#$*!?  If I don't play soccer, I don't go to Stanford.  If I don't go to Stanford, I'll never play soccer again!  Are you serious?"

The father, sensing his son's concern, returns to the room from his window transcendental meditation.

"Son, let's just get the tests.  Your mother's concerned."

"Mom's concerned?  What the hell do you mean 'Mom's concerned?'  What about me?  I never wanted to get this frickin' EKG anyway!  Look, I'm FINE.  I never so much as farted wrong.  We have no family history of heart disease.  I've never felt my heart race, I've never passed out, I'm faster than everyone else on my team and we just won the State Championship!  How's THAT for a stress test?  I've worked my ass off for YEARS to get this scholarship.  And now, just because of this EKG with bullshit findings that don't pertain to kids my age they're going to do a million tests just to be sure?  Seriously?  Honestly Dad, you gotta be kidding me...  How much is all this gonna cost, huh?  And maybe I'll lose my scholarship, too?  How much is THAT worth?"

"John, honey, it's for your safety," his mother whispers, tears streaming down her cheeks.  "We love you so.  We just don't want anything bad to happen to you...."

"Your Mom's right, John.  We just want to be sure... really....", Dr. Kiljoy continued.

John looked up at Dr. Kiljoy, and said slowly, painfully, with tears in his eyes:

"Doctor, f*&% you."

-Wes

P.S.: For more, please see Dr. John M's take on the New York Times's abysmal reporting on this issue.

The Costs of Screening Programs

It was another tragic story of a young 16 year-old high school athlete collapsing suddenly after winning a championship basketball game. An autopsy discloses a dilated cardiomyopathy. People wonder: could this happen to my son? The cries for screening to catch such cardiac disease before it manifests are raised. Hospital systems respond, ushering in free or reduced-fee screening electrocardiograms for all student athletes, arguing that such testing would likely capture heart trouble before it happens.

This story from Sue Thoms of the Grand Rapids Press sheds light on the cost and magnitude of testing required to capture heart disease in this population. From the article:

In the past two and a half years, the hospital has examined 5,200 students at Healthy Heart Checks held regularly around the Detroit area. The screening includes a medical history, blood pressure check and an ECG. About 15 to 20 percent of the students also undergo an echocardiogram.

Through the screenings, the doctors found three students who had serious underlying structural abnormalities of the heart that could have led to sudden cardiac arrest, Haines said. About 30 students had conditions that were serious enough that they were advised to stop playing sports -- though in some cases, they were able to resume sports after undergoing treatment.

Unfortunately we don't know much about the later 30 students: did they require additional invasive procedures, like radiofrequency catheter ablation of an accessory pathway and what were the costs involved? We really don't know these students' circumstances, so, in the interest of simplicity, we'll leave them out of our analysis for now, but should assume they added even more costs to the overall screening cost.

In summary, we find from this article that 5,200 EKG's were performed at a "reduced rate" of $8 each (doctors and volunteers' time was donated for free), "15-20%" then went on to an echocardiogram (we'll use 17.5%) to find three "true positive" cases of a heart condition that could potentially result in SCA. The inability to detect the severe cardiac disease with an EKG alone meant that the EKGs had a "false positive" rate of about 17.5% (minus the three "true positives"). In real numbers, about 907 echocardiograms had to be performed as a result of the screening program.

What does this mean financially to the hospital?

If the cost of this testing were paid for from fees or insurance payments, assuming a conservative estimate of $500 per echocardiogram for the technical fee to do the study and another $200 for the professional reading of the echocardiogram, a cool $634,900 was garnered for this test alone.

And don't forget the costs for office "consultations" to discuss the findings and the other invasive or imaging tests that might be required "just to be sure."

Very conservatively, this relatively small screening program cost about $676,500.

Armed with the data, we should ask if the costs were worth it so, as their athletic director said, we can all "breathe a little easier and sleep a little better knowing that all of our student athletes are safe?"

Costs and known false positive and false negative problems with EKGs is a large reason screening programs were not recommended recently by the American College of Cardiology. Rather EKG screening was only recommended if a person's medical or family history suggested a higher-than-normal chance of finding a problem.

But it is much easier to want to do things proactively when tragedy strikes and far harder to do nothing: everyone wants to feel like their doing what's best for their child or loved one going forward.

But our need to "sleep better" after such a tragedy should be balanced with the keen appreciation of the relatively low frequency of the problem in our students and the costs to our health care system for this reassurance. Nothing in medicine is "free" these days, no matter what health care systems may suggest in their promotion of these programs.

Take a moment as ask yourself if there might be teenagers who die from a cardiac death despite having had all of these tests?

Very possibly. But it's unlikely that such a story will ever make the headlines.

That's because such a story of the false negative rate of all these screening tests might be very bad for business.

-Wes

Defibrillators in Athletes?

The new ICD registry might help us understand the risks of these devices in this patient population.

-Wes

New AHA Guidelines for Screening Athletes Excludes EKG

The new recommendations for screening of athletes for competitive sports was issued by the American Heart Association and endorsed by the Americal College of Cardiology yesterday in the journal Circulation and includes careful evaluation of personal symptoms of the patient, family history, and physical examination findings. The recommendations significantly differ from the European Society of Cardiology (ESC) and the International Olympic Committee (IOC) by excluding the requirement of an electrocardiogram (EKG).

Although the Switzerland-based IOC and the ESC have advocated that all young competitive athletes be screened routinely with a 12-lead ECG (in addition to history-taking and physical examination), the updated 2007 AHA guidelines do not make this recommendation. No federal or state laws currently mandate that American physicians adopt the ESC16 and IOC guidelines. American law permits US medical organizations and physicians to assess independently the relevant variables (including the current infeasibility of routinely performing ECGs on populations of asymptomatic US athletes) and to make their own recommendations about the appropriate nature and scope of cardiovascular screening. Thus, a US physician’s decision to follow the updated AHA recommendations rather than those of the ESC and IOC does not itself constitute medical malpractice.

Part of the reason for exclusion of the EKG from screening is logistics.

For the AHA to officially adopt (or even condone) the ESC screening recommendation for routine ECGs without a reasonable expectation that such a program could be implemented in the near future could have a paradoxic, chilling effect on US preparticipation screening. Practitioners involved with screening would be potentially compromised by being unable to comply with the proposed screening strategy incorporating an ECG. Therefore, it is possible that the willingness of qualified US physicians to participate in screening would be reduced if the ESC/IOC recommendations were mandated.

Part of the reason for the exlusion of the EKG is cost:

Given the theoretical cost of a mass cardiovascular screening program of $2 billion per year, the dollar amount attached to detecting each athlete with the suspected relevant cardiac diseases would be $330 000. Assuming that (more than) 10% of these 9000 athletes with cardiac disease (1800) would harbor evidence of increased risk for sudden death, then the cost of preventing each theoretical death would be $3.4 million. We recognize that some may not regard these estimated costs per athlete as excessive for detecting potentially lethal cardiovascular disease in young people; however, the fundamental issue defined by these calculations concerns the practicality and feasibility of establishing a continuous annual national program for many years at a cost of approximately $2 billion per year.

They conclude as follows:

Indeed, on humanitarian medical grounds, the AHA supports any public health initiative with the potential to identify adverse cardiac abnormalities. On the other hand, because the panel cannot ignore the many epidemiological, social, economic, and other issues that impact this screening proposal, it must view the European model in realistic terms from a US perspective. Therefore, for a number of reasons, it is difficult to consider the European-Italian strategy as potentially applicable to preparticipation screening in the United States.

So, although the EKG is out, practitioners must not forget to take a thorough personal and family history, listen for murmurs, check the blood pressure from the arm, check for femoral pulses in the legs (to exclude coarctation of the aorta), and note physical characteristics of Marfan's Syndrome.

-Wes