cardiac screening

New Study Confirms Value and Raises Questions About Cardiac Screening for Young, Competitive Athletes

August 9, 2018 By Larry Creswell, MD Leave a Comment

SoccerSCD

In a study reported today in the New England Journal of Medicine, Dr. Sanjay Sharma and colleagues from the University of London offer the most comprehensive look yet at the utility of cardiac screening for young, competitive athletes—in this case, specifically for elite, adolescent British soccer players.

We’ve long known about the small risk of sudden cardiac death (SCD) among young, competitive athletes, but very few datasets have been assembled to look carefully at the value of cardiac screening in these athletes.

The Study

Over a 20-year period from 1996 through 2016, the English Football Association used a combination of health questionnaire, physical examination, electrocardiogram (ECG), and echocardiogram to assess the heart health of all 11,168 potential soccer players, aged 15-17 years, who were joining the Association. Because the ECG and echocardiogram were included, we might characterize the cardiac screening as comprehensive, or “aggressive.” Information was then gathered about any of these players who later died, with a focus specifically on deaths due to heart-related conditions. The investigators were then able to return to the athlete victims’ initial cardiac screening to see what lessons could be learned.

The Findings

The investigators report that with the initial cardiac screening (with health questionnaire, physical examination, ECG, and echocardiogram):

The cost of the initial cardiac screening was $342 per athlete.
42 athletes (0.38%) were found to have cardiac diseases that could cause sudden cardiac death (SCD). Among these 42 athletes, all of those with forms of cardiomyopathy or long Q-T syndrome were advised not to participate in sports.
Another 225 athletes (2%) were found to have other, non life-threatening cardiac diseases such as heart valve problems or congenital heart conditions. In many cases, these athletes received medical or surgical treatment that allowed them to return to play.
A total of 830 athletes (7%) required additional testing to sort out any potential heart problems detected by the initial screening procedure.
After complete evaluation, 544 athletes (5%) required long-term monitoring for non life-threatening heart conditions.

During a follow-up period of 118,531 person-years, there were 23 deaths from any cause, including 8 from a cardiac cause. The incidence, then, of SCD in this cohort of athletes is 1 per 14,794, which is greater than previously reported for most young, competitive athletes and similar to the rate reported for NCAA basketball players. In this report, all 8 of the cardiac deaths were sudden and occurred during exercise. Among these 8 victims:

The deaths occurred anywhere from 0.1 to 13.2 years after the initial cardiac screening.
7 deaths (88%) were caused by hypertrophic cardiomyopathy (HCM), which is known to be associated with SCD.
- 5 of these 7 deaths due to HCM occurred in athletes with a completely normal screening examination.
- 2 of these 7 deaths due to HCM occurred in athletes in whom HCM was diagnosed at the initial screening, but who chose to continue to participate in sports and exercise gainst medical advice.

My Take

This study is important because it provides a “real world” look at the use of cardiac screening for young, competitive athletes.

Here, we see that an “aggressive” approach to cardiac screening that includes health questionnaire, physical examination, ECG, and echocardiogram is useful to identify athletes at risk for SCD as well as those who require some sort of evaluation and treatment for non life-threatening forms of heart disease. The findings of the study in this regard are not surprising.

In a setting in which comprehensive, long-term follow-up is possible, this study’s estimate of the risk of SCD among the screened athletes is likely to be very accurate. Moreover, the incidence of SCD at approximately 1 per 15,000 is a bit greater than previously thought. There should be no doubt, though, that the incidence of SCD will vary among different cohorts of athletes, of different abilities, and participating in different sports.

The study raises some worry, though, about the effectiveness of “aggressive” cardiac screening programs. First, it is not clear why 2 athletes diagnosed with HCM would be allowed to continue to participate against medical advice and it is truly sad that these athletes later died. But more worrisome, though, is the finding that 5 other athletes died because of HCM that was not detected during the cardiac screening. Review of ECGs of these athletes confirmed, in fact, that they were normal. Perhaps we have an undue faith in the ability of ECG and echocardiogram to identify HCM and other potentially life-threatening conditions. These findings raise the possibility that an initially negative cardiac screening cannot provide complete reassurance that athletes are risk-free for SCD and raise the question about the need for periodic cardiac re-testing in the years after an initially negative screen.

I think there will be a bunch of headlines in the press about this study and most of the reporting will focus on the athletes who died after a supposedly normal cardiac screening exam. We will need to keep in mind, though, the positives about cardiac screening—namely, the many other athletes who learned they had a variety of heart conditions that could be treated successfully and allow them to return to play.

Updated 2015 ACC/AHA Guidelines on Competitive Athletes with Cardiovascular Abnormalities

December 9, 2015 By Larry Creswell, MD 1 Comment

The American College of Cardiology (ACC) and American Heart Association (AHA) have recently released a Scientific Statement on “Eligibility and Disqualification Recommendations for Competitive Athletes with Cardiovascular Abnormalities: Preamble, Principles, and General Considerations.” This 2015 edition is an update for the previous guidelines that were published as Proceedings from the 36th Bethesda Conference in 2005.

The new Guidelines were assembled by a large group of experts who were organized into 15 task forces. Each of these task forces considered the current scientific evidence, graded the evidence, and reached consensus conclusions about recommendations that could be supported. As such, this collection of recommendations represents the best available consensus expert opinion today in the United States.

It’s important to know that there is also a similar set of guidelines developed by the cardiology community in Europe. There are differences between the ACC/AHA and European recommendations that often stem from legitimate differences of opinion.

It is also important to remember that the new ACC/AHA guidelines are targeted toward the young “competitive athlete.” The authors define such an athlete as one “who participates in an organized team or individual sport that requires regular competition against others as a central component, places a high premium on excellence and achievement, and requires some form of systematic (and usually intense) training.” As such, these guidelines are targeted primarily at student athletes of high school and college age (up through 25 years). That said, the various recommendations may well be applicable to other athletes, including: young but non-competitive athletes; older competitive athletes; and adult recreational athletes or exercisers. Particular judgment must be used by physicians and athletes when extending the recommendations beyond the intended target population.

The new guidelines are some 115 pages long. It’s not my intention to summarize things succinctly here in a blog post, but I thought it would be useful to point out what’s new….and what caught my attention in each of the 15 sections….

Task Force 1: Classification of Sport–Dynamic, Static, and Impact

There is now a refinement of the former categorization of sports according to their “static” and “dynamic” components. A new summary chart still uses the former I-II-III (static) and A-B-C (dynamic) scheme, but recognizes that there is actually a continuum along each axis. In addition, a new table provides a useful categorization of sports according to their risk of impact, both at the junior high school and high school/college levels. New recommendations for athletes taking various forms of anticoagulant medications caution against activities where impact injuries may be expected.

Task Force 2: Preparticipation Screening

Preparticipation screening is widely applied in the United States for school-based athletic programs. Controversy remains, though, about the effectiveness of history and physical examination alone for identifying serious cardiovascular abnormalities. This Task Force continues to endorse the AHA 14-point screening guidelines or those of the American Academy of Pediatrics Preparticipation Physical Examination, suggesting particular value in standardization of questionnaire forms used. The new guidelines suggest that the use of ECG in addition to history and physical examination may be appropriate in “relatively small cohorts” of young athletes, where physician expertise is available for counseling and follow-up of test results. Mandatory screening with ECG is not recommended in young athletes or non-athletes.

Task Force 3: Hypertrophic Cardiomyopathy (HCM), Arrhythmogenic Right Venricular Cardiomyopathy (ARVC), and Other Cardiomyopathies

The Task Force recognizes the heterogeneity of disease among athletes with hypertrophic cardiomyopathy (HCM) and advises that judgment is needed in the application of the recommendations in specific situations. New from 2005, the guidelines now recognize that athletes with genotype-positive, phenotype-negative HCM (ie, carrying a gene but no overt manifestation[s] of the disease [yet]), and particularly if there is no family history of HCM-related sudden cardiac death, may participate in athletics. The new guidelines advise against the use of pharmacologic agents or an implantable cardioverter-defibrillator (ICD) solely to facilitate participation in sports. There are no major changes in the recommendations regarding ARVC, other cardiomyopathies, myocarditis, or pericarditis.

Task Force 4: Congenital Heart Disease

There is a very long list of conditions that, together, constitute “congenital heart disease.” These are inherited conditions that usually manifest during childhood, but sometimes these conditions may remain unrecognized until adulthood. Exercise prescriptions are very specific to the particular condition, but the Task Force recognizes that many athletes with “corrected” congenital heart disease may participate fully. Compared with 2005, the new recommendations remain similar or unchanged for: atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA), pulmonary valve stenosis, aortic valve stenosis, coarctation of the aorta, elevated pulmonary vascular resistance (PVR), ventricular dysfunction after surgery for congenital heart disease, cyanotic heart disease including Tetralogy of Fallot, and Ebstein’s anomaly. The new guidelines now provide greater detail in the recommendations for patients with transposition of the great arteries (TGA) treated by either atrial switch (eg, Mustard procedure, Senning procedure) or by more contemporary arterial switch operations. In the area of coronary artery anomalies, additional evidence and experience now allows for recommendations for various subsets of patients, including those who have had surgical correction.

Task Force 5: Valvular Heart Disease

The 4 most common valve problems are aortic stenosis (AS), aortic regurgitation (AR), mitral stenosis (MS), and mitral regurgitation (MR). In many respects, the new guidelines parallel the former guidelines. The new guidelines specifically recommend that athletes with these conditions, even if mild, should be evaluated yearly to determine whether sports participation can continue safely. A new recommendation is offered for athletes with severe AR and normal left ventricular dimensions and function; it may be reasonable for these athletes to participate fully if they have normal exercise tolerance and echocardiography shows no progression of ventricular size or dysfunction. MS is probably the least common of these valve conditions. The new recommendations suggest that exercise testing to the anticipated level of sports activity may be useful in patients with MS to ensure that no symptoms develop. The recommendations specifically recommend only low-intensity activities for those with severe MS, but most of these individuals would probably best be treated with valve repair or replacement. Exercise testing is also recommended for asymptomatic patients with MR, again to the anticipated level of sports activity.

For those patients who have undergone operative procedures for valve repair or replacement, the guidelines make the important point that decisions about future participation in sports activities be made together, by both athlete and physician(s).

Task Force 6: Hypertension

The new guidelines recommend that athletes with sustained hypertension undergo screening echocardiography. For those with left ventricular hypertrophy (LVH) beyond what might be expected from “athlete’s heart,” activities should be curtailed until the hypertension is controlled. The guidelines also remind athletes and treating physicians that some medications used for the treatment of hypertension (eg, beta-blockers, diuretics) are considered banned substances by some sports governing bodies. Athletes should be aware that a therapeutic use exemption (TUE) may be required for participation, both outside and during competition.

Task Force 7: Aortic Diseases, including Marfan Syndrome

There was a separate Task Force that reported on the collection of aortic diseases in the new guidelines. In the previous version of the guidelines, these conditions were parceled out among the other task forces. The new organization is helpful because all of the pertinent recommendations can easily be found in one place. Particular mention is made of the importance that aortic size (eg, diameter) be considered in the context of the athlete’s size (eg, age, gender, body surface area). In many circumstances, use of a z-score–the number of standard deviations above/below the mean for a size- or age-specific population–may be more appropriate than absolute measurements alone.

Athletes with Marfan syndrome or any of the other connective tissue disorders that affect the aorta (eg, Loeys-Dietz syndrome, Ehlers-Danlos syndrome, familial thoracic aortic aneurysm and dissection [TAAD] syndrome) should receive frequent reevaluation with echocardiogram, computed tomography (CT), and/or magnetic resonance imaging (MRI). The recommendations regarding safe levels of activity parallel the previous guidelines.

For athletes with bicuspid aortic valve (BAV), the new guidelines focus on z-scores to define the degree of aortic enlargement: not enlarged, z-score < 2; mild enlargement, z-score 2 to 2.5; moderate enlargement, z-score 2.5 to 3.5; severe enlargement, z-score >3.5. Athletes with mild enlargement of the aorta should be confined to low-and moderate-intensity static and dynamic sports that do not have a likelihood of bodily injury. In this group, intense weight training should be avoided. Athletes with moderate enlargement of the aorta should participate in only low-intensity sports that do not have a likelihood of bodily injury. And finally, those with a severely enlarged aorta should not participate in competitive sports.

Task Force 8: Coronary Artery Disease

We think of coronary artery disease (CAD) as a disease of older individuals, but there are sometimes young athletes with acquired diseases of the coronary arteries.

One important aspect of the new guidelines in the area of coronary artery disease is the recommendation that athletes should participate in decisions about safe exercise with their physician(s), taking into consideration the health and psychological benefits of exercise as well as any potential risks. The new guidelines are explicit that asymptomatic athletes with known CAD but with normal LV function and no inducible problems with stress testing should be able to participate fully in their sports. For those who have had myocardial infarction (MI) or coronary revascularization procedure (eg, coronary artery bypass grafting [CABG] or coronary stenting), participation in sports activities should be curtailed for a period of 3 months.

A new section is devoted to the problem of spontaneous coronary artery dissection, a condition where a tear develops in the inner wall of the coronary artery itself, without warning and seemingly without explanation. The new guidelines recognize that there is not yet sufficient experience and evidence with this problem to formulate specific recommendations, but that it may be reasonable to restrict affected athletes from high-intensity sports.

Also new in these guidelines is a section devoted to heart transplant recipients. The guidelines recognize that for many such patients, participation in sports activities can be safe, especially if there is annual stress testing designed to demonstrate the safety of exercise up to the level of exertion that is anticipated during sports activities.

Task Force 9: Arrhythmias

The section on athletes with arrhythmias is the longest and most complicated section of the new guidelines, in part because there are many different arrhythmias to consider. This is an area where particular expertise on the part of the physician is required to make sound judgments about participation.

The recommendations suggest that athletes with permanent pacemakers can participate fully in sports if there is no limiting underlying heart condition or symptoms. Those who are pacemaker-dependent (ie, require the pacemaker continuously to generate the heartbeat) should avoid sports in which a risk of collision might result in damage to the pacemaker system. All others with a pacemaker should recognize the inherent risks of bodily injury that might also damage the pacemaker.

Atrial fibrillation (AF) deserves special mention because it is so common. For athletes with AF, the new guidelines recommend evaluation that includes thyroid function tests, queries for drug use, an ECG, and an echocardiogram. The new guidelines remind us that athletes with well-tolerated and low-risk AF may participate fully. Those who are taking anticoagulants other than aspirin alone should consider the bleeding risk in deciding which sports activities may be safe. Finally, the new guidelines recognize that catheter ablation for AF might eliminate the need for medications and should be considered in athlete patients.

The new guidelines suggest a similar evaluation for patient with atrial flutter. For this condition, catheter ablation has a high likelihood of success and should be considered.

For athletes with SVT (eg, AV nodal reentry tachycardia, AV reciprocating tachycardia, atrial tachycardia), catheter ablation should be considered.

For athletes with ventricular arrhythmias (eg, premature ventricular contractions [PVC’s], non-sustained ventricular tachycardia [VT], sustained VT, or ventricular fibrillation), careful evaluation for underlying structural heart disease. The algorithms for determining safe levels of exercise are complex and athletes should seek expert guidance.

The new guidelines have a new section on syncope, the problem of blacking out unexpectedly. Athletes with exercise-induced syncope should be excluded from sports activities until a full evaluation is completed. Cardiac causes of syncope can sometimes be life-threatening. If the cause of syncope is determined to be neurally mediated, athletes can resume all sports activities once treatment measures are shown to be effective. If no cause for the syncope can be determined, athletes should not participate in sports activities in which a transient loss of consciousness might result in serious bodily injury.

The final new section relates to athletes who have an implanted internal cardioverter-defibrillator (ICD). The guidelines recommend that the indications for ICD implantation be no different for athletes and non-athletes. In particular, an ICD should not be implanted solely to allow participation in sports. For athletes with an ICD who have no episodes of ventricular arrhythmias that necessitate device defibrillation for a period of 3 months, participation in low-intensity sports activities may be reasonable. Decisions about participation in sports activities with higher degrees of intensity, though, should consider the possibilities of greater likelihood of inappropriate shocks or device dislodgement with contact sports.

Task Force 10: Cardiac Channelopathies

The new guidelines include the recommendations from a new Task Force devoted to the cardiac channelopathies. These disorders are typically characterized by a structurally normal heart but a predisposition to develop syncope, seizures, or cardiac arrest from VT or VF. At a cellular level, these disorders are caused by abnormalities in various ion channels in cardiac muscle cells that ordinarily permit the coordinated ebb and flow of charged ions with each heartbeat. Approximately 1 per 1,000 individuals is affected by such conditions. The most common types are long QT syndrome (LQTS), catecholaminergic polymorphic ventricular tachycardia (CPVT), Brugada syndrome (BrS), early repolarization syndrome, short QT syndrome, and possibly idiopathic VF.

Historically, athletes with any channelopathy have been restricted from sports activities of all types because of the potential risk of sudden death. Since the 2005 guidelines, though, much has been learned about the genetics, clinical manifestations, and course of these disorders. It is now thought that some affected athletes may participate safely in sports activities. The key, though, is careful evaluation by a cardiologist who specializes in heart rhythm disorders or by a genetic cardiologist.

Task Force 11: Drugs and Performance Enhancing Substances

Not surprisingly, the guidelines contain the recommendation that athletes meet their nutritional needs through a healthy, balanced diet without dietary supplements. The guidelines further recommend that the use of performance-enhancing drugs (PEDs) and supplements be prohibited by schools, universities, and other sponsoring organizations as a condition for participation. The guidelines suggest the use of the principle of “unreasonable risk” (the potential for risk in the absence of defined benefit) as the standard for banning or recommending avoidance of substances being evaluated for use by athletes.

Importantly, the guidelines recommend that athletes receive formal education about the potential risks of PEDs and supplements, including the specific risks of sudden death and acute myocardial infarction.

Task Force 12: Emergency Action Plans, CPR, AED’s

The new guidelines include the recommendation that schools and other organizations that host athletic events have an emergency action plan that includes provision of basic life support (BLS), the use of an automatic external defibrillator (AED), and activation of the emergency medical system (EMS). Coaches and athletic trainers should be trained in CPR and the use of an AED and the AED should be available within 5 minutes, if needed.

Task Force 13: Commotio Cordis

Commotio cordis is an unusual event, but t is important for coaches, athletes, and officials to be aware of this possibility and be prepared to respond to a lifeless victim. Prompt initiation of bystander CPR and early defibrillation are the keys to survival.

Task Force 14: Sickle Cell Trait

A section devoted to sickle cell trait (SCT) is included in the new guidelines. Although athletes with SCT may participate fully in their sports, the guidelines recommend strategies such as adequate rest and hydration to reduce the likelihood of an event occurring during sports participation. This risk is greatest during periods of high environmental temperature or extreme altitude.

Task Force 15: Legal Aspects

The section of the new guidelines devoted to legal aspects considers the various conflicts that may arise when the guidelines are put into practice.

Related Posts:

In the News: Cardiac Screening for Adult Recreational Athletes

December 8, 2014 By Larry Creswell, MD 6 Comments

An important new study caught my eye. In last week’s British Journal of Sports Medicine, Andrea Menafoglio and her colleagues from Bellinzona, Switzerland published (epublished ahead of print) a report entitled, “Cardiovascular evaluation of middle-aged individuals engaged in high-intensity sport activities: implications for workload, yield and economic costs.”(1)

The study is important because it addresses the issue of cardiovascular screening in adult, recreational athletes, an area that’s received very little attention.

By comparison, the issue of cardiac screening for young, competitive athletes has received a great deal of attention over the past 25 years. Many prominent medical scientific organizations have issued recommendations for pre-participation screening in young athletes, including the American Heart Association (1), American College of Cardiology (ACC), American Academy of Family Practice (AAFP), American Academy of Pediatrics (AAP), American College of Sports Medicine (ACSM), American Medical Society for Sports Medicine (AMSSM), just to name some of the American organizations.

These recommendations form the basis for the widespread use of mandatory pre-participation screening in secondary schools and colleges. The goal of such screening programs is to reduce the number of fatalities from sudden cardiac problems that arise during sporting activities. The successes and pitfalls of such screening programs have been reported and the findings have engendered lively debate about what elements to include in screening programs, their effectiveness, and justification of their cost.

In this new study, the investigators report on a “real world” glimpse into cardiovascular screening in adult, recreational athletes. Their aims were to evaluate the practicality of such a screening program, to measure the prevalence of previously unrecognized cardiovascular conditions in this group, and to determine the costs associated with initial screening and follow-up evaluation of athletes with an abnormal initial evaluation.

The Study

The investigators enrolled 785 athletes, aged 35-65 years (mean, 46.8 years), who engaged in “high-intensity sports” for at least 2 hours per week. The athletes’ sports included running (in 33%) and cycling (in 24%), among others. The majority of subjects (73%) were male. The athletes were primarily “amateur” (69.7), but the group included some who competed in regional (23.7%), national (4.6%), or international competition (2.0%).

Athletes with a known history of cardiovascular disease, except for treated high blood pressure, as well as athletes who had previously undergone cardiac screening within the previous year were excluded.

Each athlete underwent a cardiac screening evaluation according to the current guidelines established by the European Association of Cardiovascular Prevention and Rehabilitation (EACPR). The evaluation was free to each athlete and included:

Thorough personal and family medical history
Physical examination
ECG
Estimation of the individual’s cardiovascular risk using the Systemic Coronary Risk Evaluation (SCORE) chart for Switzerland
Blood testing for total cholesterol and serum glucose.

The SCORE chart was used to estimate the athlete’s 10-year risk of death due to atherosclerotic heart disease based on gender, age, total cholesterol level, systolic blood pressure, and smoking status. Athletes were deemed at “high risk” if their predicted risk was >5% or if any single risk factor (eg, total cholesterol, blood pressure) was markedly abnormal. The cost of this screening evaluation was reported to be $130 per athlete, or $102,050 total.

The Findings

The screening evaluation was abnormal in 112 athletes (14.3% of the total):

5.1% due to abnormal, “pathologic” ECG findings
4.7% because of abnormal physical examination
1.6% due to a “positive” personal or family medical history
4.1% because an athlete was at “high risk” for atherosclerotic heart disease

Each of these athletes then underwent subsequent, more detailed testing to shed more light on the athlete’s cardiac circumstance and to determine if a true cardiac problem was present. These tests included, among others: echocardiogram (an ultrasound examination of the heart’s structure and function); stress test; 24-hour blood pressure monitoring; 24-hour Holter monitoring (of the ECG, continuously, to evaluate for arrhythmias); cardiac MRI; coronary angiography; and tilt testing. A total of 194 such tests were performed and these additional tests had a total cost of $54,556.

In the end, a new, previously unsuspected cardiovascular problem was identified in 22 (or 2.8% of the 785) athletes:

8 with hypertension
5 with mitral valve prolapse and at least moderate mitral regurgitation
3 with biscuspid aortic valve (2 with moderate aortic regurgitation and 1 with mild aortic stenosis)
1 with mild pulmonary valve stenosis
1 with vaso-vagal syncope
1 with Wolf-Parkinson-White syndrome
1 with hypertrophic cardiomyopathy (HCM)*
1 with significant coronary artery disease and “old” myocardial infarction*
1 with abdominal aortic aneurysm*

This group included 19 men and 3 women. Of these 22 athletes with newly diagnosed cardiac conditions, 3 were deemed ineligible to participate in their sports because of unacceptably high risk of cardiovascular events (indicated by an asterisk, above). Each of the 3 athletes who were deemed ineligible for sports activities were identified by an abnormal ECG during the initial screening.

The other 90 athletes with an abnormal initial screening evaluation were “cleared” on the basis of their subsequent testing. We might refer to these athletes as the “false-positives”–those with an abnormal initial screening evaluation, but no real cardiovascular problem.

Interestingly, no diagnosis of coronary artery disease (CAD) resulted from the 76 exercise stress tests that were performed.

The Investigators’ Conclusions

The authors reached 4 main conclusions:

The screening program was effective in identifying a small, but significant, number of athletes with significant cardiovascular conditions that required treatment or monitoring.
The screening program was effective in identifying a very small number of athletes in whom continued participation in sports activities was thought to be dangerous.
Inclusion of the ECG in the initial screening evaluation was important.
The screening program was practical and the costs were reasonable.

My Thoughts

This study provides some pertinent data to help frame our discussions about cardiovascular screening for adult, recreational athletes. The study population here appears to be typical in many regards, and I suspect the study results can reasonably be generalized to athletic populations far beyond Switzerland.

Adult, recreational athletes are not typically bound by the mandatory pre-participation cardiac screening programs that are used for young, competitive athletes. They have to make their own decisions in this regard. They must decide whether “getting checked out” is worth the expense. Athletes might have a variety of relevant questions. How likely am I to discover a previously unrecognized cardiac problem–particularly if I don’t have any symptoms? What are the chances that I could be a false-positive–with the burden of additional diagnostic testing to sort things out? What will this all cost?

Each of these questions now has an answer.

With regard to the first question, there is an approximately 3% chance of identifying a previously unrecognized, unsuspected, and presumably asymptomatic, cardiovascular condition. On t op of that, there is an approximately 4% chance of identifying a high risk profile, based on risk factors, that deserves close follow-up. And finally, there is an approximately 0.4% chance (3 athletes among 785) of identifying a serious cardiovascular condition that places an athlete at undue risk of sudden cardiac death during exercise. It’s not clear from the study whether these risks are similar for men and women.

The second question also has an answer. The chance of a false-positive, using this particular screening evaluation, was approximately 11.5% (90 athletes among 785). That is a fairly large number. Recall that each of these athletes required additional diagnostic testing–at additional cost–to establish that they didn’t actually have a problem after all.

The third question has also been answered–at least in Switzerland. The average cost of the screening program–initial evaluation plus the costs of additional testing that was needed–was $199 per athlete. The cost for the 663 athletes who had a normal screening evaluation was only $130. Obviously, the costs for the remaining 122 athletes, with an abnormal screening evaluation, and who required additional diagnostic testing, were greater. All of these costs would be much higher in the United States, I suspect, and this issue is compounded by the fact that most health insurance policies don’t cover screening evaluations such as these. For many American athletes, these expenses would be out-of-pocket.

At any rate, this new information will be helpful as athletes have discussions with their physicians about whether or not to pursue cardiac screening.

Those are my thoughts about the issue from the athlete perspective.

From the physician perspective, I think it’s important to note that all of the stress testing results were normal. These are expensive tests. We need to keep in mind that the pre-test probability of an abnormal finding in an asymptomatic population of exercisers is extraordinarily low. Perhaps, it’s best to think twice before ordering a stress test in this situation.

And finally, from the perspective of the event organizer, the prevalence data here is enlightening. Governing bodies and race directors should be aware that several percent of participating athletes will have unsuspected cardiovascular problems, including 0.4% who are at high risk of sudden cardiac death during exercise. These numbers should inform safety planning efforts. It shouldn’t be surprising that we have a small number of cardiac emergencies and even fatalities in recreational competitions involving adult athletes.

Reference:

1. Menafoglio A, Di Valentino M, Porretta AP, et al. Cardiovascular evaluation of middle-aged individuals engaged in high-intensity sport activities: implications for workload, yield and economic costs. Br J Sports Med 2014;01-6. doi:10.1136/bjsports-2014-093857.

Debate Continues on Cardiac Screening for Youth Athletes

November 25, 2013 By Larry Creswell, MD Leave a Comment

This post is for the parents out there. I don’t have many youth athlete readers here at the blog, but I’ll bet there are more than a few parents.

We’re all familiar with the sad stories of young athletes who die suddenly while playing their sports. According to most estimates, about 1 young athlete per 50,000 to 100,000 per year will have sudden cardiac death during practice or competition. These incidents often receive a great deal of attention in the media. They also have a lasting impact on families, schools, and communities that struggle afterwards to deal with the tragedy.

The medical community also struggles with this issue. There are very legitimate differences of opinion about what best to do. We know that most of these young athletes die from some sort of unrecognized heart problem, so there’s an obvious motivation for cardiac screening programs to find these heart problems before a young athlete dies as a result. Yet we also know that such screening programs are costly in both monetary terms and in the needed resources. We also know they’re not foolproof.

In last week’s November 21, 2013 edition of the New England Journal of Medicine, a Clinical Decisions feature was devoted to the topic of “Cardiac Screening before Participation in Sports,” focusing on school-aged athletes. This feature asked experts in the field to respond to 2 related questions.

The first question asked: Should young athletes be required to undergo cardiac screening before participating in sports?

Dr. Sanjay Sharma, a cardiologist from the St. George’s University of London answered YES.
Dr. Mark Estes, a cardiologist from Tufts University in Boston answered NO.

The second question asked: If an athlete does undergo screening, should the screening involve only a history and physical examination, or should electrocardiography (ECG) also be required?

Dr. Victoria Vetter, a pediatric cardiologist from Children’s Hospital in Philadelphia, recommended AGAINST the ECG.
Dr. Domenico Corrado, a cardiologist from the University of Padua in Italy advocated FOR the ECG.

The position statements are intended for a physician audience, but even non-medical folks will be able to read them and learn something. Take a moment to read what these doctors say. In just a few short paragraphs, each summarizes the important arguments. You won’t find a better summary of the arguments.

The journal also has an online poll for readers to weigh in on the issue. The poll asks readers to consider the expert opinions and then answer the 2 questions for themselves. I answered YES for screening and YES for an ECG. As I sit here writing on Sunday afternoon, nearly 900 readers have responded to the poll, with the following results:

18% voted for requiring NO screening
23% voted for screening with medical history and physical examination alone
57% voted for screening that also included an ECG.

At the level of schools, communities, and states, there is increasing awareness about the issues surrounding cardiac screening for young athletes. Some have created screening programs that are available to athletes, often at little or no cost. In the end, though, in most communities parents will need to make appropriate decisions about cardiac screening for their children. Be informed.

2. Ask the experts: Pre-participation heart screening for adult endurance athletes.

George W. Bush Gets a Stent

August 21, 2013 By Larry Creswell, MD 1 Comment

We learned from news reports earlier this month that former President George W. Bush was treated with a coronary stent for a blockage in a coronary artery that was discovered during his annual medical check-up. Of course, a great many Americans are treated each day for coronary artery disease (CAD), but Bush’s case draws my attention not only because he’s the former President but also because he’s known to be physically active, especially with cycling.

Bush’s Medical History

The fine details of Bush’s most recent health matters haven’t been made public, and might never be. But we know that while President from 2001 to 2009 he enjoyed comprehensive medical check-ups performed at the Bethesda Naval Medical Center. Each year, short statements were issued by the White House that summarized the President’s health. We can take a look back at some of that reporting.

Before taking office, the President received annual medical check-ups from Dr. Kenneth Cooper at the Cooper Clinic in Dallas, Texas. We know that, at the time he took office in 2009, he had no heart problems and no significant family history of heart disease. He occasionally smoked a cigar, did not drink alcohol, and had typical caffeine intake in the form of diet soft drinks and coffee.

From his examination at age 58 in 2004, we know that: he was 6 feet tall, weighing 200 pounds; his body fat was 18.25%; his resting heart rate was 52 and the blood pressure was 110/60; and the total serum cholesterol level was 170 mg/dL, with a decrease in the LDL (bad cholesterol) and increase in the HDL (good cholesterol) from one year previously. He was noted to have mild calcification of the coronary arteries (presumably based on a screening cardiac CT scan) and both aspirin and a cholesterol-lowering agent were prescribed. At the time, he was running 7 1/2 minute miles on the treadmill and was cycling several times per week.

In 2005 we learned that the President’s weight had decreased by a few pounds and the blood pressure and resting heart rate remained low. He underwent an exercise treadmill test that was normal and his doctors concluded that he was at “very low risk of coronary artery disease.” By 2005 Bush had given up running because of difficulties with knee pain, but continued to be active with cycling and weightlifting.

In 2006 at age 60 he was noted to have an EKG without worrisome abnormalities and a normal stress echocardiogram. Doppler ultrasound studies of the arterial blood supply to the legs was normal and a screening ultrasound of the abdomen showed no evidence of abdominal aortic aneurysm. Laboratory values included: total cholesterol 174 mg/dL, HDL 60 mg/dL, LDL 101 mg/dL, triglycerides 61 mg/dL, and normal values for C-reactive protein (CRP) and homocysteine. Interestingly, it was reported that he was taking no prescription medications despite the 2004 statement about the recommendation for a cholesterol-lowering agent. On the basis of the available information, the President was thought to have “low” to “very low” coronary artery disease risk.

The Coronary Stent

As we all know, Bush left office in 2009. Since then, his medical affairs have been private. So, fast forward to 2013….

We know that Bush went recently for his annual medical check-up at the Cooper Clinic and the following day at Texas Health Presbyterian Hospital was treated with a coronary stent for a blockage in a coronary artery that had been discovered duringn his evaluation. The details have not been made public, but it’s probably fair to assume that he underwent a stress test that was abnormal and that coronary arteriography was organized for the following day, with implantation of the coronary stent at the same setting.

The fact that Bush was treated with a stent for the coronary artery blockage has created a bit of a stir in the medical community. For those who are interested you can read more at:

“Did George W. Bush really need a stent?,” an article by Larry Huston in Forbes.

“The George W. Bush stent case: An incredible teaching opportunity on the basics of heart disease,” a blog piece by Dr. John Mandrola.

“Heart stents still overused, experts say,” an article by Anahad O’Connor at NY Times Well.

Basically, the controversy revolves around the appropriate treatment for asymptomatic patients–those without chest pain, heart attack, etc.–or those with so-called “stable” symptoms–for instance, chest pain with exertion–who are found to have blockage(s) in the coronary arteries. In truth, there has been no public reporting on whether or not Bush had any such symptoms, either with exertion or at rest. And there has been no updated reporting on Bush’s physical activity level or other relevant risk factors for CAD. But information from the best scientific studies suggests that asymptomatic patients and those with “stable” CAD fare no better, with respect to heart attack, stroke, or death, with a stent than without, so long as the best possible medical therapy is provided.

At any rate, this controversy will be one for our community of heart professionals to discuss and sort out.

What Can We Learn?

From the athlete’s perspective, though, Bush’s story reminds us of the importance of coronary artery disease as we age, even if we remain physically active. A few thoughts….

1. The discovery of CAD is almost always a surprise….particularly for an athlete. Nobody is immune from this disease, even if remaining physically active helps guard against it.

2. There is a set of well-established risk factors for CAD. I’ve talked about this issue previously here at the blog. Let’s remember that there are some risk factors that, unfortunately, can’t be modified: increasing age, being male, and having a family history of early CAD. Other risk factors are under our control: obesity, high blood pressure, smoking, abnormal serum cholesterol and lipid levels, diabetes, and physical inactivity. Adult athletes should know where they stand with respect to these risk factors and work to improve any that can be modified favorably. An ongoing relationship with a healthcare provider will offer the necessary framework for this. Periodic measurement of the blood pressure and testing of the serum cholesterol/lipid levels every 5 years are recommended.

3. Our personal situation with CAD will likely change over time. The process in which plaque builds up in the coronary arteries can begin early in our lives. But this process is often progressive as we age. That’s why we say that increasing age is a risk factor. Bush’s story illustrates just how this can happen. In 2004-2006 he had very favorable clinical and laboratory data regarding his risk of CAD, including a normal stress echocardiogram in 2006. Yet today we know that an important blockage had formed, or more likely progressed, in the interim. It’s important, then, to periodically re-visit our circumstance with CAD.

4. Warning signs are important. Important blockages in the coronary arteries often lead to symptoms of angina–chest pain/discomfort or perhaps difficulties with breathing. When angina occurs with exertion, we call it exertional or stable angina. When angina occurs at rest, we call it unstable or rest angina. Either form of angina should prompt timely evaluation. That evaluation may take the form of stress testing or coronary arteriography to look for blockages in the coronary arteries. Unfortunately, there are some patients whose first sign of trouble is a heart attack, or myocardial infarction. This can occur in athletes and non-athletes, alike.

Related Posts:
1. Coronary Artery Disease: The Essentials
2. Two Stories, Two Endings, a blog post about endurance athletes and CAD.
3. In the News: Coronary Plaque Build-up in Marathoners