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      Can Cardiac Screenings Save the Lives of Young Athletes?
      Courtesy Lori Herbert
      April 17, 2017

      Can Cardiac Screenings Save the Lives of Young Athletes?

      On January 17, the first morning back from winter break, the Northern Michigan University football team conducted a fairly routine conditioning workout.

      After practice, starting right guard Anthony Herbert (Herbie to his NMU teammates) grabbed a quick breakfast and went back to his dorm, where he sat down to watch a movie. He was acting normally right up until his roommate saw him stop breathing. His roommate called 911 and started to perform CPR while emergency crews rushed to the scene. They arrived in less than ten minutes but were unable to resuscitate Herbert. He was 20 years old.

      An autopsy later revealed that Herbert had an enlarged heart, nearly twice the size of an average healthy adult's, from a condition called hypertrophic cardiomyopathy, or HCM, which causes ventricle walls to become thicker, potentially obstructing blood flow and leading to other complications. It's one of the leading causes of sudden cardiac arrest in young athletes.

      But Anthony was healthy, said his mother, Lori Herbert. A big guy, but healthy. His yearly sports physical never found anything wrong with his heart.

      "He never had any symptoms," Lori said. "His first symptom was his last."

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      Athletes like Anthony and parents like Lori are the emotional center of a debate within the American cardiology community. When a seemingly healthy kid dies on the field or court from sudden cardiac arrest, the questions that follow are obvious: Could we have known about the underlying problem, and could those deaths have been prevented?

      When it comes to answering those seemingly straightforward questions, however, U.S. cardiologists are split. The American Heart Association (AHA) currently recommends that pre-participation heart screening include a brief physical exam by a doctor and a survey of personal and family history "designed to identify, or at least raise the suspicion of, cardiovascular diseases that place certain athletes at risk." Some cardiologists believe that these guidelines omit a crucial method of cardiovascular screening: an electrocardiogram, or EKG, which measures electrical activity in the heart. Advocates say that EKGs could help identify more athletes with conditions like HCM. Others, however, are adamant that enhanced screening protocols won't help prevent sudden cardiac deaths and could, in fact, do more harm than good.

      The debate over adding EKGs to pre-participation protocols is a complicated tangle of issues such as disease risk levels, health-care costs, and ethical obligations. Every doctor approaches the problem with good intentions, says pediatric cardiologist Seth Lapuk, and everyone wants the best for young athletes. They just disagree about what "the best" looks like.

      Herbert's teammates gave his family a signed jersey at the funeral. Courtesy Lori Herbert

      Numbers Game

      "The first issue is, how big is the problem," said Paul Thompson, the chief of cardiology at Hartford Hospital in Connecticut. Though every death is a tragedy, he said, introducing nationwide EKG testing could be an outsize response to what is believed to still be a relatively uncommon occurrence.

      No one knows exactly how frequent sudden cardiovascular deaths are among young athletes (from adolescent to college age) in the U.S.; there is no mandatory reporting or national database to track such cases, making reliable data difficult to come by. Estimates vary, Thompson said, but a commonly cited rate is one in every 200,000 athletes per year. Other studies estimate that the absolute numbers come in at fewer than 100 deaths per year.

      But the rates are much higher for certain demographic groups, says Jonathan Drezner, the director of the Center for Sports Cardiology at the University of Washington in Seattle and one of the authors of a 2015 study of sudden cardiac death among NCAA athletes.

      "If you look at college athletes, for reasons that we don't know precisely, college male basketball players are at much greater risk than every other sport," he said. "An African-American college basketball player is at 19 times the risk of a Caucasian high school athlete."

      The study, which looked at causes of death in NCAA athletes over a period of ten years, found that black male college athletes' risk of sudden cardiac death was roughly one in 16,000 players per year; for black male basketball players, the rate rises to one in 4,400 players per year.

      Drezner believes that the best approach to reducing the risk of death—particularly for these high-risk athletes, but for others as well—is additional screening with an EKG.

      "When you add an EKG to a physical, you will identify more kids with heart conditions at risk for sudden cardiac death," he said.

      But other cardiologists like Lapuk say that the overall rates of sudden cardiac death in young people are so low that additional testing might not be the most effective use of health-care spending.

      "Getting struck by lightning affects more people by far, but we don't run around with lighting rods on our head," he said. "You have to keep it in perspective. If you look at causes of death in the young, heart disease is way low on the list, and you're better off putting resources into other things."

      A Need to Screen

      For about 80 percent of young athletes who suffer sudden cardiac death, the first symptom is fatal—they exhibited no outward symptoms or other indications that they were at risk of a massive cardiac event. By measuring the electrical activity of the heart, an EKG can reveal abnormalities and patterns indicative of some of the heart problems that can lead to sudden cardiac death, like hypertrophic cardiomyopathy. But other cardiovascular diseases like coronary artery anomalies, which are the second-leading cause of sudden cardiac death in athletes, wouldn't show up on the EKG.

      "If you want to find disease, I think EKG is the way to go," said Jimmy McKinney, a sports cardiologist at the University of British Columbia. "The EKG doesn't catch all causes of sudden death, but for the most part, it catches about 60 or 70 percent."

      Although EKG screening might have a higher potential to pick up disease, critics argue that finding a cardiac problem does not always mean doctors can prevent it from becoming fatal. Alternatively, an abnormality flagged by testing might never go on to cause death, Thompson said. HCM affects one in 500 people in the U.S., for example, but less than one percent of patients die from sudden cardiac death— and there is limited data on the amount that exercise elevates risk.

      "A lot of people out there have the abnormality and nothing happens to them," he said. "If you took everyone with asymptomatic cardiomyopathy and did an intervention, would you have saved them?"

      Few large-scale scientific studies have looked directly at the potential for widespread EKG screening to reduce death by sudden cardiac arrest among athletes. The largest such study, published in 2006, was conducted over 26 years in the Veneto region of Italy. It found that the number of sudden cardiac deaths among athletes age 35 or younger fell by 89 percent between 1979 and 2004 after the country implemented mandatory nationwide EKG screening for athletes in 1982. Critics of the study, however, say that other factors could have caused the drop in deaths, like improved lifesaving treatments or a change in the makeup of the athlete population.

      A second major study came out of Israel in 2011 and found no reduction in the risk of sudden cardiac death after implementation of a nationwide EKG screening program. That work had its critics, as well (notably, from the researchers of the Italian study), because it drew its data from newspaper reports rather than any centralized national registry of cardiac deaths.

      Herbert, a sophomore, started 11 games last season for Northern Michigan. Courtesy Lori Herbert

      Risk and Reward

      Though he acknowledges that this is a controversial area, Drezner would still like to see wider implementation of EKG screening, even without a formal recommendation or mandate.

      "You do it because it's good medicine," he said.

      But other cardiologists like Seth Lapuk are concerned that adding an EKG to the recommended screening protocols will not reduce deaths, and could actually harm young athletes if it turns up too many false positives—that is, flagging people as high-risk when they're actually not.

      "If you label some kid with a potential disease that you can't prove, and you keep them out of sports, they become depressed, they can become obese—you're trading off on a very unlikely thing," Lapuk said. "And you're generating all kinds of additional testing." That follow up testing can be both invasive and expensive, he said.

      For parents like Lori Herbert, though, that reasoning is more difficult to understand.

      "It would have been devastating to my son to stop playing football, but I could guarantee he would rather be here than where he is now," she said.

      One month after Anthony's death, Lori and her family volunteered at a community screening event in Birmingham, Michigan. She said that what she saw from some families was shocking and upsetting.

      "I heard a lot of, 'oh, my kid can't play sports'. Most of the parents' reaction is my kid can't be number one," she said. "That was their biggest concern: finding out that their kid has to get more testing done rather than their kid's safety. It's sickening to me."

      There are multiple ways to interpret EKG tests, and the different sets of criteria have different false positive rates. The current American Heart Association–recommended screening, with the questionnaire and physical exam, also flags a high number of athletes for further evaluation or testing: about a quarter of athletes screened positive in the AHA questionnaire, while the actual incidence of cardiovascular disease is significantly lower.

      A number of groups are working for make screening more accurate. Drezner and his team came up with a system for interpreting EKGs that has a six percent false positive rate, compared to a 26 percent rate with the European Society of Cardiology's recommendations. A new "Refined criteria" might be able to push that false positive rate down even further.

      Cardiologists in Canada took note of both the reduction in false positives rates on EKGs and the high false positive rates on the AHA questionnaire and worked to create their own system for screening, which was published in January in the Canadian Journal of Cardiology.

      "We're just mild-mannered Canadians, we're not claiming we're superior, but we wanted to make a better and more efficient way," said McKinney, who worked on the project. They created a new questionnaire with more specific questions about cardiac symptoms, which improved on the AHA's false positive rate. They then paired that refined questionnaire with an EKG.

      But McKinney noted that Canada's universal healthcare system makes it easier—and much cheaper—to implement a nationwide EKG protocol there than in the U.S.

      The AHA estimates that costs of widespread EKG testing in the U.S. could be on the order of billions of dollars, even before taking into account costly follow-up tests needed by those who screen positive; echocardiograms, for example, cost anywhere from $1,000 to $2,000 each, or more, and even with insurance, out of pocket expenses could be up to half of that.

      "If that turns up nothing, that's an enormous amount of money for a lot of people," says Lapuk. "You can work out very easily and very real terms in how it affects people's lives."

      Overall, such a program could cost between $10 and $15 million per life saved.

      But, Lapuk continued, "It comes down to if you save one life, you save the world. So how much do you subject everyone else to the downsides of that in terms of potentially diagnosing some people?"

      The Herbert family recently volunteered at a community screening event in in Birmingham, Michigan. Courtesy Lori Herbert

      Moving Forward

      Without more definitive research about the benefits of widespread EKG screening, in the United States the decision to include it in pre-participation evaluations has largely been left up to individual athletic organizations. Many professional athletes are required to get EKGs. The NBA, for example, implemented a league-wide standardized cardiac screening in 2006 that includes both the AHA–recommended protocol and EKGs.

      High school and college athletes, on the other hand, generally do not. The NCAA requires pre-participation evaluations for its athletes, but it does not require EKGs, although many schools, such as the University of Pittsburg, do use them. Free screening events are also often organized for high school students and athletes at the community level, like the one Lori Herbert and her family volunteered at. The debate over whether that's enough remains.

      "Until we have large randomized controlled trials saying definitely [that large-scale EKG screening] is not effective, I don't think the answer will ever be solved, and people will firmly sit on one side of the fence or another," said McKinney.

      Lori thinks that families of young competitive athletes should at least be made aware of the option to seek out their own EKG screening to supplement the normal protocol.

      "We'd never even heard of the need to get a cardiac screening. I'm a nurse, and it was never mentioned that he could have any additional screening past the general sports physical," she said. "I would rather give people the opportunity to be screened if they want to."

      But Thompson cautioned against recommendations by a group like the AHA for an EKG at basic screenings nationwide, citing concerns about causing greater harm by scaling up to a large program without enough research.

      "I really don't think we know the answers," he said. "And in medicine you get into trouble when you think you know the answer."

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