The tragic stories, it seems, keep on coming. A 38-year-old pediatrician and mother collapsed and died while running on a treadmill in Maryland. A 17-year-old Boston boy died suddenly during a pickup basketball game. Last year, National Public Radio compiled a list of professional athletes who suffered sudden cardiac arrests in the last few years, including an Atlanta Hawks center, a Denver Broncos running back, and a Toronto Blue Jays pitcher.
Preventing sudden cardiac death in athletes isn't a new challenge. Most doctors worldwide agree on how to do it. And yet authorities such as the American Heart Association have consistently opposed widespread adoption of the measures necessary to combat the problem. The fact that Americans continue to accept the preventable sudden deaths of athletes says a lot about our complacent attitude toward the problem. We don't lack good science. We lack the motivation to act on it.
The leading cause of sudden death in American athletes is a genetic disorder called hypertrophic cardiomyopathy, which by some estimates affects roughly one in 500 people. Like weeds that overrun an unkempt yard, the heart muscle fibers proliferate rapidly and in a disorganized manner, often leading to a tripling or quadrupling in heart size during adolescence (see a picture here). People with HCM usually have no idea this is happening until they're exercising one day and the electrical system in the heart suddenly fails. The heart takes on the appearance of a bag of worms struggling to get free (a problem called ventricular fibrillation), and cardiac arrest occurs.
Back in the 1970s, the government of Italy began a radical experiment and passed the Medical Protection of Athletes Act, which mandated that every athlete between 12 and 35 years of age get a physical exam and an electrocardiogram, a test that records on paper the athlete's heart rhythm pattern for a few seconds. The EKGs yielded a bonanza of interesting findings, and many athletes were found to have previously unsuspected heart problems that disqualified them from high-intensity participation. In 2006, researchers determined that sudden death in Italian athletes had dropped by an incredible 90 percent—because of the reduction in deaths due to HCM as well as some rarer conditions detected by the test.
Typically, American athletes get screened by a simple history and physical exam but no testing like an EKG. That's not good enough. In a review of 158 sudden cardiac death in young athletes, for example, only 3 percent were suspected of having heart problems based on the history and physical exam alone. In the largest study of seemingly normal American high school athletes, EKGs found serious cardiac problems in about one in 350 teens—yet the history and physical missed almost 19 out of 20 of these conditions. The principal author of the American Heart Association guidelines on athletic screening wrote that an athlete's history and physical exam alone "lacks sufficient power to identify important cardiovascular abnormalities consistently."
In 2004 and 2005, the European Society of Cardiology and the International Olympic Committee began recommending universal EKGs for athletes less than 35 years old. ("Athletes" means people participating in "competitive activities"; some argue that it includes anyone exercising regularly at high intensity.) Yet in 2007, the AHA issued guidelines that broke with their European counterparts and failed to endorse routine EKGs. Of course, scientific disagreements over evidence occur frequently. However, the guidelines offered a baffling, non-evidence-based justification for inaction. In a tortured passage, the American Heart Association argued primarily that "the framework" for EKG screening doesn't exist since screening would "have to be unusually efficient to process thousands of athletes"—an excuse that ignores the fact that Italy now screens millions of athletes routinely. The AHA claims that sudden deaths of athletes are "unlikely" to "achieve sufficiently high priority when competing with a myriad of other public health issues." The U.S. health care system, they conclude, is "already overburdened."
That's an odd argument from an organization that recommends all manner of fabulously expensive therapy for heart attacks, cholesterol problems, and other conditions. The AHA's rationale inflamed Dr. Robert Myerburg, chair of cardiovascular research at the University of Miami, who co-wrote a devastating critique of the guidelines. "We need to lead," he recently told me, "and get away from the idea [that] screening isn't feasible." In particular, Myerburg assails cost-effectiveness figures of the AHA, whose estimated hospital costs fail to factor in any discount for mass screenings. Nor do the estimates take into account the potential savings of modern automated reading technology. Like opponents of drug treatment for AIDS in poor countries, he implies, the AHA has cooked the books to suit an anti-screening agenda.
Consider how the savviest, and wealthiest, organizations now protect their athletes. Ninety-two percent of American professional athletes get screening EKGs. Following the death of Atlanta Hawks center Jason Collier in 2005, all NBA players get a cardiac ultrasound—an even more reliable, if expensive, test than an EKG—to exclude causes of sudden death. Several college sports programs, such as those at Purdue, Ohio State University, and Georgia Tech, also perform echocardiograms. Anecdotal evidence suggests that some private high schools have begun offering routine EKG screening for athletes, since the AHA guidelines explicitly say they are "not intended to actively discourage individual local efforts." This contradiction between the AHA's population-wide and individual recommendation inevitably will lead to a two-tier approach to young athletes. (Already, more than half of all young athletes who die are African-American.)
Why does the AHA really oppose screening tests, even though their statement plainly asserts that the tests "would have benefit?" Though not stated explicitly, widespread screening with EKGs, or even echocardiograms, threatens traditional, lucrative fee-for-service norms for expensive cardiac testing. According to Medicare reimbursements, an EKG scores about $50, though it takes only minutes to obtain and a few seconds to read. An echocardiogram gets roughly $400. What would happen if these tests were subjected to market pressures and economies of scale? Consider what Purdue's athletic department did: They contracted with local cardiologists to perform focused two-minute echocardiograms for only $35 instead of $400. Such creative solutions might save lives—but could also dispel the mystique (and monetary rewards) of many cardiologists' work.
Widespread screening, whether it's mammograms, blood pressure measurements, or other tests, is often complicated and not always helpful. But the debate over expanded EKG testing largely concerns the politics, not the science, of the test. Ultimately, it would be better for America's young athletes if the scientists stuck to the science, the politicians handled the politics, and the entrepreneurs tackled the franchising.
Feb 3, 2009