Heart of the Matter

January 29, 2015
Although the NATA's latest guidelines do not call for ECG screenings on athletes prior to participation, some schools have begun to implement them anyway. In this two-part article, athletic trainers at the high school and university levels explain why and how.
By Josh Woodall and Jamie Woodall

Josh Woodall, MEd, ATC, LAT, is Head Athletic Trainer at Bryan High School and Jamie Woodall, ATC, LAT, is Head Athletic Trainer at Rudder High School. Both schools are part of the Bryan (Texas) Independent School District and recently won NATA Safe Sports School awards. The authors, who are married to each other, can be reached at: [email protected] and [email protected].


The evening of Sept. 2, 2011, started like any other fall Friday night here at Rudder High School in Bryan, Texas. The football squad was in the thick of a home game against a rival team and the stands were full of fans. But that normalcy would not last.

At the end of a routine play, one of our defensive linemen, David Wilganowski, laid motionless on the field. His collapse was much different than typical reactions to an orthopedic injury. He simply became limp, falling to the grass field without making any effort to brace himself. David had not even been hit during this play. In fact, he was having a stellar game.

Watching the action in my role as Head Athletic Trainer at Rudder, I rushed on the field with Assistant Athletic Trainer Phillip Lozano, MS, ATC, LAT, and we promptly determined that David was experiencing cardiac arrest. Along with two team physicians, we administered CPR and applied the AED. Bryan Fire Department EMTs and paramedics, who are routinely on standby during football games, responded quickly and continued advanced care.

After several cycles of CPR, two shocks from the AED, and the joint efforts of athletic trainers, team physicians, EMTs, and paramedics, David regained a pulse. He was immediately transported to St. Joseph Regional Health Center before being transferred by air to Texas Children's Hospital in Houston. He would undergo many tests and procedures, including one that implanted a defibrillator into his chest, before making a full recovery--with one exception. He never played football again.

For the athletic training staff in the Bryan Independent School District (ISD), which includes Rudder and Bryan High Schools, the incident was not something to quickly move on from. While we were proud that our emergency action plan worked so well, we could not stop asking ourselves how this type of incident could be prevented in the future.

One of the first things we did after David's cardiac arrest was to examine his preparticipation physical forms. He had no family history of cardiac conditions and no abnormalities were found during any of his examinations. That raised a question: "If there was nothing we missed from our traditional screening process, what could we have done differently?"

To answer this, we started by taking a few steps back. We knew that some high school and college athletic departments had begun offering cardiac screenings to their athletes, but we had questions about them, from what types of tests are best to cost and effectiveness. We began our search for answers by forming Bryan ISD's Athletic Health Care Team (AHCT).

This team included all school athletic trainers, team physicians, local EMS personnel, school nurses, a nutrition consultant, and district administrators. The goal of the group was to improve student-athlete health and safety by facilitating communication between school medical personnel and physicians, which would help us make the best decisions about sports medicine policies.

One of the first objectives of the AHCT was to discuss offering heart screenings to Bryan ISD student-athletes. Kory Gill, DO, one of our team physicians, suggested we make ECG screenings available, arguing that it is a cost efficient, non-invasive test, which takes only a few seconds to perform and has a low rate of false positives. From there, we discovered the Cypress ECG Project, a Texas-based company that will come to a school and perform the tests.

Initially our concern with this was cost--surely the expense of transporting equipment and trained staff to conduct these screenings would be significant. However, we were pleased to find out the price tag is only 15 dollars per test. Space was not a problem either, as Cypress only needed one classroom to perform the exams.

The AHCT also decided that the most effective way to offer ECG screenings would be to incorporate them into the preparticipation physicals Bryan ISD offers to student-athletes, which are conducted on a Saturday toward the end of the spring semester. We determined the screenings would be made available to all students, not just student-athletes, including those in our middle schools. However, the target audience would be student-athletes. We also discussed whether to make ECG screenings mandatory, ultimately deciding not to.

Our next step was educating student-athletes and their families on why they should participate. With so many requirements already in place by governing bodies, we wondered if families would see these heart screenings as just another hurdle to participation. To make our case, the Bryan ISD AHCT organized a town hall meeting to discuss student-athlete health care.

The overriding topic of the meeting was sudden death in student-athletes, with a focus on cardiac arrest. We talked about the benefit of preventative screening and details of the ECG tests that would be offered. Athletic trainers, team physicians, district administrators, and the school district's registered sports dietitian all spoke at this event.

We knew there would be questions, and that some people might be hesitant to ask theirs publicly. So we set up a system that allowed community members to text message questions to the moderator during the meeting. Common topics raised included cost, whether or not the screenings would become mandatory, who would be allowed to take the tests, and how results would be disseminated.

One of the best outcomes of the town hall meeting developed after it had officially ended. We had a surprise guest, Scott Stephens, the father of Cody Stephens, a young athlete from the Houston area who had passed away in May 2012 due to sudden cardiac arrest. Mr. Stephens approached us after the meeting, offering to help through the Cody Stephens Foundation. We then applied for and received a grant from the foundation that would fund all of the ECG screenings performed on Bryan ISD students.

Along with the town hall meeting, we informed parents of the ECG screens in other ways. This included using local media outlets, Bryan ISD Web sites, and flyers distributed to all campuses for display around athletic facilities.

Because most of the student-athletes we work with are minors, consent forms were required prior to the ECGs being performed. Cypress ECG helped in this area, sending us an informational handout with a consent form at the bottom that the student-athlete could bring with him or her on the day of the test. Approximately two weeks prior to the screenings, this information was sent home with the student-athletes who planned to attend.

On the day designated for Bryan ISD's annual preparticipation physicals, a team from Cypress ECG arrived on our campus with all the necessary equipment in tow. The student-athletes signed in at a table in the hallway outside the exam room, and if they had a consent form, they submitted it at this time. If not, a form was provided for parents to complete on the spot. Students entered the exam room individually, were set up, and the ECG was administered. The wait time was only three or four minutes between exams, there was never a long line, and no concerns were voiced.

Approximately one week later, we received an e-mail from Cypress ECG containing all results, including detailed information on three individual tests that suggested a follow-up. Those three students and their parents were given a copy of their ECG, along with a brief summary and explanation of the findings. They were told that while they were welcome to follow up with a cardiologist at the Cypress group, they also could call their primary care physician to get a referral to a local cardiologist. The test results were noted in the students' files and further clearance was required prior to participation the following school year.

Since that tough day back in 2011, we have learned a lot about cardiac arrest in athletes. While the event was most significant for David, it was a life-changer for us, too. We are now committed to offering ECGs and are convinced they can be a very effective tool in preventing unnecessary cardiac health risks to young student-athletes.


Leading the Way

By Patrick Jenkins

Patrick Jenkins, MA, ATC, LAT, NASM-CES, has been Head Athletic Trainer at the University of Washington since 2005, after serving as Assistant Athletic Trainer at UW for four years. He can be reached at: [email protected].


While it is a topic of ongoing debate, screening athletes for cardiac abnormalities is not currently endorsed by the medical community in the United States. The risks for cardiac death are low and the cost of screening is fairly high.

But that doesn't mean you should not consider implementing cardiovascular screening for your athletes. Here at the University of Washington, we have spent the last decade debating and eventually putting into place a mandatory screening protocol for all our student-athletes. The process started with a challenge, continued with asking and answering questions, and has resulted in important findings.

Our story begins in 2004, when our Team Physician for Men's Basketball, Jonathan Drezner, MD, pushed us to rethink the status quo. A leader in the education and prevention of sudden cardiac related deaths in athletes, Dr. Drezner proposed a baseline cardiac screen for UW student-athletes.

This was initially met with resistance from fellow physicians and athletic trainers. What if we had to tell someone their athletic career was done? No one wanted the task of looking an athlete in the eye and saying they could no longer participate. We also balked at the costs and reported problems with false positives.

But Dr. Drezner did not back down. He steadfastly presented more and more compelling evidence that showed today's baseline ECG screening does an excellent job at identifying athletes with at-risk conditions and using this tool could reduce the number of sudden cardiac deaths.

I distinctly remember when he said this: "Often, the first sign of a potentially fatal cardiac condition is sudden death." Immediately I flashed back to 2002, when a women's basketball athlete went into sudden cardiac arrest. She was at home with her teammates, who fortunately knew CPR and administered it until EMS arrived. They saved her life and after the incident, she had an internal defibrillator implanted.

Had her teammates not been in the same room with her, the outcome may have been different. Despite all of our athletic department emergency action plans, AEDs, and CPR-trained health care providers, we could have lost this student-athlete because we didn't even know she was at risk. Dr. Drezner's arguments, taking me back to this incident, convinced me we had to strengthen our preparticipation screening procedures. Eventually, others in our sports medicine department agreed.

We began performing baseline ECG screenings during preparticipation exams (PPEs) on all student-athletes in 2009, with the primary objective of finding silent but potentially deadly cardiac disorders. These include hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy, left ventricular non-compaction, Long QT syndrome, Wolff-Parkinson-White syndrome (WPW), and myocarditis.

MANY QUESTIONS
Our sports medicine team had a long list of questions prior to implementing a baseline ECG screening program, however. We knew the roadblocks that lay ahead--costs, follow-up testing, tough discussions--and wanted to clear them before we hooked our first athlete up to an ECG. Here are some of the questions we addressed:

Should these screens be conducted annually or just during the initial PPE?
We decided that for most of our athletes, one ECG was sufficient. However, men's basketball players are screened annually as they have shown to be the highest risk group for sudden cardiac death. A recent study led by UW Team Physician Kim Harmon, MD, found the incidence of sudden cardiac death in NCAA student-athletes is 1 in 43,770, but is 1 in 3,100 for NCAA Division I men's basketball players.

What are the costs?
How can you weigh the value of a young life compared to the expense of an ECG? You will never be able to justify costs or procedural hassles if an athlete dies under your watch. However, we still needed to get a handle on expenses in order to present our proposal to the athletic department.

Here's how we saw it: In 2009, the NCAA Catastrophic Injury Insurance Program (CIIP) deductible was $75,000 and a potential lawsuit for the preventable death of a student-athlete had an unknown but presumably large expense. In comparison, the total cost to implement baseline ECG screens in the first year of the program was an estimated $12,000. Expenses included $5,000 for the ECG machine and $7,000 for cardiology over-reads for around 500 student-athletes. There is also a small expense for disposable pads. In future years, the total expense was estimated at $2,100 annually since there would be fewer athletes tested and the equipment would already be purchased.

With these estimated annual costs, it would take 35 years of baseline screening, or 5,357 athletes tested, to equal the deductible of one CIIP claim. With today's $90,000 CIIP deductible, it would take approximately 43 years, or 6,428 athletes, to balance out. Just think about that for a second. Four decades of screening compared to one CIIP deductible. We asked the athletic administrative team: Aren't the ECG costs worth it from a risk management perspective?

We also made it clear to the administration that there are additional expenses associated with positive findings. Follow-up testing, which usually includes an echocardiogram or stress ECG and is not normally covered by insurance, typically costs an additional $2,000, and we estimated four student-athletes might require such testing per year. The false positive rate of ECGs is three percent, which means sometimes the follow-up work would show the athlete was fine. We would have to be okay with spending a lot of money even if there was no problem.

How would findings be interpreted?
Athletes' hearts undergo many physiologic changes related to regular training and exercise that can look like abnormalities on an ECG. These changes must be distinguished from ECG findings associated with a pathologic cardiac condition. After several meetings between our team physicians and cardiology consultants reviewing the available evidence, our medical team defined the ECG criteria that would be used to classify an ECG as "normal" (no further evaluation needed) or "abnormal" (further evaluation needed).

How would we conduct the testing?
We decided that the ECGs, which take less than five minutes per athlete to administer, would be integrated into the vitals portion of our athletes' physicals, which they undergo prior to seeing our team physicians. The ECG is not optional and is considered an essential part of the PPE.

To make the process run as efficiently as possible we have certified athletic trainers taught to set up and administer the ECG. Prior to starting testing, we arranged several training sessions with an ECG technician from the UW Medicine Regional Heart Center so we could learn lead placement, patient data entry, and data transmittal processes.

After each ECG, a printout is available immediately and read on-site by our team physician. The data are also transmitted electronically to a sports cardiology team, assembled by Dr. Drezner, at the UW Medicine Regional Heart Center where they are over-read using the Seattle Criteria, which accounts for routine ECG abnormalities commonly found in athletes' hearts. These criteria significantly reduce the number of false positives. The over-read happens within 24 to 48 hours of the initial test and results are relayed to team physicians through Dr. Drezner.

A nice feature of the electronic over-read is that the patient data and interpretation both end up in the student-athlete's electronic medical record. This allows our team physicians access from any secure computer in the UW Medicine system.

What steps would follow a positive test?
When putting 500 athletes through ECGs, we knew there would be positive findings, both false and real, and we needed to be prepared to deal with them. Along with cost, such tests involve time and emotional energy.

We began by exploring a relationship with the UW Medicine Regional Heart Center, asking them questions about their process, availability, affordability, and willingness to expedite the relatively urgent nature of student-athlete assessment. They were open to working with us and we reached a reasonable follow-up scheduling timeline of 24 to 48 hours.

One of the greatest challenges to the baseline ECG screening program is that we typically perform our PPE the day of or the day before practices begin, as most institutions do. This does not leave a lot of wiggle room to complete any follow-up testing necessary for positive ECG findings, and we all know coaches and student-athletes want the test scheduled yesterday! Needless to say, a positive finding can take an otherwise healthy student athlete, excited sport coach, and nervous parent by surprise.

In the case of a positive test, we immediately call the UW Medicine Regional Heart Center and ask them to expedite the follow-up testing. We explain to the athlete and coach that finding out the reasons for the abnormal ECG is critical before allowing the athlete to practice or compete.

RESULTS
Since implementing the baseline ECG screening program we have had several positive findings each year. The most common diagnosis has been Wolff-Parkinson-White syndrome, but there have been others. Our toughest finding was a men's basketball player who had participated the previous two seasons but was found to have hypertrophic cardiomyopathy (HCM) in 2009.

The case was particularly difficult because this athlete had to sit out his freshman year due to a lower leg injury that required surgery. As a redshirt freshman, he participated without symptoms and was looking like he could be a regular contributor to the team. But the ECG screening during his annual health exam between his redshirt freshman and sophomore years suggested something was not right with his heart.

A follow-up cardiac echo was ordered for further investigation, which showed an abnormality. A cardiac MRI was conducted to confirm and better characterize what appeared to be pathologic and asymmetrical hypertrophy. After reviewing the results with the sports cardiology team, it was confirmed that this athlete had HCM. Gulp. This was our first experience with the conversation we all dreaded.

In the following days, we circled the proverbial wagons and arranged a meeting with the head coach, the athlete, and his mother to deliver the news. It was important that we had already established a department policy. With this or any other life-threatening diagnosis (where the risk cannot be adequately mitigated by medical management), the student-athlete is not permitted to participate in athletics at the University of Washington. It was tempting to be sympathetic with the coach, athlete, and parent and let the athlete play--after all that's what he came to UW to do. But when presented with the potential reality of sudden death, cooler heads prevailed.

As unfortunate as situations like this may seem, we avoided a potential catastrophe for the player and his family as well as the team. The athlete demonstrated immense character and strength in handling his diagnosis.

COME ABOARD
I would encourage all athletic departments to examine the idea of cardiac screenings for their athletes. Funding can be a challenge, but there are ways to negotiate deals with local medical centers and physician offices. And there are several organizations that can help such as the Nick of Time Foundation or Parent Heart Watch.

In addition, the NCAA is currently offering institutions the chance to test athletes for free as part of a study to understand findings, challenges, and costs of ECG screening. We helped pilot the procedural steps for the study and are participating in it. Currently 24 institutions have signed up and so far, the study has found three percent of athletes have an ECG abnormality requiring further work-up. In addition, 1 in 300 athletes have been found to have a cardiac disorder associated with SCD.

Cardiac screening is now a mainstay at the University of Washington, but it was important we figured out the logistics first. Essential components to a successful ECG screening program are that physicians and athletic trainers are in agreement to screen, interpretation standards have been agreed upon by the sports medicine and cardiology team responsible for ECG over-reads, and secondary investigations can be conducted quickly. Possibly most critical is also having a plan in place for those unfortunate--yet also fortunate--findings of a heart abnormality.


The author would like to thank Jonathan Drezner, MD, Team Physician for Men's Basketball at the University of Washington and Immediate Past President of the American Medical Society for Sports Medicine, who assisted with this article. For information on participating in the NCAA study, Dr. Drezner can be contacted at: [email protected]
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