Jan 29, 2015
Heart of the Issue

By Greg Scholand

This week’s tragic death of 22-year-old Spanish soccer player Antonio Puerta, who collapsed during a match and died in a hospital three days later, provides the latest grim reminder of athletes’ susceptibility to heart failure. As fall high school and college sports get underway and the NFL, NHL, and NBA seasons are just around the corner, it’s something sports medicine professionals at all levels should be thinking about.

Immediately after Puerta’s death, Jiri Dvorak, the Chief Medical Officer for FIFA (the international soccer governing body), publicly called for more heart screenings across the entire soccer world.

Dvorak was instrumental in implementing mandatory cardiac screenings for the first time at the 2006 World Cup. While he admitted that not every potential problem can be identified, he said the value of such screenings is clear. His warning was reported in the British Daily Telegraph:

“There are one thousand sudden cardiac deaths a year in sport. It is occuring [sic] due to different underlying diseases. If someone is going into top professional sport and even in a recreational high profile sport, you need to be cautious and take appropriate preparation. We have one country in Europe – Italy – where this screening is routinely done, and there are less cardiac arrests in sport there. You can’t pick up everything, but you can reduce the risk factors.”

On our side of the pond, the issue of cardiac screenings for sports participants seems to pop up every time there’s a heart-related tragedy involving athletics. Maryland’s Bowie Blade ran a lengthy article on the subject this week, in which Dr. Stephanie Jacobs, a heart specialist at Maryland-based Cardiology Associates, discussed some of the most common heart ailments that can plague athletes:

“There are some structural abnormalities of the heart, hereditary things such as hypertrophic cardiomyopathy, a condition where the heart muscle is thicker than it should be and sets up an abnormal heart rhythm that accounts for about one-third of sudden athletic deaths in this country,” Jacobs said.

Another condition is arrhythmogenic right ventricular dysplasia, which is the next most common cause, followed by problems with the coronary artery that when you increase activity increases the risk factor, abnormal electrical problems that predispose you to an abnormal rhythm.

Other categories are undiagnosed carotid artery disease and congenital heart problems that people have lived with since birth.

More and more schools are instituting heart screening programs for athletes, such as this one at Milford (Mass.) High School, but they’re still far from standard practice across the country.

That begs the question: If it could save lives, what’s stopping every athletic program in the country from screening their athletes? Cost is a major issue, but it’s not the only one. Even with the most sophisticated tests, there’s the problem of false positives–a screening with a very high accuracy rate will still flag athletes who are perfectly healthy. (For a technical explanation of how a test’s accuracy rate can be deceiving when it comes to false positives, click here to read about Bayes’ Theorem.)

And whether a positive screening result is accurate or not, it can force young athletes, their parents, and their school’s athletic program to make a difficult decision: Are the benefits of athletic participation worth the risk? A few years ago, Training & Conditioning looked at that dilemma, as well as the cost issue, in an article on heart-related issues in athletics:

“In times of limited budgets and limited resources, I’m concerned that if people start doing EKGs and echocardiograms, it will become the standard of care,” says Michael Koester, MD, FAAP, ATC, CSCS, Primary Care Sports Medicine Fellow at Vanderbilt University. “Parents will think, ‘They’re doing this at that school, why aren’t they doing it at my kids’ school?’

“There’s no single test that we can do that will prevent every case of sudden cardiac death, and my biggest concern is the high rate of false positives,” he continues. “Even if you had a test that was close to perfect, you’re going to get thousands of kids who are going to test false positive. And what do you do with those kids? You can tell the parents the kid may be at risk of sudden cardiac death, then they go through test after test only to conclude that the kids is at a risk that is difficult to quantify.

“Or after scaring them half to death, you tell them, ‘Nope, that was a false positive and they aren’t at risk of dying suddenly during athletic participation.’ How much does that weigh on the parents, along with the financial cost of having to do more referrals?”

Greg Scholand is an Assistant Editor at Training & Conditioning.

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