{"id":28681,"date":"2012-05-02T16:20:06","date_gmt":"2012-05-02T20:20:06","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=28681"},"modified":"2012-05-02T16:38:27","modified_gmt":"2012-05-02T20:38:27","slug":"half-the-news-thats-fit-to-print-ny-times-on-ecg-screening-for-student-athletes","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2012\/05\/02\/half-the-news-thats-fit-to-print-ny-times-on-ecg-screening-for-student-athletes\/","title":{"rendered":"Half the News That’s Fit To Print: NY Times on ECG Screening for Student Athletes"},"content":{"rendered":"

There may be no more horrifying medical catastrophe than the sudden death of a young athlete on the playing field in front of a large crowd of friends, family, and community. But it’s also a dizzyingly complex subject with no easy solutions. Experts are divided. The American Heart Association recently reaffirmed that it does not<\/em>\u00a0recommend universal screening for potential cardiovascular disease with electrocardiograms (ECGs) in young athletes. On the other hand, universal screening has been adopted, apparently successfully, in Italy.<\/p>\n

According to\u00a0Anahad O\u2019Connor in the\u00a0New York Times<\/em><\/a>, however, the movement toward routine ECG screening for student athletes may be inexorable, as it is not just cost-effective but also desirable from a medical and a societal perspective. The\u00a0Times<\/em> article states that sudden cardiac death (SCD) of young athletes \u201cis far more prevalent\u2026 than previously believed.\u201d\u00a0About 2000 children each year die from SCD, according to the American Academy of Pediatrics, as cited by the\u00a0Times,\u00a0<\/em>but this includes\u00a0all\u00a0<\/em>children, not just athletes. The\u00a0Times\u00a0<\/em>quotes\u00a0the mother of a young athlete who died: \u201cthis happens all the time.\u201d<\/p>\n

But the world’s leading expert on SCD, Barry Maron, of the Minneapolis Heart Institute, insists that there has been no noticeable change in prevalence, and that SCD in children\u2013 whether athletes or not\u2013 is a rare event. \u00a0\u201cThe peer-reviewed data on this topic suggest that there are about 75 sudden cardiovascular deaths in competitive athletes every year in the U.S.,\u201d he told me in an interview. (The\u00a0Times<\/em>\u00a0article is similarly dizzy about the cost of an ECG test. Although medical costs are always a byzantine topic, the $1400 cost cited in the article is preposterous. Move the decimal point one place: $140 is a lot closer to reality.)<\/p>\n

O\u2019Connor acknowledges that the AHA does not recommend universal screening, but argues that the position \u201cpivots on old data.\u201d He cites\u00a0a 2010 study from Stanford published in the <\/a>Annals of Internal Medicine<\/a>\u00a0<\/em>suggesting that ECG screening may be cost-effective, but doesn\u2019t cite\u00a0an accompanying article in the same issue<\/a>\u00a0that reached a much less positive conclusion. Also not mentioned is\u00a0an editorial accompanying the articles<\/a>, written by Maron himself, offering a number of reasons why widespread ECG \u00a0screening should not be widely adopted at this time. (Click here for my previous coverage of the\u00a0Annals<\/em>\u00a0articles.<\/a>)<\/p>\n

Even the Stanford author tells the\u00a0Times\u00a0<\/em>that \u201cwe are not advocating this as a mandatory test for all students or all athletes,\u201d but the article moves on to quote another expert who thinks \u201cthe time has come for thorough heart screenings for all young athletes.\u201d James Willerson, of the Texas Heart Institute, told O\u2019Connor: \u201cIf we save even one life, it will be worth it.\u201d But Willerson, who had a distinguished career as a cardiology thought leader, is not an expert in SCD, and has an important conflict of interest in this case. As mentioned in the\u00a0Times<\/em>\u00a0article, Willerson has a $5 million private grant to screen\u00a010,000 students in Houston middle schools.<\/p>\n

In his interview with me, Maron offered a far more balanced perspective. He acknowledged that \u201ceach of these deaths is greatly tragic, and it is never the intention to minimize it by citing numbers, however large and however small. Furthermore,\u201d he continued, \u201cno one would ever feel comfortable placing a monetary value on a young athlete\u2019s life.\u201d<\/p>\n

Maron spoke about the limitations that most cardiologists, Willerson aside, understand about ECGs. The test is far from perfect. There are false-negative and false-positive results, and these need to be considered when evaluating the test. The high rate of false negatives associated with the ECG means that \u201cin a significant proportion of the screened population important diseases would be expected to be missed,\u201d said Maron. \u201cThis limitation is not even mentioned in the [Times]\u00a0<\/em>article.\u201d False positives are also important, Maron observed, \u201cbecause they create the possibility of unwarranted disqualification from sports as well as substantial anxiety among the families and participants.\u201d<\/p>\n

Another cardiologist,\u00a0electrophysiologist Wes Fisher<\/a>, talked about false positives in more graphic terms:<\/p>\n

The psychological and emotional toll of telling a young student athlete that they can no longer participate in sports\u2026 is huge. Anyone who thinks it\u2019s as easy as \u201cjust get an EKG\u201d has never had to evaluate the marginal 18-year old who\u2019s life you\u2019ll potentially\u00a0change forever.<\/p><\/blockquote>\n

Maron was also highly critical of the exclusive focus on student athletes:<\/p>\n

All this discussion about limiting preparticipation screening for the detection of potentially lethal cardiovascular disease to athlete populations does not make a lot of sense because it is exclusionary and discriminatory. More sudden deaths from these same genetic diseases occur in nonathletes, numerically speaking. Therefore it would seem most prudent to discuss screening in young people, athletes\u00a0and<\/em>\u00a0nonathletes, for these diseases. However, the numbers involved in those projected screening programs are so large that they limit any reasonable discussion of practicality.<\/p><\/blockquote>\n

According to Maron, there are about 10.7 million athletes out of a total population of 63 million children and adolescents.<\/p>\n

On the same day as the\u00a0Times<\/em>\u00a0article appeared, the AHA issued\u00a0a science advisory about screening approaches for heart disease in children and adolescents<\/a>. Once again, the AHA did not endorse mandatory screening for athletic participation. As Stuart Berger, one of the authors of the AHA statement, wrote:<\/p>\n

New screening programs, including mass ECG screening, must be based on sound and evidence-based principles rather than a reaction to catastrophic events.<\/p><\/blockquote>\n

The\u00a0Times<\/em>\u00a0article appears to be one of the first articles featured in the\u00a0Times\u00a0<\/em>new \u201cWell\u201d blog<\/a>, which is intended to bring substantially enhanced coverage of health topics onto the\u00a0Times\u2019<\/em>\u00a0website. This article does not bode well for the future of this coverage, as it falls short in so many respects.<\/p>\n","protected":false},"excerpt":{"rendered":"

A \u201cdizzy\u201d New York Times article exploring whether to screen young athletes for heart risk leaves out relevant research and exaggerates some pretty important numbers.<\/p>\n","protected":false},"author":196,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[13,7],"tags":[1089,1216,898,664,1245,897],"class_list":["post-28681","post","type-post","status-publish","format-standard","hentry","category-electrophysiology","category-prevention","tag-athletes","tag-ecg","tag-scd","tag-screening","tag-students","tag-sudden-cardiac-death"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/28681","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/196"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=28681"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/28681\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=28681"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=28681"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=28681"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}