Sports Medicine Research: In the Lab & In the Field: Getting to the Heart of the Problem: What is the Cost of Saving a Life? (Sports Med Res)


Monday, September 17, 2018

Getting to the Heart of the Problem: What is the Cost of Saving a Life?

Outcomes of Cardiac Screening in Adolescent Soccer Players

Malhotra A, Dhutia H, Finocchiaro G, Gati S, Beasley I, Clift P, Cowie C, Kenny A, Mayet J, Oxborough D, Patel K, Pieles G, Rakhit D, Ramsdale D, Shapiro L, Somauroo J, Stuart G, Varnava A, Walsh J, Yousef Z, Tome M, Papadakis M, Sharma S. N Engl J Med. 2018 Aug 9;379(6):524-534.

Take Home Message: Cardiac screening can identify some high-risk athletes, but no screening strategy is likely to be perfect.
The debate lingers about the use of cardiac screening to reduce the risk of sudden death among athletes. This debate is impaired by the lack of systematic registries, which could help estimate the incidence of sudden death and impact of screening. Malhotra and colleagues sought to determine the incidence and causes of sudden cardiac death among adolescent players in the English Football Association (soccer), which started a cardiac screening program in 1996. Between January 1996 and December 2016, a total of 11,168 elite soccer players underwent mandatory cardiovascular screening (~16 years of age; 95% males). The cardiovascular screening included a health questionnaire, physical examination, electrocardiography (ECG), and echocardiography. The expert cardiologist reviewed the results and classified an athlete as normal, needing further evaluation, and/or cardiac disease detected (i.e., hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, long-QT syndrome, Wolff-Parkinson-White).

11,168 elite soccer players screened
     830 (7%) underwent further investigation
          42 (0.4%) had a cardiac disorder related to sudden death and received intervention
               36 (86%) had abnormal ECG
          225 (2%) had other cardiac disorders (e.g., septal or valve disorders)
               48 (21%) had abnormal ECG

Deaths among athletes were acquired through voluntary reports to the Football Association, secure survey to the 92 affiliated clubs, and internet searches. Death certificates for all deceased persons in the cohort were used to establish causes of death. During the study there were 23 deaths, of which cardiac disorders accounted for 8 deaths (6 of which had normal ECG findings), and all were sudden and during exercise. Of the 42 athletes who received diagnosis of cardiac disorders associated with sudden cardiac death 40 (95%) were alive at the end of the study period. Two athletes continued to compete despite medical advice and subsequently died during intensive exercise. The cost of the preliminary screen was $342 per athlete, to detect serious cardiac disease (42 athletes) the cost was $102,782 per case, and the cost to detect any cardiac conditions (267 athletes) was $16,167 per case.

This was one of the first longitudinal studies to perform systematic cardiac screening and follow the athletes prospectively to determine outcomes. The authors found that the prevalence of disorders associated with sudden cardiac death in young athletes was ~0.4%; however, when considering other septal and valvular disorders the overall prevalence for all cardiac conditions was ~2.4%. The incidence of sudden cardiac death among previously screened athletes was ~6.8 per 100,00 athletes, which is higher than previous estimates. Out of the 7 athletes that suddenly died from cardiomyopathy, 5 (71%) had normal ECG and echocardiogram findings at ~16 years of age. Screening at this age is appropriate since most people will be postpuberertal and will have evidence of any electrical or structural abnormalities. However, this study demonstrates that ECG and echocardiogram missed some cases, which suggests that this screening method is not sensitive enough to detect early disease in some adolescents. However, it is interesting to note that of the 42 identified with cardiac disorders associated with sudden cardiac death, only the 2 that did not take medical advice succumbed to sudden cardiac death due to exercise. Out of the 267 athletes that had any cardiac condition only 6 were picked up by history, and 76 were picked up by examination alone. This study is a nice reminder that screening can identify some high-risk athletes, but no screening strategy is likely to be perfect. Ultimately, the decision to implement cardiac screening should be made by each community with stakeholders (e.g., parents, athletes, coaches, medical professionals) weighing the pros and cons of adopting cardiac screening. Medical professionals should use studies like this one to help stakeholders make an informed decision. Even if a league or school opts out of a screening program it may be beneficial for medical professionals to offer enough information for parents/athletes to make an informed decision about whether they want to independently pursue cardiac screening.

Questions for Discussion: How confident are you that your preseason health screening is effective at finding cardiac abnormalities? Would you consider adding ECG and echocardiogram into your PPE?

Written by: Jane McDevitt
Reviewed by: Jeffrey Driban

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Austeen Freeman said...

Thank you for sharing this study. This is a sensitive topic. I am a current student and the PPE's I have been involved in do not have an ECG or echocardiogram as an option. The physician's asses history and oscillations, but no other cardiac screening is done. The college I attend issues a referral for an ECG or echocardiogram if they are flagged during the history collection. After speaking with the one of the college's Athletic Trainers, they have found a relationship between physical's that are not done my the medical director or campus physician and incident rate. It may be an important policy of the school to only accept physical's done my a certain physician or by the college or university itself. An approved physician who better understands the important of cardiac screening. Saying this brings up the issue that not all physicals are the same but is a conversation we should have.

Jane McDevitt said...

That is an excellent point. Additional requirements such as an EKG may be necessary if students go outside the institution's medical system. Additionally, many school's, institutions, and programs use their own PPE form, which may not have all of the relevant questions that would help to ascertain any red flags for further testing. Ensuring an inclusive protocol with a full cardiac history and possible stipulations if they go outside the institutions network may be worth while conversations to have to update PPE policies and procedures.

Savannah Monette said...

Hello, thank you for posting this article. When I was reading through, it reminded me of a case that occurred at my college. The college I attend actually offers cardiac screenings to all student athletes, or at least has offered that in the past. A couple years ago, the extensive and thorough cardiac screening may have saved a student-athlete's life as it was discovered that he had a faulty valve, a congenital heart defect. He did not have any history of abnormal ECG's and did not have any symptoms. Had this defect gone undetected, it could have led to sudden cardiac death. With that being said, I too had this testing performed on me. Unfortunately, I was the small percentage that was found to be diagnosed with a false positive. After this "mass" that was found on cardiac imaging, I underwent a very long visit to a cardiologist and had a cardiac MRI done. After all of this, my heart was found to be completely normal with no "mass".

Thus, in most cases, I think that cardiac imaging to this extent can be beneficial but like I said, there are some downfalls like false positives and the cost. For my school, the cost was free because the external company performing the screening billed the insurance companies of the students. But what if the student does not have insurance to cover this type of screening? Therefore, this brings up the debate on what the cost is of saving a life.

Like Austeen mentioned above, many PPE's do not cover history of ECG's or echocardiograms. An athlete would only warrant a referral to have these types of tests done if they had any "red flags" in their medical history section, and that's only if the PPE form asks the right questions to detect red flags. I think that PPEs should include a cardiac specific section since sudden cardiac death is the leading cause of death in athletes. I also think there should be conversation to make revisions to PPE forms so they become universal between all healthcare providers while also asking relevant and important medical history.

Jane McDevitt said...

Thank you for sharing your cases. You really shed light on the polar extremes of what cardiac screening can do. I agree with you that we may need reassess the PPE. A cardiac specific section (maybe a more in depth mental health section would be beneficial as well) would be beneficial to determine who needs to be followed up with. In regards to your point about billing. I think this is a cause for concern. It would be difficult to say that every athlete needs an EKG when there is such a small incidence rate.

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