To Prevent Sudden Death in Student Athletes, Look Beyond the ECG

The approach to screening young athletes and measuring the potential risk of sudden death is an important issue that could mean the difference between an adolescent reaching his or her potential in competitive sports — or perhaps being disqualified for play.

That’s a message at the heart of a talk pediatric cardiologist Kenneth Zahka, MD, is delivering this week at Cleveland Clinic Children’s Pediatric Innovation Summit at the Global Center for Health Innovation in downtown Cleveland.

His presentation, “Sports Clearance: What Do I Need to Know?” is part of the Annual Helen and Ronald Ross Symposium on Pediatric Cardiology at the start of the summit on June 11.

Sudden death in young people: Getting a proper perspective on risk

Sudden death in young athletes has attracted a great deal of interest, leading to calls for mandatory pre-participation screening guidelines.

That, in turn, has led to debate about the most effective and practical methods for diagnosing a wide array of cardiovascular diseases known to cause sudden death, including the following leading causes:

• Hypertrophic cardiomyopathy
• Coronary artery anomalies
• Indeterminate left ventricular hypertrophy
• Myocarditis
• Arrhythmogenic right ventricular cardiomyopathy
• Mitral valve prolapse

This heightened interest has also raised concerns about screenings being exclusionary and discriminatory since most sudden deaths due to genetic disease are in nonathletes.

Dr. Zahka points out that recent data show the risk of sudden death in U.S. college athletes attributable to cardiovascular disease to be relatively low (1.2/100,000 athlete participation-years) and similar to the combined risk of suicide and death from drug abuse. And among causes of sudden death for all 15- to 24-year-olds in the U.S. population, major cardiovascular diseases rank fifth, after motor vehicle accidents, homicides, suicides and cancer.

Sorting out the screening options — and the role of ECG

There are several different approaches to screening young athletes for risk of sudden death from cardiovascular causes, including:

• Not screening anyone
• Screening everyone through family history and physical exam
• Screening with careful family history, physical exam and electrocardiography (ECG)

While ECG can detect some cardiovascular diseases and benefit some individuals, it is not considered an ideal or effective test when applied to large, healthy populations, according to statements from the American Heart Association (AHA) and the American College of Cardiology (ACC).

“When you look at the data and at the recent recommendations from the AHA and ACC, it comes down to the notion that we should do a family history, a personal history and a physical exam as the core basis of our screening,” Dr. Zahka says. “The ECG does not add significantly to the identification and protection of the student athlete.”

He also warns that there is a high false-positive rate for ECG, which can disqualify a number of individuals from competitive sports. “There is a very low mortality risk in general,” he notes. “We need to be careful about how we decide. Doing an ECG separate from a clinical assessment and history has a lot of potential for raising a false-positive concern.”

The general public is subject to the same diseases and anomalies that can cause sudden cardiac death or heart failure in athletes, he adds.

Dr. Zahka says the sports medicine team at Cleveland Clinic worked through all the data and made a recommendation that supports the AHA and ACC recommendations — i.e., that ECGs are not going to be helpful in most young athletes.

For asymptomatic young athletes in whom the history and physical exam do prompt the need for further evaluation, unique skills and expertise — often from a multidisciplinary team — are required to identify the appropriate tests. At Cleveland Clinic’s Sports Cardiology Center, the health of athletes of all ages is the focus of multiple adult-care and pediatric specialists, including cardiologists, cardiothoracic surgeons, exercise physiologists, sports pulmonologists, dietitians and psychologists.

Recommendations that promise greater impact

Dr. Zahka notes that the AHA and ACC recommend promoting development of team-based care at schools that involves athletic trainers, team physicians, school nurses, primary care providers, cardiologists and cardiac subspecialists. The recommendations also call for educating athletes, coaches and front-line providers on the warning signs and symptoms of sudden cardiac arrest.

“We should focus on the training of staff in the schools and everywhere for high-quality CPR and the availability of automated external defibrillators (AEDs),” he says. “Those two things have saved many more lives.”