COMMENTARY

Back-to-School Athletic Screening: Yea or Nay?

Michael J Ackerman, MD, PhD; Frank Cetta, MD

Disclosures

August 24, 2015

Editorial Collaboration

Medscape &

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Frank Cetta, MD: Greetings! I'm Frank Cetta. I'm the chair of the division of pediatric cardiology at the Mayo Clinic. On Medscape this morning, we're bringing you an interesting topic related to going back to school.

Summer is in full swing, children are going back to school, and questions come up about what kind of screening they need before participating in sports.

Joining me today is my colleague in pediatric cardiology, Dr Michael Ackerman, who is a world-renowned expert in the assessment of children and young adults for possibilities of sudden death. He's the head of the [Sudden Death Genomics Laboratory] here at Mayo. Welcome, Mike.

Michael Ackerman, MD, PhD: Thanks a lot, Frank. Great to be here.

Dr Cetta: Mike, this is an area of great controversy in the United States. Programs in Europe are fairly well established for screening children prior to attending school. What do you think about the status of US programs? We see it done on an ad hoc basis in some communities where there's ECG screening or echo screening. Maybe we should just start from the beginning: What's probably the most important thing to start with in programs?

To Screen or Not to Screen

Dr Ackerman: The issue is, of course we should be doing [sudden cardiac death screening], but then we look under the hood and say, "Well, wait a second." I think that's the dilemma.

We make sudden-death screening sound as if we're screening for a single heart condition that causes sudden death. But what we're really talking about one or two dozen discrete heart conditions that can culminate in sudden death for which the same screening strategy may not work.

Dr Cetta: Right.

Dr Ackerman: The Italians do it.[1] They're probably the best example. But it's not simple or straightforward. There are a lot of issues that one has to dissect if we're going to do it right, and I'm not sure we're there yet.

You could say, "Of course we should screen, because these conditions cause sudden death. Sudden death is an awful thing to happen. We would like to prevent that." And most of the conditions we're talking about screening for are highly treatable conditions.

In that sense, of course we should. It affects one in 80,000 people; one in 100,000 kids will die suddenly each year.[2] Thankfully, that's rare, but should we be screening for those conditions? Why are we not doing what Italy does? You and I have talked about some of the "why nots."

Dr Cetta: Right. It's an emotionally, highly charged issue when a young athlete goes down suddenly on the soccer field or the football field during summer practice or two-a-days for football. The local media is all over it. It is highly charged, obviously, for the families. It's an incredibly tragic event.

What do you think is the most important aspect of this? Should you have an ECG, should you have an [echocardiogram], should you do treadmill testing, should you have all three or two of the three? Where should we start with this? And what are the basics?

Basic Elements of Sudden Death Screening

Dr Ackerman: When you talk in general about a screening program, it starts with the 12-lead ECG. But even that is insufficient for some conditions, such as a coronary artery anomaly, which will never be detected by an ECG.

It's also unclear when to do the ECG. Do we do it right out of the gate, for newborns? That would be a great idea for long-QT syndrome. It would be a terrible idea for hypertrophic cardiomyopathy.

Even the ECG—which has been rolled out in various communities—has stumbling blocks. One concern about ECG screening programs is that there's very little guidance. It's a bit of the Wild West. What do you flag? When do you flag it? How long of a QT interval? What about the T waves? What about a Q wave? When?

We're now starting to receive guidance (for example, the Seattle ECG Criteria, which we've now generated a second version of) as to the fouls, the penalty flags that we'll toss. There's been a greater sensitivity to the dark side of the screening, which is the false positives.

What we see here at Mayo are the false positives.

Dr Cetta: Exactly.

Dr Ackerman: Nobody really talks about that. It's sobering to pause and think about the cost and the energy to remove a diagnosis when the penalty flag has been raised because of a screening ECG finding. Nobody talks about how difficult it is to pick up the flag.

Dr Cetta: I agree. Also, before we get to any type of testing, awareness about family history (via the primary-care physician) is key. That's the best starting point in any of these screening programs. Knowing the family history is a fairly good way to catch some of these things ahead of time.

I agree with you completely. With the ECG, we don't know how many adolescents have been screened and labeled as normal, yet they go on to have an event. We don't have data on that. We have more data about the false-positive [patients], who may have had previous abnormal ECGs or heart surgery.

Dr Ackerman: Right. The point you made about the family history is huge. We and others have published data showing that, in about half of all of the sudden deaths that occur in young people, there was a legitimate warning sign before the sudden death.[4]

That warning sign has usually been one of two things: either a personal warning ("I fainted suddenly during exercise" or "I had sudden exertional chest pain"); or a legitimate warning sign in the family tree of unexplained sudden death. If we acted on the warning signs, we could, in theory, decrease half of sudden deaths.

Now the other half, where the death is truly the sentinel event, we only have two options. We either screen for those or we have a postevent reaction.

The post–sudden death reaction plan would entail the physician community getting more active in setting expectations. Wouldn't it be great if every high school kid needed to do CPR as a high school graduation requirement? Or we get automated external defibrillators (AEDs) in the public square? So, for that athlete, artist—whoever goes down, whatever their tagline is—there's a chance to revive them successfully.

The Need to Target Individual Diseases

Dr Cetta: True. Public access to AEDs has probably made a big impact on this whole area.

As we close, I think one comment, maybe, about echo: We see more echo screening occurring because we have these small portable machines. There's some that are the size of a cell phone.

There are limits to them. Many of us in the echo community have always felt that if echocardiograms took 5 minutes to do, cost $5, and were reproducible from operator to operator, they would be a great way to perform universal screening. But we know we're not meeting any of those criteria yet.

Obviously, echo can help screen for cardiomyopathies. On the fly, looking for coronary anomalies, [they are] much more variable and need much more experienced operators to do that.

There are limits to echo screening, but we know there are a lot of programs around the country that involve good history taking, ECG, and a limited echo. Those seem to be propagating more in the school systems. I think we're in the "let's start gathering some data on these things" stage.

Dr Ackerman: I think the way forward is, we need to stop talking about presports screening for sudden death and start talking about individual diseases that cause sudden death. We should ask the questions: Is that disease worth screening for? Are we there yet? Do we have it right yet?

When we lump the conditions together, we're missing the point that the same strategy for screening won't work for each. For long-QT syndrome, we are at a point where we could advocate for universal screening.

That's the other point: If these conditions are worthy of screening, they're worthy of screening in all children, not just those who happen to be on the basketball court.

Dr Cetta: That's a great point. Thanks, Mike. I think these are great insights, great conversation. We'd like to thank those viewers who tuned into Mayo Clinic at theheart.org on Medscape to review this. Thank you.

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