UK Soccer Study Reignites Debate Over Cardiac Screening in Kids

Patrice Wendling

August 10, 2018

A new study of cardiac screening in adolescent English soccer players identified a threefold higher death rate than previously estimated, inviting praise as a landmark paper and at the same time rekindling concerns that screening programs don't save lives.

"I do fear a little bit that this study could be just the ammunition that the AHA [American Heart Association] requires to say that screening is an absolute waste of time, but I'm hoping it would be perceived in a slightly different way," senior author Sanjay Sharma, MD, St. George's University of London, United Kingdom, told theheart.org | Medscape Cardiology.

The data show for the first time an incidence of sudden cardiac death (SCD) of 1 case per 14,794 athlete-years, or 6.8 per 100,000 athletes. Previous reports have suggested an incidence of 1 in 50,000 to 1 in 200,000.

"I agree that 1 in 14,700 is not a lot, but it's far, far more than the 1 in 200,000 that the AHA points out," he said.

"The second point is that of the 42 athletes that actually had serious conditions, only 3 had symptoms, ie, 7%. So if we were going to be using the AHA recommendations, we'd have missed practically all of them."

The AHA/American College of Cardiology (ACC) recommend family history, physical examination, and other parts of a 14-point questionnaire to screen young people, age 12 to 25 years, for congenital and genetic heart disease, but they also say there isn't enough evidence that mandated screening of athletes or other youngsters with 12-lead electrocardiography (ECG) saves lives.

The English Football Association, however, mandated cardiac screening for all adolescent players as early as 1997. The 11,168 athletes  (mean age 16.4 years) in the study were screened from 1996 through 2016 with a health questionnaire, physical exam, 12-lead ECG, and echocardiography —  with the results reviewed by a cardiologist with expertise in cardiovascular adaptation in the athlete.

Nevertheless, during a follow-up period of 118.351 person-years, there were 23 deaths, of which 8 (35%) were from cardiovascular disease. Moreover, the screening result was normal in 6 of the 8 sudden cardiac deaths, according to the study, published July 8 in the New England Journal of Medicine.

"You're absolutely right, of the eight people that died, six had normal screens and we wouldn't have been able to pick them up, but let's look at the positives," says Sharma, who is also chair of the expert cardiac consensus group for the English Football Association.

Among the 42 people (0.38%) identified as having conditions that could cause SCD, 26 had the Wolff-Parkinson-White ECG pattern and could be ablated, 2 people had anomalous coronary arteries that could be operated on, and 2 people had serious valvular abnormalities that were also surgically corrected.

"So 70% of people who were picked up and treated actually went back to sport," he said. "We diagnosed hypertrophic cardiomyopathy in 2 out of the 42 people I've alluded to and we advised them not to compete, but they continued and died as a result of it."

"I think you'll agree there is nothing normal about a 16-year-old person dying."

Commenting for theheart.org | Medscape Cardiology, Kimberly G. Harmon, MD, University of Washington, Seattle, said, "Methodologically, this is the best article on the topic that's come out, ever. This is a landmark article. They screened over 20 years, they screened 11,000 athletes, and were able to follow them to see if they died or not."

"One of the takeaway points is that screening once at age 16 is not enough. This really points out the need for serial screening" because "sometimes cardiomyopathy doesn't manifest until people are older," she said.

As a result of data like these, Harmon said the University of Washington has changed its policy to screen athletes every 2 years, beginning at entrance.

The English Football Association has taken a similar step and "will now screen players again at 18, 20, and 25 years old," Sharma said.

Chair of the ACC's Sports and Exercise section, Matthew W. Martinez, MD, Lehigh Valley Health Network, Lehigh, Pennsylvania, said in an interview, "This is the most comprehensive study we've seen in terms of an aggressive work-up using all of the modalities," but it also shows how difficult it is to set up "a complete one-stop shop" to evaluate athletes.

"Even if you do an electrocardiogram, there are still going to be missed diagnoses, and even if you do an echo on top of that, this study again confirms there are still going to be things we miss," he said. "At this point in time, I would not think that adding an electrocardiogram and/or an echocardiogram is going to be enough to change the current guidelines published by the American Heart Association and ACC. I don't think this single study is enough to change that."

Martinez pointed out that images in the study were reviewed by experts and highlighted the need for more education in this area, such as the ACC's yearly Care of the Athletic Heart event.

"I don't think there will ever be an accreditation process for the quote, 'sports cardiologist,' but maintaining a high level of expertise and understanding is an ongoing process for the athlete assessor, as well as the athlete," he said. "One can't say, 'I'm a cardiologist, I can interpret these ECGs.' Because they're different."

Commenting on the study, long-time opponent of mandatory screening for athletes, Benjamin Levine, MD, University of Texas Southwestern Medical Center, in Dallas, said, "This is as good as it's ever going to get, that's important."

"The major take-home point is that I have no idea whether the procedures that were done helped anybody, and my fear is that if this kind of screening process is used to justify mandatory screening across the United States, huge numbers of people will be hurt," he added.

"The chances of this high level of expert care and management would be very difficult to do on the large scale of the American population."

Rare but Costly?

SCD is often thought to be a relatively rare event, but Harmon argued this may be because incidence data in the United States are very poor.

Data from National Collegiate Athletic Association (NCAA) athletes, which she said are among the best available in the United States, show that SCD rates in NCAA basketball players are consistent with those in the UK soccer players. A 10-year review of NCAA deaths, by Harmon and colleagues, also found that SCD rates were higher in males than females and in black athletes than white athletes.

"The incidence of sudden cardiac death in our white soccer players was 1 in 25,000, but the incidence of sudden cardiac death in black players was 1 in 4,000 — so it was sixfold higher," said Sharma.

"Because the black population only made up 5% of our soccer players, the New England [Journal] really didn't want us to focus on the ethnic differences, but we're quite concerned about this statistic," he said. "We want to look more into the black athlete's heart and work out electrical patterns that may identify those that may be at particular risk of sudden death."

One of the biggest arguments against any kind of widespread screening, rather than targeting at-risk populations, is cost. The investigators estimate that screening the 11,168 athletes cost $3.8 million plus $499,531 in further investigating 830 athletes — for a total outlay of $4.3 million.

The cost to pick up a serious cardiac condition that could potentially cause SCD was $102,782 per case and $16,167 per case to identify any cardiac disorder.

"If we actually looked at quality annual life-years, I'm sure the Americans would charge more, but our government is prepared to say they will spend £30,000 per quality of annual life-year saved," Sharma said. "Thereby intervening in these individuals — and I'll remind you it cost us about $102,000 per case that we diagnosed —  we probably gave those individuals back 5 or 6 decades of life."

"And when I say it like that, it seems like a no-brainer."

Anything under $50,000 per quality life-year saved generally is considered cost-effective in public health data, said Harmon. She argued that use of history and physical exam is not cost-effective in preventing SCD and that savings could be had using ECG alone, which cost $33 in the study and would be about $25 under Medicare rates.

"The false-positive rate [for ECG] with the new international athlete-specific guidelines that came out about a year ago is about 2%, which is great for a screening test," she said. "The echo found things the ECG wouldn't have found, like the coronary artery anomalies and the dilated aorta, but it also found a lot of the nonlethal things."

"So if I was really looking at this from just a cost-effectiveness standpoint, I'd say forget the history and physical — just do the ECG," she said.

"I think the sports physical — and it's totally my opinion — should be done in a primary care provider's office and a cardiovascular screen should be added to the well-child exam," Harmon added.

Levine agreed that "the standard history and physical done in the US to clear people to participate in sports is frankly quite inefficient," and said "it's hard to argue" with universal well-child ECG screening exclusively to identify electrical diseases.

Later this year, his team will report on a study recently completed at North Texas schools, in which athletes as well as marching band members were randomly assigned to history or physical exam alone or with ECG.

"I'm not advocating for every child in America to have an electrocardiogram, but if ECG screening to detect electrical diseases is ultimately mandated or imposed on American families, then it's not just athletes who should benefit from that," but all children.

The research was funded by the English Football Association, Cardiac Risk in the Young (to Malhotra and Dhutia), and the Charles Wolfson Charitable Trust (to Finocchiaro). Martinez disclosed working for Major League Soccer. Harmon and Levine reported no relevant financial disclosures.

N Engl J Med. 2018;379:524-534. Abstract

Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.

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