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Sudden Cardiac Death in Teen Athletes

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In the United States we have a set of pre athletics standards that are in place for sports physicals. Yet every year student die in cardiac related deaths. Do we adhere to the guideline adequately and do parents, coaches and students know what to watch for? Lets take a look at the literature.

Storified by · Sat, Jul 20 2013 07:47:27

Every year American students lose their lives suddenly during active sports participation.  The statistics show that as many as 1000 students die each year related to sudden cardiac death.  Tragic for families and fellow students as many of these incidents happen on the athletic field, court, rink or other sports arena.  This is exactly what happened to Wes Leonard, a 16 year old sports star for the Fennville, Michigan Blackhawks in 2011.  What Wes’s parents did not know was that his heart had doubled in size and was repeatedly being beat up while he worked out.  The night of the March 3rd, marked the best game of his career, but also became the last game of his life.

In the United States, student sports physicals are required by the Athletic Associations and students are required by district rules to get the paperwork completed to be allowed to participate in sports.  Our screening is minimal and maybe even inadequate.  In addition to minimal screening, our current process is applied in what I would describe as a population versus personal based approach, parents, students and coaches alike are often undereducated about the signs of cardiac concerns.  How can we begin to protect our students when we do not have approaches in place to screen and educate effectively up front?

High School athletes are at the greatest risk of sudden cardiac death following physical activity.  In my first research source, “Athletes at Risk for Sudden Cardiac Death” Kim Subasic reviews the inadequate current state related to standards for sports physicals.  The most common cause of sudden cardiac death in athletes is HCM, an autosomal dominant disorder effecting 1:500 person in the United States (19),  In 1996 the American Heart Association supported a public initiative to promote sports screenings.  Although the intent of the screening is to prevent injury and harm, they are guidelines and are not mandatory.  Even with support from the American College of Cardiology Foundation, the American Academy of Pediatrics, and the Council on Sports Medicine and Fitness over the past eight years the screening process is inadequate and does not require a 12 lead electrocardiogram.  What it does consist of is a series of 12 questions designed to  increase concerns specific to family and personal history related to cardiac disease.  Physical exams are only required for sports participation every 2-4 years unless the screening questions raises a positive concern.  In addition to the heart health history, the practitioner is to do a physical exam including listening for a heart murmur, checking femoral pulses, screening for Marfans syndrome and bilateral blood pressure reading. 
 Although I have been present at several of my son’s sports physicals, I do not recall anything other than a routine review of systems and physical exam.  For our family this potential became a real life screening 2 years ago when my oldest son developed a sudden onset of “stroke like” symptoms, nausea and vomiting and severe headache following an intensive day of training in the summer heat. He is a show choir student and competes each season.  Show Choir may not sound like a sport but when you consider the balance of breathing, singing and dancing for 20 plus minutes, it is easier to consider the cardiac stress of this type of competition. Look closely in the video as they try to hide being winded, during the final song of the set.

The thought of a cardiac event was not top of mind for me at the time It wasn’t until we were sitting in the ER being evaluated did I begin to see the recommendations of the true sports screening being implemented.  What we learned is that he has a severe murmur; a true “gallop” so uncommonly noted in teens in the ED that he was turned into “test” subject so staff could listen.  The good news is that after a “million dollar” workup including a TEE and bubble study, ECG, Neurology exam, CT , labs and many history reviews…he was cleared as a migraine related to dehydration.  Wow…not an event I was expecting. 
Old Abe Show Choir 2012 'Enter Sandman' · apollo204060
I was surprised to see that the medical community does not routinely follow the guidelines for sports physicals.  Why?  It seems simple enough to do.  Yet parents and student trek off to the MD once every 2 years to be cleared to participate.  What does that really mean? How would I as a parent know what to ask or what to look if no one ever told me?  Most students who die from sudden cardiac death experience symptoms of some nature prior to the final event.  Several studies referenced in this article noted that despite adequate guidelines, many states in the US continue to fall short in meeting them. 

The easiest test for cardiac abnormalities is the ECG.  This test is required in many countries for participation in sports, why not in the US?  Italy implemented this as a requirement and decreased the incidence of sudden cardiac death in its athletes by 89% over a 26 year study (23).  In the US there has been a push to forgo the ECG due to costs, and to place more AEDs (Automated External Defibrillators) where sports events take place.  It feels a bit like a reactive preparation vs. preventive approach? 

So why can’t we do more ECG screening as the recommendation state?  According to my second source, “The electrocardiogram as an adjunct in diagnosing congenital coronary arterial anomalies”, Mitchell Cohen et al reviewed the value of the ECG and the ease of application.  They noted that for many students abnormalities of the heart and arteries supporting it are often present at birth but do not surface as a medical concern until the heart cannot compensate for the increase in stress. 

Athletes place a significant amount of stress on their bodies during training as well as during competitive sports events. This study again looked at the decrease in the rate of sudden cardiac death in athletes after implementing the use of the ECG for screening.  The article also supports a thorough history and investigation of cardiovascular symptoms such as chest pain, shortness of breath with activity, period of dizziness or lightheadedness with exercise (62).  They noted that the physical and history alone are not sensitive enough to detect the kinds of anomalies that would be a precursor to sudden cardiac death. 

They also question our limited approach to screening athletes only.  They state this view is too narrow and will miss many other children at risk.  This study placed as much or more weight on the value of the extensive history and family history along with additional testing for any child with a history of signs or symptoms of cardiac disease.  All athletic activities should be stopped until a full evaluation can be completed to ensure the safety of the child.  Imaging such as the ECK certainly has a place in the process of evaluation, but should not be a standalone option.

Do students play a role in the process?  Screening can be challenging as children do not always report symptoms accurately based on the study published in my thirds source by Mohammad Movahed et all in 2008 Cardiology in the Young.  This study looked at the reporting of cardiac symptoms by both boys and girls in the teenage population.  They used portable cardiac monitors to track cardiac activity and to correlate this to symptoms.  Unfortunately the study shows that girls in particular, report symptoms more frequently and both boys and girls both report symptoms when no cardiac concerns are noted in the physical testing. 

Why is this important?  Well if we only use personal history and review as a means of screening for pre-athletic participation, we may be chasing the wrong patient for the wrong reasons and missing those with true cardiac concerns. This again supports the need for regulated standards for screening which include both the history and the testing component before a student is cleared to participate.  Parents also need to understand this information and the necessity of a clearly reported history for the student and of the family. 

So what is too much and what is enough then when it comes to sports screenings for students?  Where does the cost of the ECG become too expensive, and who’s choice is that?  As a parent am I comfortable enough knowing that my kids should have easy access for an AED should something terrible happen to them while participating in a physical activity at our local park or school event?  With health care costs rising every year and insurance companies refusing to pay for what they view as unnecessary, what is the best thing to consider?

In my fourth source, “Sudden Cardiac Death in Young Athletes: Time for a Nordic Approach In Screening?.” in the Scandinavian Journal of Medicine & Science in Sports, they reviewed the Italian practice of screening all elite athletes with ECG.  The Nordic approach is looking at a consistent history and physical as well as family history and utilizing the ECG when patients meet specific guidelines.  They reviewed the potential financial impact of completing ECGs on all athletes and considered it a wasteful use of expensive medical resources.  I really felt challenged with this.  As health care consumers we should have some ability to help drive the testing we want.  In the United States we can if we have the money to do so.  I didn’t think twice about all of the testing my son went through, even though it took me 6 plus months to pay the final bill.  It was worth it, I felt some peace of mind knowing his cardiac status had been looked at.  As a mom I would be sitting in the stands waiting for something bad to happen.  Could it still?  Nothing is a sure thing when it comes to medicine.

 

So what can I say about my research process?  First I was shocked at the number of deaths related to cardiac conditions for athletes.  I had no idea it was as common as 1 in 100,000 annually in the United States for students between the ages of 5-19 years of age.  I know that until faced with a real life scenario I was clueless even as a nurse.  I considered it something that was  a “never” event.  Yet as I reviewed the resources it became clearer to me that the screening most parents rely on is not what we may think it is.  In addition, our children may miss vital components of the intent of the guidelines even if we take them every 2 years as required in our district.  As a parent I did not have the correct information, nor was I ever asked any specific questions about sudden cardiac death before age 40, for anyone in my family or my husband’s family. 

As a nurse, I feel confident I would know what to look for when it comes to acute cardiac symptoms, but I might also under report or investigate knowing that children are not always good reporters. Unfortunately the research I found may also supported that  and I potentially place my kids at risk too.  I believe that we all deserve enough information to be educated and able to protect our children.  In the United States we have both the resources and infrastructure to implement the AHA guidelines for sports screenings.  I’m not content with the idea that having acute access to an AED is enough when it comes to the welfare of athletes.  We need a more robust screening adherence as well as parent, coach and student teaching about the warning signs in order to prevent an event like the one the Leonard family faced on March 3rd 2011. 

Wes Leonard dies from enlarged heart · CBS

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