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    Wednesday, October 04, 2006

    Young Hearts: A study in today's Journal of the American Medical Association suggests we should be doing EKG's on young athletes. That's pretty radical. The conventional wisdom has been that EKG's are not good screening tools. They provide good information when people are having symptoms - passing out, chest pain, paliptations, but as predictive tools they are lousy. So what is it about this study that changes that?

    The study looked at athletes in the Veneto region of Italy, ages 12-35, from the years 1979 to 2004. The region has an ethnically homogenous population of 4,379,900. In 1982, Italy began requiring that EKG's be performed on all young people as part of their pre-participation sports exams. The Italian guidelines povide clear rules for what constitutes a positive screen in a young athlete:

    Family History

    Close relative(s) with premature myocardial infarction or sudden death at <50 years
    Family history of cardiomyopathy, coronary artery disease, Marfan syndrome, long QT syndrome, severe arrhythmias, or other disabling cardiovascular diseases

    Personal History
    Syncope or near-syncope
    Exertional chest pain or discomfort
    Shortness of breath or fatigue out of proportion to the degree of physical effort
    Palpitations or irregular heartbeat

    Physical Examination

    Musculoskeletal and ocular features suggestive of Marfan syndrome
    Diminished and delayed femoral artery pulses
    Mid- or end-systolic clicks
    Abnormal second heart sound (single or widely split and fixed with respiration)
    Heart murmurs (systolic grade ?2/6 and any diastolic)
    Irregular heart rhythm
    Brachial blood pressure ?140/90 mm Hg on more than 1 reading


    Left atrial enlargement: negative portion of the P wave in lead V1 ? 0.1 mV in depth and ?0.04 s in duration
    Right atrial enlargement: peaked P wave in leads II and III or V1 ? 0.25 mV in amplitude
    Frontal-plane QRS axis deviation: right ?+120° or left –30° to –90°
    Increased voltage: amplitude of R or S wave in a standard lead ?2 mV, S wave in lead V1 or V2 ?3 mV, or R wave in lead V5 or V6 ? 3 mV
    Abnormal Q waves ?0.04 s in duration or ?25% of the height of the ensuing R wave, or QS pattern in ?2 leads
    Right or left bundle-branch block with QRS duration ?0.12 s
    R or R' wave in lead V1 ? 0.5 mV in amplitude and R:S ratio ?1
    ST-segment depression or T-wave flattening or inversion in ?2 leads
    Prolongation of heart rate corrected QT interval >0.44 s in men and >0.46 in women
    Premature ventricular beats or more severe ventricular arrhythmia
    Supraventricular tachycardia, atrial flutter, or atrial fibrillation
    Ventricular preexcitation: short PR interval (<0.12 s) with or without delta wave
    First-degree (PR ?0.21 s, not shortening with hyperventilation), second-degree, or third-degree atrioventricular block

    It also happens that since 1979, the medical establishment in the Veneto area has been studying the hearts of dead athletes in great detail:

    Since 1979, all fatalities occurring in young people aged 35 years or younger in the Veneto region have been collected and investigated in the setting of a prospective clinicopathological study. The medical centers participating in this research project constituted an active network that served 94.4% of the population and permitted an accurate monitoring of fatal events occurring in this well-defined geographic area. (Participating centers are listed at the end of this article.) Regional newspapers were also systematically used at the coordinating center (The Institute of Pathological Anatomy, University of Padua, Padua, Italy) for daily monitoring of articles on sudden death in young people that occurred in the Veneto region, either sports-related or sports-unrelated.

    Athletes and nonathletes who died a sudden death were examined postmortem by the local pathologist or medical examiner at each collaborative medical center to rule out extracardiac causes of death by routine autopsy. The entire heart was subsequently forwarded to the Institute of Pathological Anatomy for detailed morphological assessment, including macroscopic examination and histopatogic study of coronary arteries, ventricular myocardium, and the specialized conduction system as reported in detail elsewhere.... Clinical history, athletic activity, and the circumstances surrounding the cardiac arrest were investigated in each athlete who had a sudden death. According to the 1995 World Health Organization classification,1 cardiomyopathies included dilated, hypertrophic, restrictive, and arrhythmogenic right ventricular cardiomyopathy.

    The researchers looked at the incidence and causes of sudden death in young athletes before the 1982 screening guidelines, early in their implementation, and later, when they were standard of care. The incidence rates did go down during those successive years.

    The authors claim this decline is due to the ECG portion of the pre-sports physicals, but there's no data to confirm that. The history and physical portion, may be just as important, and may be providing the real benefit. It also may be why here in the States, our rates of sudden cardiac death in young athletes are the same as in Italy, even though we don't routinely perform EKG's (we only recommend EKG's if the history or physical suggest a problem):

    An accompanying editorial raised questions about the study, noting that the sudden cardiac death rate before Italy’s screening program was high compared to rates found in other studies. And the lowest annual death rate achieved after screening was similar to the U.S. rate for high school and college athletes from 1983-93.

    The editorial also noted that different heart conditions are the most frequent cause of exercise-related sudden death in the two countries.

    “I think we have to be very cautious,” said editorial co-author Dr. Paul Thompson of the University of Connecticut. “You can actually cause problems by screening. There are a lot of abnormalities out there that, if left alone, won’t actually do harm, and screening could lead to people getting procedures done that aren’t necessary.”

    He added: “There’s a large medical-industrial complex willing to embrace screening, and they just happen to sell the tools used for screening.”

    Drs. Gaetano Thiene and Domenico Corrado, co-authors of the Italian study, said their country’s higher mortality rates can be explained by the older age and higher proportion of men compared to the U.S. athletes.

    posted by Sydney on 10/04/2006 07:26:00 AM 1 comments


    This is very much a public policy issue with far ranging consequences. If we have a tool do we then impose this tool on the entire population. Not only do we need to address this issue, but also HPV, and the current call for mandatory HIV testing.

    I have no issue with making these test and vaccines available to those who are in need or feel they are of benefit. I would also be the first to argue for there coverage by insurance.

    The issue become do we test, or treat, an entire population for a benefit that may be hard to measure. On the personal side a false positive and then additional testing will take a very big toll on those caught in that trap. While many in the medical field will say it was just an error and you should be glad you know you do not have a problem. The reality of explaining to a spouse the need for additional testing for HIV will destroy marriages and homes. Additional testing for cardiac problems will always leave doubt in a persons mind and possible in the mind of an employer limiting future promotions or even insurance coverage. HPV vaccination without the proper information and support system could leave many confused about it's purpose and coverage.

    Financial I do not think we, as a country, can afford to fund every possible test. Mike Strobbe in an AP story dated 9/22/06 outlines the cost at $2.50 - 8.00 for the HIV test and a potential of 250,000 new patients at a cost of $10,000 per patient, per year for medications. Again, anyone in need of testing and medication should receive them, but do we actively search out those by testing the entire population.

    The potential financial gain by the drug companies is huge. Do the math on the HIV example. The policy issue is: Can we afford it? The second issue is: Can we afford the next big medical test or treatment? While these issues are fairly clear, what about those treatment or test that have less value? Do we allow a medical society, or drug firm, to promote and then mandate an infinite list of test and treatments?

    We do need to look at the financial ramifications and personal responsibility involved in these decisions.

    Steve Lucas

    By Anonymous Anonymous, at 9:01 AM  

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