EP Lab Digest - September 2007 - (Page 8)

COVER STORY SEPTEMBER Cardiac screening in the young — particularly newborn infants and competitive athletes — is a long-running, often polarizing point of controversy in cardiology. The debate over the feasibility of cardiovascular screening programs in the United States has intensified in response to recent international recommendations to identify those at risk for sudden death. In 2005, the European Society of Cardiology (ESC) released its consensus statement on Cardiovascular Pre-participation Screening of Young Competitive Athletes recommending a 12-lead electrocardiogram in addition to the focused health history and physical exam.3 In 2004, the International Olympic Committee (IOC) directed that cardiovascular screening be included, along with family history and physical exam, for all its athletes.4 The EOC and IOC recommendations are well-founded on decades of European and Japanese experience in cardiovascular screening of the young. Starting in 1979, the Italian government’s Medical Protection of Athletic Activities Act mandated screening for all athletes aged 12–35 wishing to participate in organized team or individual sports. Between 1979 and 2004, the Italians screened 42,386 athletes of the ages between 12–35, and demonstrated that the annual incidence of SCA in athletes decreased by 89%.5 Since 1973, Japan has required that school children be screened by ECG in the 1st, 7th, and 10th grades.6 The Japanese experience has demonstrated that the ECG is far more sensitive than medical history or physical exam in identifying high-risk cardiac abnormalities such as LQTS, HCM, WPW, and dilated cardiomyopathy.7 The largest reported screening study to date in the United States evaluated 5,615 student athletes in Nevada. The ECG demonstrated greater sensitivity to identifying those at risk for serious heart disorders compared to the medical history and physical exam alone, 70% vs. 3%. The specificity of the ECG was 97.4%.8 There are approximately 10 million student athletes competing annually in a variety of sports in the United States.The incidence of SCD in this population is estimated to be less than 300 per year, although there is no mandatory reporting system in place to precisely track the number and causes of these events. Studies suggest that as many as 70–90% of these deaths were due to pre-existing disorders that could have been identified by ECG screening. In March 2007, the American Heart Association, in its Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes, reaffirmed its longstanding opinion that routine ECG screening of competitive athletes is not warranted.9 In spite of the current data confirming the benefits of such testing following decades of Japanese and European studies, as well as the state of Nevada’s screening program, the AHA position has remained unchanged from its original 1996 statement. AHA recommends a 12-point evaluation to help reduce sudden cardiac death in young athletes. The process includes eight medical history questions and four physical tests. For example, the young athlete is to report any personal history of chest pain or discomfort during exercise, any unexplained fainting or near-fainting, episodes of excessive and unexplained fatigue with exercise, a heart murmur and/or high blood pressure. Questions regarding family history look for any recollection of sudden or unexpected death in one or more relatives before age 50 or in any close relative under age 50 with a disabling heart condition. Furthermore, the young athlete is asked to report any known cardiac conditions, such as HCM or dilated cardiomyopathy, LQTS, Marfan syndrome or serious arrhythmias, in family members. The AHA’s confidence in this protocol assigns tremendous responsibility to both the parent and athlete to understand the serious nature of these questions and their ability to provide accurate and objective responses. Per the AHA recommendations, examiners should test for the presence of heart murmur, the quality of femoral pulses to exclude narrowing of the aorta, any obvious physical characteristics of Marfan syndrome, and a brachial blood pressure. Parents are expected to participate in completing their children’s 12-point screening questionnaire. If any of these elements has a “yes” answer, the child should be referred for additional cardiac evaluation. In a perfect world, a system would exist to guarantee testing compliance and require standardized skills and qualifications for all authorized health examiners. However, current testing is conducted by a wide range of physician and non-physician examiners with varying degrees of training and experience. Referring an athlete for additional testing is at the discretion of the examiner and dependent on their expertise to differentiate between benign conditions and more serious indicators of potentially lethal cardiac abnormalities. This concession at the outset challenges the validity of the AHA panel’s recommended guidelines and does not engender confidence that the 12-point The current system in place for physical and history exams could be expanded to include acquisition of ECGs. evaluation will effectively reduce the incidence of sudden cardiac death in student athletes. While the scientific community continues to debate points for and against universal screening, patient advocates, parent groups, schools and healthcare professionals have taken it upon themselves to conduct grass-roots screening programs in hundreds of locales around the United States. Surveying dozens of these community-based programs, we found a range of testing methods, including 12-lead ECG with or without 2D echocardiography, stand-alone echocardiograms, medical and family history, brachial blood pressure, and cholesterol and blood glucose checks.The authors of the AHA recommendations appreciate the benevolent intentions of these volunteer efforts and grant that there may be incremental benefits to these initiatives. However, they suggest that these non-standardized programs may create medical liability concerns and are neither financially or technically sustainable on a regional or national scale.9 Though large-scale cardiovascular screening programs with 12-lead ECG have been successfully instituted in other countries, the AHA panel feels that similar practices would be impractical and costly to implement in the United States9 specific to the following concerns: • Cost-effectiveness: the panel estimates a total annual program cost of $2 billion for 10 million athletes. Per athlete costs include $25 for history and physical exam, and $50 for an ECG. Additional testing for positive results on history, physical exam or ECG (~15%/1.5 million) is estimated at $500 per athlete. Program administration costs could be as much as $500 million.9 The AHA’s proposed 12-point evaluation has a minimum cost of $25 per history and physical exam.With or without an ECG, as many as 15% of those examined will require additional testing at $500 per athlete.The basic premise of the 12-point evaluation is to identify those who may be at risk for sudden death, and the added cost of further study should not be viewed as unwarranted. Administering the 12point evaluation program has minimum fixed costs as well.Therefore, using the raw A 4-year-old gets her first ECG at a Philadelphia screening program. figures suggested by the panel, the addition of ECG screening to an already existing cost structure would not be $2 billion, but more likely in a range of $500–$750 million. It should be noted that the panel’s financial analysis does not take into consideration the opportunity for cost reductions based on economies of scale in a large, nationalized program. • Lack of existing infrastructure: the panel suggests that the addition of ECG to the existing sports physical exam would require the creation of a new system with significant resources to obtain these recordings. Furthermore, new legislation would be necessary to enforce compliance and set standards for disqualification.A program of this magnitude would require more physician examiners qualified to acquire and interpret ECG results and understand when further testing is warranted.9 The current system in place for physical and history exams could be expanded to include acquisition of ECGs.There is a clear opportunity for industry to improve the acuity of computerized interpretive algorithms with more age-specific criteria. Though not an immediate solution, considering a centralized analysis and storage system modeled on the Federal Aviation Administration’s ECG database may provide a solution for acquisition and

Table of Contents Feed for the Digital Edition of EP Lab Digest - September 2007

The ICD Shock and Stress Management Program: Interview with Samuel F. Sears Jr., PhD Universal ECG Screening: The Advocate’s Perspective Contents Letter from the Editor Spotlight Interview: Morristown Memorial Hospital 10-Minute Interview: About the Mended Hearts and Mended Little Hearts Organizations ICD Patient Support Groups Email Discussion Group: September 2007 Technology: Only As Good As the Attitude Behind It! Electrophysiologic Management and Treatment of Chronic and Acute Cardiac Device Infection First Annual EP Lab Digest Salary Survey Events Calendar Industry News and Products

EP Lab Digest - September 2007

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