Should your child have an Athletic Heart Screen?

In recent years I've been getting more and more reports of athletic heart screenings. Local schools and sports clubs are offering to have athletes get a heart work up for a relatively small fee. Of course most are perfectly normal, which is a peace of mind to parents. Some have found minor things that aren't of much consequence, but a few have found important heart issues. So why is there even a question of whether or not to do an athletic heart screen if it discovers important heart issues?

Why worry about healthy athlete hearts?

Sudden cardiac death in athletes has been in the news a lot over the years. We all want to minimize the risk that our child has an undiagnosed heart condition that may cause sudden death when exercising. We want to prevent sudden death by identifying those at risk and keeping them from the activities that increase risk.

Communities and schools now are more likely to have defibrillators on hand in case of problems, but some children might benefit from an implantable defibrillator.

If you've not taken a CPR class in the past few years, a lot has changed, including teaching people how to use defibrillators. And you no longer follow "A B C" so it is very different. CPR is recommended for all teens and adults.

Is the cost of a heart screen worth it?

Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age): A Scientific Statement From the American Heart Association and the American College of Cardiology is a review of whether or not electrocardiograms (ECGs) are beneficial for all athletes prior to sport participation. It is endorsed by the Pediatric and Congenital Electrophysiology Society and American College of Sports Medicine.

There has been a lot of controversy over the years whether or not routine ECG screening of athletes is a cost-effective means to find at risk young people. Northeastern Italy has done a comprehensive screening program of competitive athletes and has lowered their sudden cardiac death rate, which is evidence for the ECG screening. Despite this shown benefit, there are many problems with the feasibility of testing a broad range of athletes to evaluate for risk of sudden death (SD).

Complex issues from the Statement linked above:

1. the low prevalence of cardiovascular diseases responsible for SD in the young population

2. the low risk of SD among those with these diseases

3. the large sizes of the populations proposed for screening

4. the imperfection of the 12-lead ECG as a diagnostic test in this venue

It is generally agreed upon that screening to detect cardiovascular abnormalities in otherwise healthy young competitive athletes is justifiable in principle on ethical, legal, and medical grounds. Reliable exclusion of cardiovascular disease by such screening may provide reassurance to athletes and their families.

In short: 

To do an ECG screening on all athletes is not inherently unwarranted nor discouraged, but it isn't recommended either.

What is recommended?

Although an ECG is not recommended, it is recommended to do a 14 point questionnaire for all athletes at their pre-participation sports exam. This is listed below.

Why isn't an ECG (commonly called EKG) recommended?

Positive findings on the history (questionnaire) or physical exam may require further testing, but using an ECG as the initial screen for underlying problems in the 12- to 25-year age group hasn’t been found to save lives.

Changes in the heart in growing teenagers can make it difficult to tell if an ECG is abnormal or a variation for age (unless read by a pediatric cardiologist, which is often not possible for these mass screenings).

False negative and positive results can lead to missed diagnoses (normal ECG but real underlying condition) or unneeded testing (abnormal ECG with a normal heart).

Mass ECG screening of athletes would be very expensive and has not been proven to save lives.

If your family can bear the cost and wants to do the screening, it should be done. But if the screen is abnormal, do not jump to the conclusion that your athlete will be banned from sports forever. A more complete exam by a pediatric cardiologist will sort that out.

Know that hearts can change over time. One normal screen does not guarantee there will never be a cardiac event in your child.

If you do not feel that the screening is something you want to pay for or if you feel that it is not necessary for your child who has a negative 14 point screening, you should not be required to do so.

The evidence does not support mass required screenings.

If your child has identified risks based on the questionnaire, a more thorough testing should be done.

What are the 14 points?

These 14 points are listed in Table 1 of the above linked statement: The 14-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes

Medical history*

Personal history 

1. Chest pain/discomfort/tightness/pressure related to exertion 2. Unexplained syncope/near-syncope† 3. Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise 4. Prior recognition of a heart murmur 5. Elevated systemic blood pressure 6. Prior restriction from participation in sports 7. Prior testing for the heart, ordered by a physician

Family history

8. Premature death (sudden and unexpected, or otherwise) before 50 y of age attributable to heart disease in ≥1 relative 9. Disability from heart disease in close relative <50 y of age 10. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members

Physical examination

11. Heart murmur‡ 12. Femoral pulses to exclude aortic coarctation 13. Physical stigmata of Marfan syndrome 14. Brachial artery blood pressure (sitting position)§

• AHA indicates American Heart Association.

• *Parental verification is recommended for high school and middle school athletes.

• †Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or after physical exertion.

• ‡Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.

• §Preferably taken in both arms.

What do I recommend?

I think that if you can afford the screen and any potential follow up recommended if it is abnormal, it is a great tool. It can be reassuring, though nothing can guarantee that no problem will develop.

In a perfect world cost wouldn't matter, but I know it does, so if people can't afford the screening, they should not feel like they are not doing the right thing if they skip it.

The 14 point question is all that is recommended to be done and can catch the majority of problems if done with a thorough physical exam.

A plug for an annual well visit in your medical home.

I think all kids and teens should have annual physicals in their medical home. The medical home is where their primary care physician is.

I know this is difficult due to the requirement of all athletes have a physical in a specified time frame before a season starts, but there are benefits to doing a physical in the medical home. At your usual physician's office there should be record of growth over the years, a complete personal and family medical history, and previous vital sign measurements. Not to mention that your regular clinic should be able to update your vaccines if needed so there are no surprises when your school nurse looks at your record in the fall. Seeing your physician yearly also helps to build a relationship, so there is a better comfort level to talk if problems develop.

At this time insurance generally covers one well visit per year. Most physicians will fill out the sports physical form at this annual visit. When you go elsewhere, you usually must pay cash. You might as well get a comprehensive physical using your insurance. You pay a monthly fee for the privilege of having it - use it! Just be sure to schedule well in advance - everyone needs physicals at the same time due to state or club requirements, so slots fill up quickly.

Schedule your physical when you schedule a sport or camp.

When you sign your kids up for any new school, sport or camp, look to see what forms are needed. Call your doctor's office at the same time you sign up for the sport or camp to schedule the annual physical. Just be sure the date you schedule is in the time frame that is needed  to get the forms completed.

Pay attention to your insurance rules for how often physicals can be done. Don't necessarily schedule near your child's birthday if it is outside the range that is needed to fulfill form requirements so you can avoid a second physical when only one per year is allowed.

If in doubt, call your pediatrician's office and ask!

Should your child have an Athletic Heart Screen?