echocardiograms have approached the committee ever since its formation in 2001. Dr. Fenrich says the commit- tee first produced a mandatory com- prehensive history and physical form that includes all 14 elements of the AHA recommendations for prepar- ticipation cardiovascular screening of competitive athletes. (See “AHA’s 14 Steps for Athletic Physicals,” opposite page.) “The Advisory Committee has
always felt like mandatory [EKG] screening is not the direction we should be going at this time because of the lack of data,” Dr. Fenrich said. Last September, AHA and the
American College of Cardiology (ACC) published a scientific statement that examined the effectiveness of using a 12-lead EKG to detect cardiovascular disease in healthy people aged 12 to 25. The AHA/ACC statement notes
that a 26-year survey of high school athletes in Minnesota reported one in 150,000 cardiovascular-related deaths per academic year from 1986 to 2011. A study of young competitive athletes in Minnesota during the 12-year pe- riod from 1993 to 2004 yielded a rate of one cardiovascular-related death in 110,000 per academic year. In Min- nesota, screeners examine young ath- letes only with a history and prepar- ticipation physical examination. AHA and ACC concluded that in- sufficient information exists to sup- port the appropriateness or feasibility of universal EKG screening for asymp- tomatic young people in the United States. The statement recommends examiners use the AHA’s 14-point screening guidelines, as well as those of other societies, as “a comprehen- sive history-taking and physical ex- amination to detect or raise suspicion of genetic/congenital and other car- diovascular abnormalities.”
CHALLENGES AND LIMITATIONS The AHA/ACC statement and TMA physicians note the limitations of an EKG for detecting heart abnormali- ties. Dr. Snyder agrees the evidence
over time hasn’t shown that an EKG lowers the risk for sudden death in athletes. He says EKGs come with “an unacceptable high number of false- positives and false-negatives in this patient population.” The AHA/ACC statement says training-related alterations in EKGs
“often overlap with pathological pat- terns frequently in physically active children and adolescents.” “I’ve seen patients who are ac-
tively having heart attacks [where] their EKG looks absolutely normal,” Dr. Snyder said. “And one of the most common reasons why I get consulted is the EKG is interpreted by the com- puter [as a] heart attack, acute heart attack, old heart attack, time frame undetermined — and they haven’t had a heart attack. So we really take the EKG with a grain of salt — normally in old patients who might be having chest pain, but especially in young athletes who have physiologic adap- tation to athletic training, which can simulate pathology. But the vast ma- jority of the time, it is not.” Although proponents of HB 767 say
EKGs are a low-cost test, Dr. Swan- son says the mandatory screening program wouldn’t be cheap. HB 767 didn’t specify a funding mechanism for the program nor say how much it would cost. Its fiscal note anticipated no significant fiscal impact to the state and said school districts could either choose to pay for the costs or pass them on to parents or guardians of students. “The fact that you can get an EKG
for $15 because you have a grant, someone … is supplying that grant money,” Dr. Swanson said. “And if Tex- as puts this through and mandates it, Texas is going to have to foot the bill for this. Just the basic EKG is not that expensive, but you’re going to have to make it available to every child in Tex- as, you’re going to have to find pedi- atric cardiologists to read everything, and then all the abnormals are going to have to be worked up. So it’s not go- ing to be inexpensive, and it isn’t going
July 2015 TEXAS MEDICINE 51
to find everybody with heart lesions.” Dr. Terk says a screening of all
Texas City Independent School Dis- trict athletes in 2014 helped shape the TPS response to HB 767. Dr. Terk said a local cardiologist “donated the use of his machine and his time” to provide the Texas City screenings, which iden- tified an abnormal EKG result in 96 of about 500 student athletes, or almost 20 percent. “The district would not allow any
of these student athletes to partici- pate without being seen and cleared by a cardiologist,” Dr. Terk said. “All of them were referred to a cardiologist and had echocardiograms, and none were found to have any abnormalities precluding athletic participation after their expensive workups.” The AHA’s recommendations said
that 12-lead EKG screening “in associ- ation with comprehensive history-tak- ing and physical examination” may be considered “in relatively small cohorts of young healthy people 12 to 25 years of age, not necessarily limited to ath- letes,” provided that such a program includes close physician involvement and sufficient quality control. But if an organization undertakes such a program, the AHA/ACC paper states, it should recognize the limitations of a 12-lead EKG, including false-positives and false-negatives. n
Joey Berlin is a reporter for Texas Medicine. You can reach him by phone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email at
joey.berlin@
texmed.org.
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