Screening & Football: Some Call ‘Foul’

One pro football team’s decision to screen team members for heart disease has elevated awareness of cardiovascular health and sports, but it also raises questions about the effectiveness and cost-effectiveness of such approaches.

This year the Washington Redskins made a blood test available to players, coaches and staff that screens for heart disease. The partnership with the health management company Health Diagnostic Laboratory provides “cardiometabolic screening,” which analyzes biomarkers such as cholesterol, lipid particle size, inflammation, risk for diabetes and genetic factors.

The Redskins have taken a step that no other National Football League franchise has yet to follow. Despite the fact that every year, stories of young football players suddenly collapsing and dying on the field make national news headlines, not all health professionals embrace the idea of pre-athletic screening. Experts disagree about cost-effectiveness in light of the evidence about the benefits of testing

Perhaps the biggest controversy exists in the area of screening the youngest athletes.

Anthony Rossi, MD, of Miami Children’s Hospital in Miami, directs a program that offers free electrocardiograms (EKGs) to middle and high school athletes. The hospital has an agreement with Miami-Dade public schools to screen all children who participate in sports.

He says the screenings are fast, effective, inexpensive and reliable. “We will probably screen between 3,000 and 4,000 student athletes,” he says. “We’ve already found three children with potentially life-threatening conditions based on their EKGs.”

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▪ 36% Hypertrophic cardiomyopathy
▪ 17% Coronary artery anomalies
▪ 8% Indeterminate left ventricular hypertrophy/cardiomyopathy
▪ 6% Myocarditis
▪ 4% Arrhythmogenic right ventricular cardiomyopathy, Mitral valve prolapse
▪ 3% Tunneled left anterior descending, Coronary artery disease, Aortic stenosis, Ion channelopathies, Other, Normal heart
▪ 2% Dialated cardiomyopathy, Aortic rupture, Other congenital HD
▪ 1% Sarcoidosis

Source: Circulation, online March 12, 2007 (1980-2005 data)

He also notes that in the past year, two children screened through the program then had catheterization procedures. “There are a whole bunch of disorders that we can pick up that put athletes at risk for sudden cardiac death,” he adds. “Certain rhythm disorders can only be diagnosed with an EKG and can then be medically managed or cured.”

But he acknowledges that EKGs are not the perfect tool. “There can be false negatives and false positives,” he explains. “There are also some heart problems that can’t be picked up, such as hypertrophic cardiomyopathy.”

Others argue that incidents of sudden cardiac death are not common and do not justify the use of mass EKG screening.

“These cases do happen, and each one is a terrible tragedy that traumatizes the community and people in general,” says Paul D. Thompson, MD, director of the Athletes Heart Program at Hartford Hospital in Connecticut. “But how often does this happen? One study in the U.S. suggested that over the past six years or so, there were 66 deaths in athletes per year. What is perceived as a very common event is actually a very rare event.”

Thompson co-authored an American Heart Association (AHA) position on cardiovascular screening in which he and his colleagues estimated the cost of screening every high school and middle school athlete in the U.S.—assuming there are 10 million throughout the nation—would be about $750 million (Circulation, online March 12, 2007).

“EKG changes are common in young people and in athletes,” Thompson says, so this type of expense is unwarranted.
“There is a ‘do no harm’ rule of medicine, and this should include do no financial harm,” he adds.

Instead, the AHA recommends a personal history, family history and physical examination that includes blood pressure evaluation. These are the same recommendations physicians have for adult football players.

Aaron Baggish, MD, of Massachusetts General Hospital in Boston, co-authored a study of Harvard University football players and found that overall, their blood pressure became elevated to pre-hypertensive levels after the season despite being normal before the season. There also was evidence of left ventricular hypertrophy (LVH), especially among linemen who tend to gain a lot of weight in order to perform well at their position.

While the study does not suggest that playing football causes either high blood pressure or LVH and that the exact relationship between football and cardiovascular disease is still being fleshed out, Baggish stresses players need to be cognizant of risk.

“Athletes should be aware that they are not immune to cardiovascular disease and that they should pay attention to their risk profiles and have a discussion about age-appropriate screening,” Baggish says. “Screenings should, at the very least, include history and physical examination as endorsed by the ACC [American College of Cardiology] and AHA.”

As for EKGs, he believes they should be routine only for teams or colleges that have the financial and medical resources to ensure they are performed and interpreted correctly.

Recommendations can be as simple as making lifestyle changes and undergoing regular blood pressure monitoring. “Taking care of athletes means identifying the subsets that are most at risk for having high blood pressure, monitoring them and starting with lifestyle changes,” he says. “It can involve simple things, like avoiding sodium, cutting back on alcohol consumption and medications, if necessary.”

Regardless of their opinions on EKG screening, Rossi, Thompson and Baggish are all skeptical about the benefits of blood testing as a mass screening tool.
“The use of lab-based metrics, at this point, is not supported by any strong data,” Baggish says.

Rossi adds that the tests are costly and do not yield much, but can be helpful if testing for genetic conditions. “The tests won’t pick up a number of people who have certain diseases, and many cardiologists consider them supplementary,” he says.

Tara Dall, MD, Health Diagnostic Laboratory’s medical director, says that the company’s test costs “a few hundred dollars” and may be covered by insurance. She argues that the tests help save money and can better predict cardiovascular disease than traditional lipid panels.

“Physicians over-prescribe medications that in some cases are not needed,” she says. “They use statins in some patients who would be better treated with generic metformin.”

These treatment decisions, she continues, should be made when advanced testing is done. “We cannot afford to continue practicing medicine the way we always have if we want to stop escalating healthcare costs and disabling diseases such as heart disease, diabetes and obesity.”

Until research can better explain the relationship between football and heart disease or determine the true cost-effectiveness of mass screenings, the debate still rages. Regardless of their stance on screening, providers all have something in common.

“The goal is to prevent tragedies from happening,” Rossi says. “I don’t want to see another kid show up in my ICU [intensive care unit] after they collapse on a football field.”