April 3, 2007

New Guidelines Raise Heart Issues

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Earlier this year, the American Heart Association (AHA) released a statement with new guidelines for testing the hearts of competitive athletes. This statement, the first of its kind in over ten years, focuses primarily on Sudden Cardiac Death (SCD). While SCD is extremely rare — with approximately 20-25 yearly deaths of high school and college athletes — each case is met with high public scrutiny because of the unexpected and seemingly inexplicable nature of these deaths.

A key section of the AHA report considers the idea of increasing the intensity of the pre-competition screening exam to include echocardiography and electrocardiograms (ECGs) to help identify certain conditions, particularly hypertrophic cardiomyopathy (HCM), that result in the majority of sudden cardiac deaths (SCD). HCM is a congenital heart disease characterized by the abnormal functioning of the heart due to thickening of the ventricle walls.

Echocardiography and ECGs are at the forefront of medical technology for examining the heart as the former observes the structure of the heart through the use of ultrasound, while the latter examines electric potential of this organ. Recently, both have been made available by various companies as a portable unit to be used on location for various high schools and colleges.

The AHA, however, chose not to mandate the administration of this sort of test for young athletes, indicating that high costs, among other factors, create tremendous hurdles in the institution of such policies.

Bernie DePalma, head athletic trainer at Cornell, believes that the aforementioned screening is laudable in theory, but acknowledges that considerable work must be done before it can become the standard of care in collegiate athletics.

“The issues are such that it is not black and white, although it might seem that way,” DePalma said. “Our profession is heading in the right direction, but we are not there yet.”

Italy has acted as a pioneer in this area by instituting ECGs and other screening methods as mandatory prerequsites for all athletes, aged 12-35, who desire to partake in competitive sports. Carla K. Johnson of the Associated Press reports that Italy’s policy has led to decrease in cases of SCD among athletes by almost 90 percent during the 25-year test period that ended in 2004.

However, the United States is home to over 10 million athletes fitting into the age group criteria used in Italy, making it practically inconceivable — both financially and bureaucratically — that a similar program will be introduced in the near future.

Although currently unrealistic on a national level, DePalma and others have already taken the initiative in starting this sort of testing for athletes at Cornell.

“Over the last six months, we have taken steps towards achieving this [type of procedure],” he said. “But something like this takes time. While personally, I think that this is a good idea, professionally I know that we need to do it correctly and go through the necessary steps to start our own procedures.”

Those necessary steps are multifarious as this sort of screening is not yet the standard of care, and to go beyond the recommendations of both the NCAA and the AHA takes both time and money. Because the testing costs vary between $100 and $1,000 per athlete, Cornell alone would have to spend well over $100,000 dollars in order to test its athletes, and even then, those that tested positive for HCM would, based on probability, be 2-3 athletes.

It is here where the issue meets a real crossroads. One might think that the possibility of saving one life is worth whatever cost may be necessary, but relying solely on ethics can present even greater problems in the medical arena. In addition to proper liability based on legality, the possibility — perhaps inevitability — of false-positive tests presents a real problem for practitioner and athlete alike. Additionally, as noted by the AHA, “[Using echocardiograms] does not guarantee the identification of all clinically relevant abnormalities.”

Wrestling head coach Rob Koll — who has dealt directly with SCD via the death of former Cornell wrestler Graham Morin ’04 — brings up another concern. He worries that the implications of testing all athletes for HCM may spin out of control into a fishing expedition that requires everyone — athlete or not — to get tested.

“In a perfect world, of course I’d love for all the kids to get tested,” Koll said. “But I don’t know that it is necessarily from their participation in their sport that they passed away or if it could just happen randomly. Graham was just jogging around, not exerting himself at all — it was something that every intramural athlete does. Then, would we have to test every athlete that walks on Cornell’s campus?”

Morin, who passed away in 2000, suffered from HCM, but, as is usually the case, was entirely asymptomatic before his death. Cornellians also remember George Boiardi ’04, who passed away due to SCD in a lacrosse game in 2004. Boiardi’s case, however, was due to commotio cordis resulting from blunt trauma to the chest and could not have been prevented by any precautionary medical measures.

Currently there exist no real across-the-board standards for testing the hearts of young athletes. Customarily, a family health history and basic physical examinations serve as the basic tests for signs of heart disorder. With any sign of a problem, the athlete will be sent for further testing, which often includes an ECG.

“We pull approximately 10-20 athletes per year,” DePalma said. “Based on their health history and other factors, we send them for full cardiac exams.”

The National Basketball Association, perhaps as a result of the ongoing mystery surrounding the 1993 death by cardiac arrest of Reggie Lewis — has recently necessitated yearly ECGs for all its players. Yet, professional sports possess a luxury that collegiate, and especially high school, athletics does not have: money. With that in mind, the NBA has all the resources, including access to the necessary technology, to demand full participation.

“We are not financially prepared to do [this testing] right now,” DePalma said. “The technology is becoming widely available, but available and accessible are two very different things. We are trying to get it to be both accessible and financially available.”

With continued improvement and development, the future may allow ECGs and echocardiography to emerge as the standard, but for now, it remains on shaky ground. It will likely take the authority of the AHA, the NCAA, and the United States legal system before any such procedures can become the model in collegiate athletics.

DePalma, who has worked at Cornell since 1980, believes that ECGs and echocardiograms will follow the path of other technological advancement that slowly worked their way into the standards of the NCAA, such as neuropsychology — which tests athletes predisposed to head injuries.

“Five years ago, not everybody was doing neuropsych tests,” DePalma said. “Eventually, it became the norm and now it is the standard. As time goes on, and you have a set of policies and procedures in place, I really believe that [ECGs], electrocardiograms, and such will become standard.”

Sudden cardiac death remains a pervasive and precarious issue in athletics, as each death seems to declare the need for further testing. However, the issues raised above certainly problematize such notions and create questions as to the feasibility and precision involved in the testing of all athletes. Hopefully, the future will refine the procedure and minimize the costs to a point of standardization. Thus, when the test is both accurate and inexpensive, society can really work towards saving the lives of innocent athletes — this, of course, is the ultimate goal.

Patrick Blakemore is a Sun Senior Writer. Got Game? will appear every other Tuesday this semester. Patrick can be reached at pblakemore@cornellsun.com.