In a split second, everything changed for one team, one town, and tragically, one star player. The Fennville High School basketball team had just beaten one of its rivals to complete an undefeated regular season. The team’s star, Wes Leonard, had scored the winning basket with less than 30 seconds left. Team coach Ryan Klingler described what happened next. “And then 10 seconds later…everything’s pulled out from under you, from out of nowhere.”

Seconds after the teams shook hands, Leonard collapsed in front of approximately 1400 stunned fans. He was rushed immediately to a nearby hospital, where Leonard was pronounced dead minutes after he led his team to victory. Later, an autopsy showed that Leonard died of cardiac arrest due to an enlarged heart.

Could doctors have prevented his sudden cardiac death?

The likely underlying issue is a heart condition called hypertrophic cardiomyopathy (HCM). In the days after the Michigan tragedy, many media outlets suggested that Leonard’s death, like many sudden cardiac deaths (SCD) in youth sports, could have been easily prevented with routine ECG screenings in all high school athletes.

I will state up front that I am in no way an expert on sudden cardiac death in athletes. I’m an orthopaedic surgeon, but I am involved in high school sports as a team physician. I do know that there is tremendous controversy in the sports medicine world about mandatory ECG screening. I interviewed two sports medicine colleagues to get their opinions and try to explain why the idea that sudden cardiac death is easily preventable is not quite that straightforward.

Drs. Peter Carek and Stefan Montgomery are primary-care sports medicine physicians, meaning primary-care doctors with extensive training and experience in sports medicine. Dr. Carek is a primary-care sports medicine physician with MUSC Sports Medicine and serves as a team physician for the College of Charleston and Charleston Battery. Dr. Montgomery is a primary-care sports medicine physician in Orangeburg and is the team physician for South Carolina State University. Dr. Montgomery and I both serve on the Medical Aspects of Sports Committee for the South Carolina Medical Association.

The argument for routine ECG screening

The argument for routine ECG screening comes from an Italian study that showed a decrease in the rates of SCD. The study and whether its results are applicable in the U.S. are controversial. “The Italian study proves that ECG’s decrease the mortality rate from SCD. Yes, Italians have some risk factors that are different from Americans, but they still screen out some HCM patients that would have died otherwise, “Montgomery argues. Carek points out that while the mortality rate did decrease in the study, “…they only dropped the rate of sudden death to the rate it currently is in the U.S.”

For the sake of argument, let’s say that there is definitive evidence that routine ECG’s for all high school athletes would decrease SCD (and there is anything but consensus on that statement). This exercise may be oversimplification, but let me try to show why it’s complicated. Let’s say that somehow we decided that every athlete must get an ECG – a test that costs approximately $12. For the approximately 6 million high school athletes in the U.S., that would cost about $72 million. End of story, right? No – far from it.

The argument against routine ECG screening

Montgomery estimates that about 5% of high school athletes have abnormal ECG’s that would require further testing – likely a referral to a cardiologist and an echocardiogram. (Carek suspects that 5% might be a low estimate.) The cost of the further testing would likely exceed $500 per athlete. 5% of 6 million athletes multiplied by $500 or more equals hundreds of millions of dollars. The American Heart Association states that required ECG’s for these athletes would in fact cost over $2 billion each year. And Carek points out that we would have to do these tests, not just once in an athlete’s career, but every year because obstructive lesions of the heart, such as HCM or stenosis of the heart valves, can progress over time.

Who would pay those costs? Schools and districts likely couldn’t afford to pay. With already tight budgets they might respond by cutting sports altogether. And Montgomery argues that if the government mandated that athletes had to get ECG’s, “…insurance companies would loudly protest having to pay for the inevitable cardiology referrals and echocardiograms that would result because they would, perhaps correctly, argue that most of them are unnecessary.”

Another point to consider is the potential legal nightmare. Both Carek and Montgomery express concern as to what would happen if we increase the standard of care to mandate ECG’s. Primary-care providers (family doctors, pediatricians, etc.) might be unwilling to perform preparticipation physicals and “clear” athletes for fear of missing signs of HCM or other risks for SCD. We could end up with a situation where only sports medicine physicians would be willing to perform the exams or physicians would protect themselves by ordering far more tests and referrals to work up any finding even remotely abnormal just to prevent a lawsuit for potentially missing this condition.

Another unintended consequence would be the huge number of kids who would be unnecessarily held out of sports permanently. “An estimated 200,000 children and adolescents would have to be screened with the current techniques available to detect the 500 athletes who are at risk for sudden cardiac death and the one individual who would actually experience it,” according to Carek. “Also, in absolute numbers, a large percentage of kids with HCM that die from it often die in activities other than sports,” he points out.

The debate over screening for sudden cardiac death risks will continue

I fully expect that this column will stimulate intense debate among physicians, parents, coaches, and athletes. As much as anyone, I hope that we can find an affordable and reliable means of screening for risks for SCD to prevent some of these deaths. But Carek, Montgomery, and I do not expect to see mandatory ECG’s in athletes in the near future, and for reasons mentioned earlier, maybe not in this generation. I do think that everyone who reads this column, however, will agree that Leonard’s death is a tragedy.

Monday night Fennville lost for the first time, ending a playoff run that included winning the district tournament. This loss on the court unfortunately is insignificant to what the team and its Michigan town lost on the court eleven days earlier.

 

Note: The following post appears as a column in Wednesday’s edition of The Post and Courier.