On March 4, 1990, one of college basketball’s worst tragedies occurred. Just minutes into a West Coast Conference tournament game, one of college basketball’s top players caught an alley-oop pass and slammed down a tomahawk dunk. Seconds later, he fell to the floor. Hank Gathers was soon pronounced dead at a nearby hospital.
Exactly 25 years after the Loyola Marymount star’s sudden cardiac death, the NCAA’s chief medical officer announced that he will recommend electrocardiogram screening for college athletes at higher risk of cardiac defects.
ECG screening of NCAA basketball players
Brian Hainline’s announcement last week renewed the debate among medical professionals about cardiac screening for athletes. While Dr. Hainline alone cannot create a rule that would require NCAA schools to implement ECG testing for their athletes, it is conceivable that his recommendation could place an NCAA school refusing to use the tests in legal jeopardy if one of its athletes died suddenly.
Rates of sudden cardiac death in college athletes
According to Sharon Terlep of The Wall Street Journal, Hainline bases his recommendation to screen male college basketball players on a 2011 study that found the rate of sudden cardiac death among Division I male college basketball players to be 1 in 3100 per year. Medical experts disagree on the rates for all college athletes, with some placing that figure around 1 in 43,000 athletes and others feeling it is closer to 1 in 100,000.
Use of electrocardiograms (ECGs) in sports
An electrocardiogram, commonly called an EKG or ECG, is a cardiac test that measures the electrical activity of the heart. It is often used to detect abnormal heart rhythms (arrhythmias) and other heart conditions. Professional sports leagues in the United States and the International Olympic Committee already use them as part of pre-participation physical exams. According to The Wall Street Journal, about half of the schools that comprise the five power conferences already use ECG testing for their athletes.
Barry J. Maron, M.D., the cardiologist who served as the lead author of the American Heart Association’s position statements on cardiac screening for athletes, told The Wall Street Journal that Hainline’s recommendation could create more problems than it solves. “This idea of screening selectively with [ECGs] is an unfortunate decision and initiative that will undoubtedly lead to unnecessary targeting (including by race), confusion, misdiagnosis, overdiagnosis and ultimately many unnecessary college-athlete disqualifications.”
The American Heart Association’s position
The American Heart Association has repeatedly resisted the idea of universal screening for athletes. Rather than requiring every athlete to undergo an ECG, the AHA recommends doctors use a 14-element checklist to determine if an athlete has a higher risk of sudden cardiac death. The checklist includes chest pain, unexplained fainting, a heart murmur, high blood pressure, family history of heart disease, and certain history and physical exam findings consistent with an elevated risk for heart problems. Any individual with a positive finding on the checklist would then undergo an electrocardiogram or echocardiogram.
Arguments against universal ECG screening
In a scientific statement published by the American Heart Association and the American College of Cardiology last fall, an expert panel argued that studies have failed to show that routine ECG screening prior to using the 14-point checklist saves lives compared to a thorough history and physical exam and selectively utilizing the more advanced diagnostic tests. Plus, Dr. Maron and his colleagues on the panel pointed to some other issues that they feel make universal ECG screening problematic.
• First, they observe that sudden cardiac death occurs just as often, if not more so, in young non-athletes than athletes.
• Mandatory testing of all athletes with ECGs could create huge numbers of false negatives, where the test fails to detect an underlying heart issue, or false positives, where the test suggests that a cardiac defect is present when it really isn’t. EKGs could falsely identify about 500,000 kids as having a “positive” EKG, leading to more advanced cardiac testing and possible unnecessary exclusion from sports.
• The American Heart Association and American College of Cardiology panel estimated that it would cost approximately $2 billion to screen the roughly 10 million young athletes in the United States in the first year alone. It would also require the creation of a complex infrastructure to administer the tests.
• Plus, the panel questions whether there are sufficient numbers of pediatric cardiologists and other medical professionals capable of appropriately differentiating between worrisome cardiac abnormalities and normal adaptive changes to young athletes’ hearts.
As part of his recommendation for college athletes, Hainline wants to further educate university team doctors to better interpret these tests and decrease the risk of false positive ECGs.
If Hainline ultimately recommends ECG testing for male college basketball players and other at-risk athletes to the NCAA this fall, schools might quickly adopt mandatory screening for all of their athletes, both for medical and legal reasons. Expect a vigorous debate about mandatory screening for the millions of high school and youth athletes to soon follow.
Do you think we should use ECGs on all college athletes? What about high school and youth athletes? I’d love for you to share your thoughts below!
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. Circulation. 2014.
Congenital and genetic heart disease screening recommendations for people 12-25. American Heart Association/American College of Cardiology Scientific Statement.
In the NCAA, a Push to Reform Health Standards. The Wall Street Journal. By Sharon Terlep. March 4, 2015.
Preparticipation Cardiovascular Screening of Young Competitive Athletes: Policy Guidance. American Heart Association. June 2012.
Note: A modified version of this post appears as my sports medicine column in the March 12, 2015 issue of The Post and Courier.