The NCAA News - News and Features

October 20, 1997

Screening for heart problems

Group seeks clarification on appropriate frequency

BY SALLY HUGGINS
STAFF WRITER

Although individuals and institutions affiliated with intercollegiate athletics seek to protect student-athletes by following basic health screening procedures, the frequency of the screening and the level of the cardiovascular examinations is a topic of considerable discussion.

While there is medical consensus on the level of cardiovascular screening during routine preparticipation examinations, the frequency of the screening is open to debate.

The NCAA, through its Sports Medicine Handbook, recommends that a preparticipation medical evaluation be conducted upon a student-athlete's entrance into the institution's intercollegiate athletics program, followed by subsequent annual updating of the medical history and detailed examinations when warranted by the updated history.

Those guidelines are consistent with the recommendations contained in the second-edition Preparticipation Physical Evaluation (PPE) monograph -- the only publication on sports physicals endorsed by five major medical societies. The PPE monograph also details the cardiovascular screening, minimally involving a specific personal and family history and a specific physical examination designed to assess abnormalities.

Agreement on cost-effectiveness

One area in which the NCAA, medical groups and the American Heart Association (AHA) agree is that requiring screening electrocardiograms or echocardiograms of all student-athletes is not cost-effective in identifying athletes at risk for sudden death. Instead, those tools should be considered after a cardiovascular abnormality has been identified or suspected through the initial physical examination or a subsequent change in medical history.

In a 1996 document entitled "Cardiovascular Preparticipation Screening of Competitive Athletes," the AHA stated: "It is not prudent to recommend routine use of such tests as 12-lead electrocardiography, echocardiography or graded exercise testing for detection of cardiovascular disease in large populations of young or older athletes. This recommendation is based on both practical and cost-efficiency considerations, given the large number of competitive athletes in the United States, the relatively low frequency with which the cardiovascular lesions responsible for these deaths occur, and the low rate of sudden cardiac death in the athletic community."

Dr. Gary Alan Green, a member of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports, agrees with the AHA statement, noting that studies show that one incidence of cardiovascular disease in 300,000 student-athletes likely would be found with more sophisticated testing of all student-athletes while the expense ($500 to $1,000 per student-athlete) and amount of time would be high.

"If you screen 300,000 athletes to get one person with a problem, that is not cost-effective," Green said.

Dr. Bryan W. Smith, head team physician at the University of North Carolina, Chapel Hill, and a member of the competitive-safeguards committee, said that performing more sophisticated and expensive tests on all athletes may identify some individuals with the potential for sudden cardiac death but the identification would come at an enormous financial cost.

"There is no inexpensive test available to consistently identify these conditions," Smith said.

Family history important

Both Smith and Green said the routine family medical history can provide hints of potential cardiovascular problems. A review of the history of each student-athlete then can indicate when more directed testing, such as an ECG or echocardiography, should be done, they said.

"Good medical care and a family medical history are very effective," said Green, who is team physician at Pepperdine University. "The family history is very, very important. Some conditions run in families. We redo the history every year."

By having the history updated annually and reviewing it with the student, many potential problems can be identified.

"If the student-athlete has warning signs from the history or subsequent physical, we consult with our cardiologists and order testing as indicated," Smith said. "That is the most practical and cost-effective approach at this time."

Screening every two years?

The American Heart Association also recommended in its 1996 document that a cardiovascular screening be performed every two years for collegiate athletes.

The competitive-safeguards committee recognized that this procedure is not common practice at most colleges and may pose significant hardship for many, especially if such a recommendation is viewed as a "standard of care."

In a recent letter to the American Heart Association, the competitive-safeguards committee asked for a clarification of the recommendation.

"While the competitive-safeguards committee respects the effort and expertise that went into the development of the AHA statement, it is concerned about the impact of the two-year recommendation on medical screening of collegiate athletes," the letter said. "The college athlete receives a cardiovascular exam upon entrance into the athletics program (age 17-18) and subsequent annual review of medical history. If evidence exists that cardiovascular abnormalities are more likely to be genetically expressed and identified two years later, then the committee is dedicated to passing such information on to the member institutions it represents.

"However, if such evidence does not exist, then it is concerned about the time and expense that may be expended upon 300,000 college athletes annually.

"The committee also would like to know whether it was the AHA's intent to establish the cardiovascular screening of college athletes every two years as part of the minimal standard of care for screening of these individuals. This is obviously very important to the member institutions of the NCAA as it bears directly on their potential liability in this regard."

Association has 'open mind'

Frank D. Uryasz, NCAA director of sports sciences, emphasized that the Association has an open mind regarding whether research can demonstrate that more frequent and extensive screening will provide meaningful benefits. However, it is necessary in dealing with medical matters to evaluate the potential benefit of a practice against its expense.

"This is a cost/benefit discussion that needs to occur," Uryasz said. "However, if medical consensus is reached that these every-other-year screenings detect heart problems at a level much greater than our current screening tools, then we'll need to set aside cost concerns and focus on the health of the student-athlete."

The American Heart Association has acknowledged the NCAA's concern and is reviewing its recommendation, said Randall W. Dick, NCAA assistant director of sports sciences.

Green noted that the NCAA is not a medical organization and cannot endorse medical procedures. But it can make recommendations.

"The NCAA can't mandate," Green said. "If an individual doctor wants to conduct the exam every four years, he can do that. And the statement of the American Heart Association is an opinion."

At Pepperdine, student-athletes are evaluated at the beginning of each year. The evaluation includes taking a full medical history and a directed physical examination, including listening to the heart and lungs, checking blood pressure, measuring height and weight, checking the pulse, and checking muscular/skeletal function.

Everyone agrees that it would be ideal to detect all cardiac problems and prevent all sudden deaths among student-athletes from cardiovascular conditions, but the question is whether that is a realistic option.

"Everyone, including the American Heart Association, wants to cut down on the incidence of these tragedies," Smith said. "But we don't know if this recommendation will make it any better."