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November 20, 2011

Many physicians unfamiliar with student-athlete heart screening guidelines

By Carolyne Krupa
American Medical News

SEATTLE, Wash. — A survey of Washington state physicians finds that less than half know about American Heart Assn. guidelines, and just 6% follow them.

News reports of teenagers collapsing from sudden cardiac arrest at high school sports events have fueled debate about the best way to screen young athletes for cardiac risks.

As the medical community considers requiring electrocardiograms, echocardiograms or other tests for all athletes, some physicians argue that the focus first should be on implementing uniform standards and reporting methods nationwide.

"The process is so random in its current form that we don't know where improvement needs to start," said Nicolas L. Madsen, MD, MPH, a pediatric cardiology fellow at Seattle Children's Hospital. "Before moving forward with new screening methods, it's important to standardize the process so that we can really tell what works and what doesn't."

There's no mandatory reporting mechanism for such deaths, so recent studies show a wide range of one in every 30,000 to 200,000 U.S. high school athletes dies annually from sudden cardiac arrest, he said. There are national guidelines for sudden cardiac death risk screening, but it's unknown how widely they are used.

The American Heart Assn.'s 12-point sudden cardiac death screening guidelines have been in place since 1996. They include a physical examination and collecting thorough medical and family histories. But a survey of 1,113 Washington state physicians found that fewer than 50% of doctors are aware of the guidelines and that only 6% follow them completely, according to the study that Dr. Madsen presented Nov. 13 at the AHA's Scientific Sessions conference in Orlando, Fla.

A need for education
It's no surprise that most physicians would be unfamiliar with the AHA recommendations, said G. Paul Matherne Jr., MD, a professor of pediatrics at the University of Virginia School of Medicine and past chair of the AHA Council on Cardiovascular Disease in the Young.

It's a challenge for organizations like the AHA to widely disseminate their guidelines, he said. Preparticipation physical exams may be conducted by internists, pediatricians, family physicians, physician assistants or nurse practitioners.

"You have a wide variety of practitioners performing these exams," Dr. Matherne said. "There's no uniform way of making sure you get in touch with all of the providers."

The AHA last published its guidelines in Circulation in 2007, but the journal is read primarily by cardiologists, said Reginald Washington, MD, a cardiologist and chief medical officer at the Rocky Mountain Hospital for Children in Denver.

Many primary care physicians may not have seen the guidelines. Those who did may have decided not to adopt them into practice. "Doctors tend to be bombarded by these kinds of protocols," he said.

Standardization needs to come from schools and athletic programs, said Dennis Cardone, DO, a sports medicine specialist and associate professor at New York University Langone Medical Center. Physicians now must fill out a variety of forms requiring different information on athletes, depending on their school. Having a standard form for physicals would require all physicians to do the same tests and report the same information.

"The big problem is that from state to state and even from high school to high school, there are no set guidelines," he said.

Screening young athletes
Debate over how best to screen athletes for cardiac risks has gone on for years, Dr. Cardone said. Doctors in Italy, for example, screen all athletes with an ECG. Yet the country's rates of sudden cardiac death parallel those in the U.S., he said.

Even the most thorough exams won't detect everything, said Dr. Washington, a member of the American Academy of Pediatrics' Council on Sports Medicine & Fitness. For example, an athlete may get a viral infection months after the exam and develop myocarditis or inflammation of the myocardium. "Even if you did EKGs and ultrasounds on everybody, you are still going to have kids who are going to die unexpectedly," he said.

Preparticipation exams of young athletes should be done with the athlete and both parents present, Dr. Washington said. Children and teenagers often don't know their family's medical history, or may not be completely honest with the physician about their own history.

"If a teenage athlete thinks that relaying symptoms will keep them off the playing field, they will not do it," Dr. Matherne said.

Conducting a thorough physical exam in a quiet room is also key. Schools often hold mass physical exams in large gymnasiums where physicians have trouble listening for warning signs such as an irregular heartbeat, he said.

Physicians should take preparticipation exams as an opportunity to address other health issues, such as alcohol or drug use, Dr. Matherne said.

"It could be the only time that a very vulnerable population seeks medical care," he said. "With a teenager and a parent in the room, you can have a huge impact well beyond what is happening on the playing field."

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