They are young, strong, competitive athletes, in top physical condition. Yet about 90 of them drop dead every year, often in the heat of competition, victims of sudden cardiac death. Now a new study suggests that there is a cost-effective way to lower the death rate significantly: screening athletes with an electrocardiogram.
But starting such a screening program in the United States is controversial.
An earlier observational study, published in The Journal of the American Medical Association in 2006, confirmed the value of EKG screening. For almost 30 years, the Italian Ministry of Health has required screening for competitive athletes and tracked the results. Using those data, the study found that screening reduced the number of cardiac deaths by 89 percent among athletes 14 to 35 years old, making the rate similar to that among nonathletes of the same age.
The success of the Italian approach has led the European Society of Cardiology and the International Olympic Committee to recommend EKG screening for all competitive athletes. But the American Heart Association suggests only a medical history and physical exam.
While the usefulness of preventive screening for some diseases has been widely debated, the main argument against electrocardiograms for young athletes is not that they do not work, but that they would be too expensive for the number of deaths they would prevent. But an analysis published this week in The Annals of Internal Medicine calls that argument into question.
Using estimates from the Italian data, the authors of the new study created a computer simulation of how American athletes 14 to 22 years old would be affected by screening. They found that compared with no screening at all, screening with only a medical history and a physical examination saves just 0.56 life-years per 1,000 athletes, and costs about $111 per person.Continue reading the main story
But adding an EKG would save 2.06 more life-years per 1,000 athletes at an additional cost of $89 per athlete, including all secondary examinations and treatment. This makes the cost of EKG screening $42,900 per life-year saved, on average, a number comparable to doing kidney dialysis ($20,000 to $80,000 per life-year saved).
Other experts found the work impressive. “It’s as fair a statement as I’ve ever seen on the cost-effectiveness of EKG screening,” said Dr. Robert J. Myerburg, a cardiologist and professor of medicine at the University of Miami.
Still, some remain dubious about instituting widespread screening in the United States. “Most studies in competitive athletes report that 90 percent of fatalities from cardiac causes occur in men,” said Dr. Bernard R. Chaitman, a professor of medicine at St. Louis University. “Therefore, it is not likely to be cost-effective to routinely screen the entire population of U.S. athletes, and a more selective approach makes more sense.”
Dr. Euan A. Ashley, the senior author of the study, said that in any case, establishing cost-effectiveness was not the end of the story. “That something is cost-effective does not mean that there is the money available to do it,” he said.
An editorial published with the study noted that among other problems, testing only athletes would probably be considered discriminatory, so any screening program would face the daunting challenge of giving EKGs to all 75 million children under 18.
Whether such screening is worth the effort and money can be a purely personal question, as it is for the families of two teenage athletes in central New Jersey who died last year from hypertrophic cardiomyopathy, a condition that would almost certainly have been discovered if they had been screened with an electrocardiogram. Their deaths prompted calls to encourage cardiovascular screening.
The American Heart Association is not opposed to screening, but only to making it mandatory. For Dr. Ashley, an assistant professor of medicine at Stanford, this seems a reasonable approach.
“What we’ve done is modeled the U.S. data using our best estimates from the Italian effects,” he said. “This answers the question of cost-effectiveness. But individual groups, local groups, high schools or colleges with this information in hand can make a rational decision about whether to use EKGs.”Continue reading the main story