The Case for Adding the ECG to Pre-Participation Exams

Sudden Death in Athletes – Not so Rare!

The leading medical cause of death in athletes is Sudden Cardiac Arrest (SCA). Although the purpose of the athlete Pre-Participation Exam (PPE), including review of the patient and family medical history and a brief physical exam, is to identify cardiovascular abnormalities that could progress to SCA, recent research has shown that the PPE does a particularly poor job of identifying risks. Conventional wisdom has proclaimed that including an Electrocardiogram (ECG) into the PPE to aid in finding those at-risk athletes is difficult, SCA is a rare event, and faulty initial evaluations (false positives) lead to unnecessary costs that would bankrupt the nation. But, as in most areas of health and science, technology and research can herald a new era. It’s time to take a fresh look at the value that can be garnered from the low-cost and highly sensitive ECG.

Who’s at Risk? 

Many screening organizations are reporting meaningful data on detection rates for cardiac abnormalities. It’s common to find that 2-3% of all participants actually have an ECG abnormality, compared to approximately 30 % of all participants who report abnormal findings in their medical history. Most of these abnormalities are unlikely to lead to SCA or disqualification from sports, but a significant number of them will impact the health of the participants over the course of their lives. Early detection can have a very positive impact on their lifetime health management. About 10 % of the abnormal group, or 1 in about 250 participants, have abnormalities that are strongly associated with SCA and follow-up is highly recommended.  Risks are also stratified by gender, ethnicity and sport:

Relative Risk	Higher	Lower
3x	Athletes	Non-Athletes
2x	Males	Females
3x	African-Americans	Caucasians
6.7x	Men's Basketball	All Sports

Sports that are characterized by sudden surges of energy, such as basketball, water polo and soccer, carry much higher risk than sports characterized by relatively constant effort, such as cross-country.  For an African-American male basketball player, the risk of death during 4 years of college play is about 1/1000, much higher than for other groups. These are risk levels that most of us would not knowingly accept.  It’s unconscionable to argue that high risk-athletes shouldn't be screened!

Where Do We Start?  

Available budget resources will guide how you begin a screening program that includes ECG.  We recommend that you initially gain experience and proficiency screening the higher-risk sports, with considerations for gender and ethnicity, with the goal of potentially saving the most lives possible with the available resources.  As efficiency and organizational support grow, you can extend the screening to a broader segment of your athletes.  The total cost of an ECG should be in the $10-$25 range, depending upon your providers – a fraction of the cost of a pair of athletic shoes.

What ECG system should we use?  

Most ECG systems implement automatic interpretation criteria that are outdated with respect to the best current consensus criteria for athletes, often referred to as the “Seattle Criteria,” ( Drezner, et al, British Journal of Sports Medicine, 2013). Use of these criteria have dropped false positive rates from around 12-15 % down to about 2 %, a factor of about 7x.  Although most cardiologists believe they can read an ECG correctly every time, recent blinded studies show that they are often in error 4 to 15 % of the time (reading based upon experience = 15 % error rate; reading based upon specific criteria with examples = 4 %).  An ECG device that implements the Seattle Criteria and is designed from the ground-up to deliver high-quality trace data, leveraging the tremendous data analysis capabilities of the modern PC, and with extended ECG recording time to improve beat estimates from bradycardic athletes, leads to much improved accuracy.  CardeaScreen is such a system and is being rapidly adopted in screening programs across America.

Learn more about the CardeaScreen (link includes FAQ's and video) >>

Sports Health would like to thank David Hadley, PhD, for writing this blog for us.

Dr. Hadley has over 30 years of hands-on experience blending customer needs with information technology through research and development. He spent nine years as Vice President of Research and Development for Quinton Cardiology. In this role, Dr. Hadley was responsible for rebuilding the engineering team, establishing robust new product architectures and developing the next generation of Quinton and Burdick diagnostic ECG products.

Prior to his role at Quinton Cardiology, Dr. Hadley was with Primus Knowledge Solutions and Sierra Geophysics. He earned his Ph.D. from the California Institute of Technology.

How to Save a Young Athlete’s Life: Pre-screen with an ECG

The Case for Using an ECG to Screen for Cardiac Disorders.

Does Pre-Screening Help Prevent Loss?

Each time a young athlete dies of a cardiac-related incident after athletic exertion, the debate over athletic pre-participation screening is reignited. The loss of a seemingly healthy young athlete to sudden cardiac death (SCD) is a jarring event that leaves people questioning what could have been done to prevent the tragedy. Cardiomyopathy leading to ventricular arrhythmia and SCD is actually the second leading cause of athlete death behind trauma. While SCD is rare, the statistics cause concern: almost 80 percent of athletes who die of a cardiac-related incident showed no symptoms prior to their death, and over 90 percent of SCDs in young athletes occur during or shortly after exercise. The NCAA estimates that nearly a dozen college student-athletes in the U.S. suffer sudden cardiac arrest each year.

The Gap in Current U.S. Recommendations

Current American Heart Association (AHA) standards do not recommend routine pre-participation screening for athletes, citing expense, burden to the healthcare system and false positive results. Rather, the AHA suggests use of a screening tool that includes 12 questions about personal and family medical history and a physical exam to identify aspects of an athlete’s health that could signal a cardiovascular problem.
But what about athletes who are not aware of, or do not have access to, extensive family history or who are reluctant to report these potential health issues for fear of being excluded from participation in their sport?
In 2005, the European Society of Cardiology recommended universal screening, and this position has been endorsed by the International Olympic Committee. Israel also requires ECGs as part of athletes’ pre-participation physicals (PPE).
These pro-screening policies are largely a result of a population-based study conducted in Italy which examined the athletic and nonathletic populations between the ages of 12 and 35 years. The annual incidence of SCD in athletes decreased by 89 percent between 1979 and 2004; whereas the incidence of SCD among the nonathletic population did not change significantly. Most of the reduced mortality rate was due to fewer cases of sudden death from cardiomyopathies.
Recent research supports the viability of screening with ECGs, despite concerns about cost and false positive results. A study commissioned by the NCAA screened 2,471 athletes from 14 NCAA Division 1 universities who had not previously received an ECG screening. Seven athletes were diagnosed with serious cardiac disorders, all of whom had abnormal ECGs, but only two of those athletes had an abnormal history or physical exam.

A Trend Toward Cardiovascular Screening in the U.S.

A recent survey of head athletic trainers in NCAA Division 1 football programs found that 35 of the 116 schools were already incorporating non-invasive cardiovascular screening (NICS) in their PPEs.
As the trend in the U.S. moves toward a more proactive approach to screening, and with mounting evidence pointing to the value of screening athletes with ECGs, perhaps athletic trainers and programs should consider partnering with contracted medical staff, or better yet should invest in an onsite ECG, like the ones found on Sports Health to have ECG testing readily available. After all, it could mean the difference between life and death for a young athlete.

Shop ECG Machines >>


Danielle Masursky, PhD
Janice Riley, RN, CRA

Bibliography

Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G.Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006 Oct 4;296(13):1593-601.
Coris EE, Sahebzamani F, Curtis A, Jennings J, Walz SM, Nugent D, Reese E, Zwygart KK, Konin JG, Pescasio M, & Drezner JA. Preparticipation cardiovascular screening among National Collegiate Athletic Association Division I Institutions. British Journal of Sports Medicine.2013; 47(3):182-4.
American Medical Society for Sports Medicine. NCAA-Funded Study Supports Screening NCAA Athletes for Sudden Cardiac Death Risk. [Press Release, April 21, 2013]. Retrieved from http://www.amssm.org.
American Heart Association: Pre-participation Cardiovascular Screening of Young Competitive Athletes: Policy Guidance (June 2012) Retrieved from http://newsroom.heart.org.

BOSS Hydration System Review

This blog was written by Phil Hossler, ATC. Phil has been an athletic trainer on the scholastic, collegiate and Olympic levels. He has authored 4 books and numerous articles and served as an officer in state and regional athletic training associations for 20 years. He is a member of four halls of fame including the National Athletic Trainers’ Association’s.

As a certified athletic trainer and director of several large sporting events, properly and adequately hydrating participants is one of my standard safety concerns. There are multiple solutions available to provide hydration depending upon budget and number of participants. These options range from bottles and coolers to cups, hoses and drinking stations.


In reviewing products, I was intrigued by the BOSS Drinking System. About two decades ago, I actually thought along these lines and developed a lid with a hand pump idea. I was glad to see BOSS refine this idea to one of battery power. The product seems to be well conceived with a lid that does not have to be exclusively used on ONLY their coolers but can be used on any screw on 7- or 10-gallon cooler.


Often the large 10-gallon coolers can be too heavy for many high school age athletes to transport so the inclusion of a cart by BOSS was a nice touch. The BOSS system provides a four hose assembly with auto shut-off capabilities so that when not in use the nozzle can shut off to conserve battery power. The power is provided by a 12-volt DC rechargeable battery.


There are, however, some possible negative points that I would like to explore. There are several vendors that carry the BOSS system. I found Sports Health to be the most detailed and offer the greatest variety of combinations. If I had the chance I would like to actually use the BOSS system, but my school budget will not permit me to do such an experiment.


So, my following thoughts are based on experience and product review but not on actual use:

1. It appears that the cart may not be substantial enough to last long with the weight of a 10-gallloon cooler. It appears to be aluminum and the arm holding the actual cooler should be longer to reduce the axial load at the fulcrum point.
2. Sports Health does a nice job, actually better than www.outdoorboss.com does explaining the different options available.

Learn more about BOSS Drinking Stations

Concussion Book & Documentary a Must-Read for Anyone Involved in Sports

Head Games- You need to know the rules to this game

This blog was written by Phil Hossler, ATC. Phil has been an athletic trainer on the scholastic, collegiate and Olympic levels. He has authored 4 books and numerous articles and served as an officer in state and regional athletic training associations for 20 years. He is a member of four halls of fame including the National Athletic Trainers’ Association’s.

To say that head injuries, specifically concussions, are more in the spotlight now than ever before, would be understating the obvious. With a number of retired National Football League (NFL) players coming forth since 2006, the subtle, yet substantial, effects of diagnosed concussions and “sub-concussive” head trauma have gained national attention.

One the leader of this heightened awareness is Christopher Nowinski from Boston. Chris is a Harvard graduate, former Harvard football and former WWE professional wrestler. Looking back now, Chris realizes how many and how serious some of his “dings” throughout his career(s) actually were. His book, Head Games details the National Football League’s dealings and misdealings in the area of player safety as it relates to head trauma. The combination of the text and now film is perhaps the finest, most detailed and comprehensive regaling of the underbelly of this country’s most beloved sport. These are must reading and viewing by anyone associated with sports, not just football.

The award-winning documentary is a feature length by an acclaimed director. It combines actual stories from players, surviving loved ones and some of this nation’s finest brain trauma experts. Dr. Ann McKee, MD, Dr. Robert Cantu, MD and Dr. Robert Stern, PhD - who are now known internationally for their work and examination of deceased brain tissue changes of former athletes from a variety of sports and age groups.

As someone who played 4 years of high school and 4 years of college football, I identified with the stories. On one occasion I was knocked unconscious in college practice. It took me considerable time to remember the play I was carrying the ball on. I am glad now that I did not act upon the invitation letter to attend an NFL non-drafted player tryout.

The film is an outstanding tutorial; it is not a condemnation of sports. It supports the inherent value of sports, overcoming obstacles, teamwork and life values. But all these objectives must be tempered with safety, rule changes, age-specific alterations and increased scrutiny of participants’ health. Several former professional athletes now must live their lives filled with mental and physical shortcomings. Several deceased athletes that we all loved to watch display their talents are believed to have succumbed to dementia, Alzheimer’s or depression.

Chris’s involvement and narration on the documentary expertly delves into boxing, college football, girls’ soccer as well as professional ice hockey and football. These experts detail the need to decrease or eliminate the “military mentality of organized war with rules” that sports have so often become. Dr. Cantu, father of the first grading protocol for concussions, says that with the rise in sports participation every high school that offers a sports program should have a certified athletic trainer on staff. If not, then schools should not offer sports that give rise to concussive trauma. He goes on to state that the number of practices that allow head trauma should be reduced to reduce the incidences of “sub-concussive” head trauma. He points out that the NFL typically has only one practice day a week with contact.

This five star detailing of accounts, history and real stories make the text and documentary film a requirement for every high school and college athletic department’s must read/view list.

Learn more about how to purchase Head Games

Athletic Trainer Helps Save High School Referee with AED

Watch the video of the Athletic Trainer reunited with the referee who's life she helped save on Thursday, February 7th during an exciting overtime Girls' Basketball game at Eastchester High School in NY. Neil Berniker, teacher, coach and high school referee in the Bronx, suddenly collapsed and hit the floor while officiating the game. Jason Karol, the school's Athletic Director, along with Ellen Bastoni, the school's Certified Athletic Trainer, came to his rescue.

"As soon as I ran over, I saw he wasn't breathing and I yelled to call 911," Karol said. "I told the [athletic] trainer to get the AED because he was gasping for air but he wasn't breathing." Karol, a first year athletic director, began CPR until Bastoni returned with the LIFEPAK 500 AED (Automated External Defibrillator).

Once the AED was connected to the referee, it advised a shock. Incredibly, through the efforts of Karol, Bastoni and a parent bystander, Berniker was successfully revived in front of the 200 people watching solemnly from the stands. "We saw his eyes open and he started breathing again," Karol said. "He was confused and I just held his hand until the EMT's got there. He didn't know what happened."

Once EMT's arrived, Berniker was put on oxygen and transported to the intensive care unit. It was reported that he is recovering well, and that he was up and walking and making jokes by the next day.

Eastchester has 23 AEDs located strategically throughout their buildings. Interestingly, the week before the referee collapsed during the basketball game, the placement of the AEDs was reviewed and the one used to save Berniker's life was placed in a more accessible location in the gym so that it could be utilized after normal school hours.

Sports Health is a leading provider of AEDs to schools and athletic organizations across the country. The AED Program at Eastchester High School was implemented with the help of a School Health/Sports Health Representative. If you would like more information, please contact us and one of our knowledgeable representatives will get in touch with you.

Request an AED Consultation and Download "The 10 Common Mistakes Made By School AED Programs">>

Video courtesy of Lohud.com

About Sickle Cell Disease and Athletes

Sickle cell trait needs to be identified in athletes

Sickle cell disease (SCD) is a condition in which  red blood cells can develop a “C” shape similar to the old farm tool called a sickle that was used to harvest grains. The danger of the “C” shape blood  cells is that they die early which causes a shortage  of red blood cells. Due to their non-round shape they can also become stuck and clog smaller blood vessels resulting in pain and other complications.  Tissue that does not receive a normal blood flow eventually becomes damaged. This is what causes the complications of sickle cell disease. Read more: http://www.nhlbi.nih.gov/health/health-topics/topics/sca/

Disease (SCD) or Trait (SCT)?

SCD is a genetic condition that is present at birth having been inherited from one or both of their parents. Persons who have inherited one sickle cell gene and one normal gene have SCT. This means the person won’t have the disease, but will be a trait “carrier” and can pass it onto their children. Sickle cell trait is not a type of sickle cell disease. People with sickle cell trait are generally healthy. Persons with SCD can pass either SCD or sickle cell trait (SCT) onto their children.

SCT affects 1 in 12 African Americans in this country. Estimates are that 3 million people in the United States have SCT and many are unaware of the condition. SCT is also frequently found in people living in or have families in South and Central Americans, Caribbean, India, Arabia and Mediterranean counties such as Turkey Greece and Italy.

Chances of Inheriting SCD or SCT

• Both parents have SCT = 50% chance of SCT in their children; no symptoms in children of SCD; but they can pass SCT onto their children
  
• Both parents have SCT=25% chance of SCD in their children; 25% of no SCD in their children
  
• One parent has SCT= 50% chance of SCT; 50% chance of no SCT
  

How do you know?

A simple blood test is used to detect SCT. For several decades now blood testing for sickle cell and other blood conditions has been standard on newborns. Families with inherited SCD and SCT tendencies should see a genetic counselor (contact your family physician or local hospital) to investigate the number of relatives on the husband’s and wife’s side of the family who are carriers before deciding on having children of their own.

Knowledge of medical problems possibly associated with sickle cell trait and their appropriate management is good clinical practice for athletic programs so check with the school physician and/or the athlete's physician.

How Improving Listening Skills Can Improve Athletic Healthcare

Being is a good listener is half of being a good speaker. Americans spend 80% of their waking hours communicating. We spend 45% of the time listening, but we only listen at about 25% of our ability to do so.

Student-athletes need to understand their assignments, know the techniques of the sport and to listen to -  not just hear - instructions. The following guidelines will help student-athletes and student trainers become more effective communicators by improving their listening skills:

• In order to listen you have to stop talking.
• Listen actively. You can hear someone without really listening to them. 
• Don’t get ahead of the person talking. 
• Wait. Don’t jump to conclusions. 
• Listen to them without turning their story into your story.
• Don’t finish other people’s sentences. Be patient and do not interrupt. 
• Become a student of human behavior. Observe their nonverbal language. 
• When appropriate, summarize to show you were actually listening. 

When tending injured athletes, care providers must pay attention to details that affect decisions. Asking and listening are key evaluative tools used by all health care providers. Injured athletes need to feel comfortable and reassured by the person who is caring for them. Powerful body language, positive facial expression, eye contact and professional verbal skills are trademarks of successful people in all walks of life. This is especially true in the emotional, fast paced world of athletic healthcare.

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