January 25, 2006
Screening for Heart Disease:
Can We? Should We?
John Golden, M. D.
Cardiologist
Minutes of the 17th Meeting of the 64th Year
The meeting was called to order at 10:14 AM by President William F. Haynes. Ninety-three members were in attendance. John Marks led the invocation. Bill Haynes then recognized Bill Selden for his extraordinary achievement in rising to the occasion the previous week, and giving a wonderful talk to the Old Guard on a mere 18 hours' notice. The welldeserved token of our appreciation was a gray T shirt, just the right size, with orange Princeton insignia.
There were no guests, but Claire Jacobus introduced a visitor, who was her husband, Dave Jacobus.
Charlie Stenard proposed ten nominees for Old Guard membership, and the entire list was approved unanimously by the membership. The new members are Susan Artandi, Dr. Tom Buzard, David Christie, Guy Dean III, John (Jake) Hamel, Ralph Kjorlien, Russell Marks, John Pearce, William Stoltzfus Jr., and Edwin Yost.
President Haynes announced that next week's meeting will begin with a Hospitality Hour, to begin at 9:30 AM in the usual space in the Friend Center The speaker will be Charlie Clark, who will tell us about Refugee Camps in Uganda.
Dick Golden introduced the speaker, who was his son, Dr. John Golden. Dr. Golden is a graduate of Harvard College and Rutgers Medical School. He trained in medicine in New York and in cardiology at Tufts University Medical Center. He is Chief of Cardiology and Director of Cardiovascular Research at the Mid-Atlantic Permanente Medical Group in Washington, D.C.; and he is the author of more than 20 papers on different aspects of cardiology.
Dr. Golden began with a word of advice for Old Guard members, which most of us will find difficult to follow: If you have to give a speech, he said, whenever possible, try to arrange to be introduced by one of your parents.
Dr. Golden's talk was entitled "Sudden Death in Athletes: Can it be Eliminated by Screening?" He began by answering the question, "How Common is the Problem?" Statistics from Minnesota indicate that sudden death occurs among high school athletes in that state once in 217,000 academic years, or less than 0.5 in 100,000 per year. Death from murder is 65 times as common, and death from motor vehicle accidents is 45 times as frequent. Sudden cardiac death is much more common among males than among females; and the sports most frequently involved are football and basketball. The rate of sudden cardiac death is higher among older athletes; for marathon runners, the rate is one in 50,000, and the commonest cause in this group is coronary artery disease.
The next question Dr. Golden addressed was "What are the Specific Causes of Sudden Cardiac Death in Young Athletes?" He began by recounting the stories of several well-known college and professional athletes, such as Pete Marevich, who had an anomalous coronary artery; Hank Gathers, who had hypertrophic cardiomyopathy, which is a condition in which there is overgrowth of the muscular septum between right and left ventricles; and George Boiardi, who was hit in the middle of his chest by a lacrosse ball and developed commotio cordis, which led to a fatal arrhythmia. Tom Hemon died of a heart attack due to a blockage of a coronary artery. This condition, which is due to arteriosclerosis, is more common among older athletes, such as Jim Fixx, the famed long distance runner.
The statistical breakdown of the causes of sudden death in young athletes shows that 26% of cases (the largest number) can be attributed to hypertrophic cardiomyopathy, 20% to commotio cordis, 14% to anomalous c.oronary arteries, 8% to left ventricular hypertrophy or enlargement, 5% to myocarditis, 3% to ruptured aorta, 3% to aortic valve stenosis, 3% to arterioscleriotic heart disease (which is the common cause of cardiac death among older people), and there were several other less common causes.
The final pathway leading to death in all of these causes is ventricular fibrillation, which is a rapid and ineffective cardiac rhythm. If not corrected, ventricular fibrillation invariably leads to the individual's death in a very short time. This leads to the possibility of reducing mortality by having available at athletic events an external defibrillator device. Such devices have been simplified, so that non-medical personnel can be trained in their application.
Dr. Golden noted that hypertrophic cardiomyopathy often has a genetic basis; the gene occurs in as many as one in 500 individuals in the general population. The risk of sudden death may be as high as 5% per year among asymptomatic young people with hypertrophic cardiomyopathy. Theoretically at least, the operative placement of an automatic implantable internal defibrillator could be of benefit, could save lives.
Only 3% of athletes who died suddenly were previously suspected – on the basis of screening – of having any cardiac abnormality. So the question is, should more athletes be screened, that is, given special tests to see if they are at increased risk for sudden death? Experts have tried to answer that question by a sort of cost-benefit analysis. Many conditions can not be screened for, such as commotio cordis, which results from a blow to the chest in a normal individual. Aortic valve stenosis can be detected on physical examination. What about hypertrophic cardiomyopathy? The more sophisticated and more informative tests such as echocardiograms are expensive, costing about $800 per test. Screening of all ten million high school athletes would cost about eight billion dollars. And the result would be that many individuals would probably be excluded from athletic competition on the basis of borderline or non-diagnostic findings. This would have serious implications for insurance coverage, for careers, and for income potential; and it could also lead to anxiety and other psychological disturbance.
Similarly, anomalous coronary arteries could be detected only by cardiac catherization, which is not only expensive, but also carries its own mortality of one in a thousand.
In the question period after Dr. Golden's talk, he was asked about the use of simpler and less expensive screening tests, such as the electrocardiogram or EKG, which might provide a clue to the presence of hypertrophic cardiomyopathy, the commonest heart condition which leads to sudden death in young athletes. Dr. Golden noted that the endurance training of athletes frequently leads to a condition known as "athlete's heart," in which there is an increase in the size and thickness of the left ventricle. This condition occurs in as many as 40% of elite athletes; but in only 2% are the abnormalities pathologic, that is, indicative of a serious medical condition. So for every person with hypertrophic cardiomyopathy excluded from athletic participation for valid reason, nineteen would be disqualified because of borderline or questionable findings.
Dr. Golden agreed with the official recommendations of the American Heart Association. The AHA is opposed to the routine use of high technology screening procedures, which would likely lead to too many false positive tests and inappropriate exclusion from participation of healthy individuals who are at low risk for sudden cardiac death. The AHA recommends only complete personal medical history, family history, and physical examination. These procedures should be mandatory for all high school and college athletes, and should be repeated every two years.
For "masters" athletes, that is for older individuals, the recommendations are different: A 12 lead electrocardiogram is desirable. Exercise stress testing is desirable for men >40 or 45, and for women >50 or 55, if they have other risk factors. Exercise stress testing is indicated for all masters athletes in the >65 group.
In summary, Dr.Golden stated that the risk of sudden death in young athletes is present, but the risk is low. Also, that the routine or general use of screening tests is neither cost-effective nor desirable.
An important protective and preventive measure, as recommended by the American Heart Association, is the availability of external defibrillation devices at official athletic events.
Following Dr. Golden's lucid and interesting talk, there was a spirited question period in which the speaker deftly fielded many questions about the subject of his talk, as well as other matters in the field of cardiology.
The meeting was adjourned at 11 :30 AM.
Respecfully submitted,
Harvey Rothberg
There were no guests, but Claire Jacobus introduced a visitor, who was her husband, Dave Jacobus.
Charlie Stenard proposed ten nominees for Old Guard membership, and the entire list was approved unanimously by the membership. The new members are Susan Artandi, Dr. Tom Buzard, David Christie, Guy Dean III, John (Jake) Hamel, Ralph Kjorlien, Russell Marks, John Pearce, William Stoltzfus Jr., and Edwin Yost.
President Haynes announced that next week's meeting will begin with a Hospitality Hour, to begin at 9:30 AM in the usual space in the Friend Center The speaker will be Charlie Clark, who will tell us about Refugee Camps in Uganda.
Dick Golden introduced the speaker, who was his son, Dr. John Golden. Dr. Golden is a graduate of Harvard College and Rutgers Medical School. He trained in medicine in New York and in cardiology at Tufts University Medical Center. He is Chief of Cardiology and Director of Cardiovascular Research at the Mid-Atlantic Permanente Medical Group in Washington, D.C.; and he is the author of more than 20 papers on different aspects of cardiology.
Dr. Golden began with a word of advice for Old Guard members, which most of us will find difficult to follow: If you have to give a speech, he said, whenever possible, try to arrange to be introduced by one of your parents.
Dr. Golden's talk was entitled "Sudden Death in Athletes: Can it be Eliminated by Screening?" He began by answering the question, "How Common is the Problem?" Statistics from Minnesota indicate that sudden death occurs among high school athletes in that state once in 217,000 academic years, or less than 0.5 in 100,000 per year. Death from murder is 65 times as common, and death from motor vehicle accidents is 45 times as frequent. Sudden cardiac death is much more common among males than among females; and the sports most frequently involved are football and basketball. The rate of sudden cardiac death is higher among older athletes; for marathon runners, the rate is one in 50,000, and the commonest cause in this group is coronary artery disease.
The next question Dr. Golden addressed was "What are the Specific Causes of Sudden Cardiac Death in Young Athletes?" He began by recounting the stories of several well-known college and professional athletes, such as Pete Marevich, who had an anomalous coronary artery; Hank Gathers, who had hypertrophic cardiomyopathy, which is a condition in which there is overgrowth of the muscular septum between right and left ventricles; and George Boiardi, who was hit in the middle of his chest by a lacrosse ball and developed commotio cordis, which led to a fatal arrhythmia. Tom Hemon died of a heart attack due to a blockage of a coronary artery. This condition, which is due to arteriosclerosis, is more common among older athletes, such as Jim Fixx, the famed long distance runner.
The statistical breakdown of the causes of sudden death in young athletes shows that 26% of cases (the largest number) can be attributed to hypertrophic cardiomyopathy, 20% to commotio cordis, 14% to anomalous c.oronary arteries, 8% to left ventricular hypertrophy or enlargement, 5% to myocarditis, 3% to ruptured aorta, 3% to aortic valve stenosis, 3% to arterioscleriotic heart disease (which is the common cause of cardiac death among older people), and there were several other less common causes.
The final pathway leading to death in all of these causes is ventricular fibrillation, which is a rapid and ineffective cardiac rhythm. If not corrected, ventricular fibrillation invariably leads to the individual's death in a very short time. This leads to the possibility of reducing mortality by having available at athletic events an external defibrillator device. Such devices have been simplified, so that non-medical personnel can be trained in their application.
Dr. Golden noted that hypertrophic cardiomyopathy often has a genetic basis; the gene occurs in as many as one in 500 individuals in the general population. The risk of sudden death may be as high as 5% per year among asymptomatic young people with hypertrophic cardiomyopathy. Theoretically at least, the operative placement of an automatic implantable internal defibrillator could be of benefit, could save lives.
Only 3% of athletes who died suddenly were previously suspected – on the basis of screening – of having any cardiac abnormality. So the question is, should more athletes be screened, that is, given special tests to see if they are at increased risk for sudden death? Experts have tried to answer that question by a sort of cost-benefit analysis. Many conditions can not be screened for, such as commotio cordis, which results from a blow to the chest in a normal individual. Aortic valve stenosis can be detected on physical examination. What about hypertrophic cardiomyopathy? The more sophisticated and more informative tests such as echocardiograms are expensive, costing about $800 per test. Screening of all ten million high school athletes would cost about eight billion dollars. And the result would be that many individuals would probably be excluded from athletic competition on the basis of borderline or non-diagnostic findings. This would have serious implications for insurance coverage, for careers, and for income potential; and it could also lead to anxiety and other psychological disturbance.
Similarly, anomalous coronary arteries could be detected only by cardiac catherization, which is not only expensive, but also carries its own mortality of one in a thousand.
In the question period after Dr. Golden's talk, he was asked about the use of simpler and less expensive screening tests, such as the electrocardiogram or EKG, which might provide a clue to the presence of hypertrophic cardiomyopathy, the commonest heart condition which leads to sudden death in young athletes. Dr. Golden noted that the endurance training of athletes frequently leads to a condition known as "athlete's heart," in which there is an increase in the size and thickness of the left ventricle. This condition occurs in as many as 40% of elite athletes; but in only 2% are the abnormalities pathologic, that is, indicative of a serious medical condition. So for every person with hypertrophic cardiomyopathy excluded from athletic participation for valid reason, nineteen would be disqualified because of borderline or questionable findings.
Dr. Golden agreed with the official recommendations of the American Heart Association. The AHA is opposed to the routine use of high technology screening procedures, which would likely lead to too many false positive tests and inappropriate exclusion from participation of healthy individuals who are at low risk for sudden cardiac death. The AHA recommends only complete personal medical history, family history, and physical examination. These procedures should be mandatory for all high school and college athletes, and should be repeated every two years.
For "masters" athletes, that is for older individuals, the recommendations are different: A 12 lead electrocardiogram is desirable. Exercise stress testing is desirable for men >40 or 45, and for women >50 or 55, if they have other risk factors. Exercise stress testing is indicated for all masters athletes in the >65 group.
In summary, Dr.Golden stated that the risk of sudden death in young athletes is present, but the risk is low. Also, that the routine or general use of screening tests is neither cost-effective nor desirable.
An important protective and preventive measure, as recommended by the American Heart Association, is the availability of external defibrillation devices at official athletic events.
Following Dr. Golden's lucid and interesting talk, there was a spirited question period in which the speaker deftly fielded many questions about the subject of his talk, as well as other matters in the field of cardiology.
The meeting was adjourned at 11 :30 AM.
Respecfully submitted,
Harvey Rothberg