Testing 1-2-3

Three-quarters of SCAs in adolescents occur on the playing field

Preventive screening for SCA saves lives

By Richard Huff, NREMT-B

Each year, 385,200 people experience EMS-assessed non-traumatic cardiac arrest in the U.S. and nine out of 10 victims die.1 This is more than the number who die from concussions, assault with firearms, breast cancer, fires, motor vehicle accidents, suicides and other causes combined. Young people are not immune to the deadly condition.

According to the American Heart Association (AHA), there are an estimated 5,760 pediatric (<18 years old) arrests from all causes each year. Of those arrests, 6% survive. Therefore, approximately 16 youth suffer SCA each day, and 15 die.2

Cutting into that death rate is the goal of a growing movement within the medical community to reduce the number of SCA cases in the younger demographic.3 At the heart of that effort is a push to get more young people screened with electrocardiograms (ECGs), which could identify potentially catastrophic heart problems before they occur.

Opponents of additional screening maintain that such testing would require massive changes in the medical system, starting with increased education on the part of those trained to read ECGs. Inexperience leads to higher false positives, which then leads to increased follow-up tests and other costs tied to that work.

Jonathan Drezner, MD, of the University of Washington is one of the leading advocates for more education for physicians providing general care. They need to be more aware of the specific heart issues facing younger patients and how to question them about family history to elicit better information, he says.

“There are obvious areas of education and we can do a better job,” Drezner says. “We often ask if anyone in your family had medical problems. We end up hearing grandma had a heart attack or grandpa had hypotension. What we need to ask whether anyone had heart problems and died at an early age.

Early Warning Signs

Typically, but not always, some symptoms emerge before a young patient suffers an SCA. Those symptoms include fainting, chest pain, dizziness, lightheadedness and shortness of breath. Often times, those initial symptoms are ignored or go unreported, Drezner says.

Questions about those types of events should be part of well visits, according to Drezner.

Victoria Vetter, MD, MPH, attending cardiologist at the Children’s Hospital of Philadelphia agrees. “We need to be asking patients if they have had any symptoms that could lead to sudden cardiac arrest. Do they get dizzy during exercise? Do they get out of breath easily? Do they have heart palpitations? It’s important we ask if anyone in their family under 50 has died suddenly.”

Any of those symptoms should alert doctors that something bad could happen, she says. SCAs in adolescents are typically caused by structural disorders, such as hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) or coronary artery problems. Some adolescents have electrical malfunctions in their hearts, such as familial long QT syndrome (LQT) or Wolff-Parkinson-White syndrome (WPW).

“You hear stories of young people who had recurrent syncope [fainting] on the playing field, and this warning has just not been addressed or treated properly,” Drezner says. “Then, the next time it happens, they die.” Doctors asking specific questions can help, he says.

Athletes at Risk

But what if students have a clean slate? Some advocates suggest getting more of them screened using ECGs to identify potential heart problems before symptoms emerge, or worse, they suffer an SCA.

Some college-level programs use ECGs as part of the athletic screening process (see “Emergency Action Plan: Prepare for sudden cardiac arrest on campus” p. 8). There’s a debate over whether widespread screening is useful. The AHA, for example, doesn’t support widespread ECG testing because of the lack of an infrastructure to screen adequately and the potential for a high number of false positive results.

Drezner is an advocate for ECG testing, although not for everyone. The current medical system just isn’t built to handle that level of testing, nor are there enough qualified people to read the ECG tests of the younger population, he says.

Student athletes have been the primary target for ECG testing because of the inherent risks involved. Some doctors note, however, that just because a student isn’t part of a formal school athletic program, this doesn’t mean they’re not at risk. Many students are part of traveling sports teams and recreational leagues and participate in pick-up games that could be just as strenuous. Further, SCA strikes victims in classrooms and other sedentary environments, too (see “Shocking Watts”).

According to Drezner, however, three quarters of the SCAs among young people occur on the playing field, which makes it clear the risk factors are higher for athletes.

“This is the ethical debate that comes up,” says Drezner. “How can you justify a screening program that’s not available to all students? I would never discourage interested parents to request a thorough heart screening for their sons or daughters.”

“It’s a hot topic of debate,” Vetter says. “There is a lot of controversy. I don’t think everyone should be doing screenings if they’re not evaluating them in a systematic way.”

However, if the medical field can decrease the number of false positives and ensure patients get the proper follow up, Vetter envisions that the number of tests being done will increase. Better data is needed on typical ECGs for various age, gender and race groups.

Richard Huff NREMT-B, works as a volunteer EMT for Atlantic Heights in New Jersey and is the executive news director for CBS. Contact him via e-mail at richardmhuff [at] gmail [dot] com.
 

References

  1. Roger VL, Go AS, Lloyd-Jones DM. Heart disease and stroke statistics-2012 update: A report from the American Heart Association. Circulation. 2012:125(1):188-197.
  2. Centers for Disease Control National Center for Health Statistics.
  3. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: A report from the American Heart Association. Circulation. 2010;121(7):e46–e215. Epub 2009 Dec. 17.

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The mission of the Sudden Cardiac Arrest (SCA) Foundation is to prevent death and disability from sudden cardiac arrest. The vision of the SCA Foundation is to increase awareness about sudden cardiac arrest and influence attitudinal and behavioral changes that will reduce mortality and morbidity from SCA.

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