By David Hill

David Hill is an Assistant Editor at Athletic Management.

In his tenure as Head Athletic Trainer at the University of Nevada, Marc Paul has had to tell four of his athletes they had heart conditions. For two of the athletes, there was a happy ending: Surgical procedures repaired their heart defects and they returned to action. Unfortunately for the other two, their playing days were over.

But for at least one of them, the outcome could have been much, much worse. She was found to have a serious irregularity in her heart beat, and every time she took the floor throughout her playing career, her heart was a ticking time bomb. Nevada's screening procedures may have saved her life.

"She was extremely lucky nothing happened to her," Paul says. "Who knows how many other athletes at the college level, and especially at the high school level, have no idea they are competing with potentially fatal heart problems? It's scary to think about."

The experience made Paul rethink how he had previously screened athletes for heart problems, which entailed a physician listening with a stethoscope during the pre-participation physical exam. Although his procedures had worked in this case, he realized the diagnosis could have easily been missed. He now has a cardiologist come to all PPEs to listen to his athletes' hearts. And he has a portable electrocardiogram on site.

Like Nevada, a small but growing number of athletic departments in the United States have revamped the cardiac screening portion of their pre-participation physical exams (PPEs). And many other athletic departments are wondering whether they should do the same.

RESEARCH & RECOMMENDATIONS
The latest round of discussion about heart screenings has been prompted by developments in Europe. For more than a generation, Italian teenagers have been given electrocardiograms before being allowed to participate in organized athletics. Recently, researchers at the University of Padova examined the huge database of results and determined, among other conclusions, that full electrocardiograms were 77 percent more effective in finding hypertrophic cardiomyopathy (HCM), an underlying condition responsible for about a third of sports-triggered sudden heart deaths, than was simply listening to the heart through a stethoscope and relying on cardiac histories. The researchers also concluded that the electrocardiograms were effective in screening for other hard-to-detect heart abnormalities that can lead to sudden death in young athletes.

In response, the International Olympic Committee's medical commission recommended in December 2004 making electrocardiograms part of PPEs. That was followed by a similar recommendation by the European Society of Cardiology. The question arose among American cardiologists: Should we do the same?

The answer boiled down to this: It would be a good idea, but it is unrealistic to recommend heart screenings as a national standard. The American Heart Association (AHA) and the American College of Cardiology have not altered their consensus statements on PPEs, which do not call for electrocardiograms (or echocardiograms) as a matter of course, but say instead that they are appropriate for athletes with a family or personal history of heart problems.

One of the leading authorities on HCM, Dr. Barry Marone of the Minneapolis Heart Foundation Institute, wrote a commentary for the European Heart Journal, which published the Italian studies, explaining that such a policy is not likely to be adopted in the United States given the large number of athletes and the expertise necessary to analyze the test results. Though electrocardiograms can be conducted for under $100, only experienced cardiologists can reliably interpret the data. Marone also noted that because abnormal results aren't definitive, they can lead to false positives, either needlessly denying sports participation to athletes or requiring further testing that is expensive and often unnecessary.

The NCAA concurs, explains Michael Krauss, Chair of the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports and Team Physician at Purdue University. "Someone wrote a letter to our committee saying they wanted every NCAA athlete to see a cardiologist before participating in college athletics," Krauss says. "We thought, 'Wait a second. Some of these schools are struggling just to get every athlete to see a doctor before they play.' It doesn't make a lot of sense for an organization like the NCAA to issue mandates that are out of line with what the American Heart Association says should be done."

However, Krauss adds that a general recommendation is just that: a recommendation. Every school must determine, based on its resources and situation, whether routine heart screenings can be accomplished. And, in doing so, more and more schools are finding that--with a little help from their local medical communities--such screenings are possible.

SCHOOLS THAT SCREEN
Georgia Tech is one school that conducts extensive heart screenings. All incoming athletes receive an electrocardiogram, which is read by a cardiologist, and many are also screened through an echocardiogram.

The key is the availability of John Cantwell, the school's team cardiologist, and his colleagues in an Atlanta cardiology practice. Cantwell, a former college basketball player, was the head of medical operations for the Atlanta Olympics, and is a big believer in preventive medicine.

Cantwell says the electrocardiograms are used initially to screen all athletes because certain conditions are detected only through heart-voltage abnormalities or other signs that show up on the test, and because the baseline data can provide information to help doctors make a diagnosis if a condition arises later. "It's a fairly inexpensive and painless test," Cantwell says. "It takes only a couple of minutes."

Cantwell or colleagues from his cardiology group in Atlanta read the results and listen to the hearts of all incoming athletes at physicals. If there are abnormal readings or signs of a predisposition to cardiac conditions on the history questionnaires, the doctors may then order echocardiograms, stress EKGs, cardiac MRIs, or other tests to hone in on a diagnosis. In addition, echocardiograms are automatically given to all incoming athletes in football, volleyball, and basketball because of their sports' heavy cardiac demands, and because tall athletes are more likely to have Marfan's syndrome, which can include a potentially dangerous deformity of the aorta near the heart.

Purdue University also conducts preventive screenings, although they are less extensive than Georgia Tech's. Instead of electrocardiograms, they use scaled-down echocardiograms that are scheduled as part of the pre-participation process for athletes, but aren't mandatory. Purdue is able to conduct the echos through a relationship with an Indianapolis cardiology practice that has found ways to streamline the process. Technicians are specially trained to take limited readings, which makes the process quicker and more affordable, costing about $35 per athlete.

"The technicians capture two or three views with some flow studies that take about two and a half minutes," Krauss says. "The cardiologists have worked very hard to educate the technicians on how to get it done quickly."

The limited echo doesn't pick up all the causes of sudden death, but it can uncover HCM. "The arguments against more extensive screenings are really just about time, finances, and available expertise," Krauss says. "A full echo costs $1,000 and thus wouldn't be feasible. At Purdue, it costs about $75 to do an EKG. We're doing the echos for half that cost, so we figure that's a good value."

Large university athletic departments aren't the only ones screening. In South Carolina, five high school athletes died between 2002 and 2004 partially due to undetected heart conditions. In response, several high schools in the state have found ways to screen without breaking their budgets.

Brookland-Cayce High School in Cayce, S.C., started a screening program with help from The Imaging Co., which supplies doctors' offices with portable echocardiogram equipment. The company charges $50 per athlete, which is subsidized through a non-profit organization, Athletes for Life, and waived for athletes whose families can't afford it. The organization pays a cardiologist who reviews the results for a reduced fee.

Student-athletes are called from class one at a time to the athletic training room and screened by a technician who videotapes the examination for the cardiologist's later review. The equipment used at Brookland-Cayce also allows for a scaled-down EKG to be conducted simultaneously through leads attached to the athlete's chest. A report is generated and copies are sent to the family and athletic department.

"No single test is a guarantee that an athlete has no heart condition of any kind, but our philosophy is there is a lot of information to be gained from screening echocardiograms," says Brian Blackburn, Brookland-Cayce's Head Athletic Trainer.

At Dutch Fork (S.C.) High School, A Heart For Sports, a Yorba Linda, Calif., non-profit foundation formed by a family who lost several members to HCM, helped the school screen 140 winter athletes in 2003-04 with echocardiograms. Athletes were charged $50, and the fee was reduced or waived for low-income families.

"We used three or four portable machines, and A Heart For Sports had a cardiologist come and supervise everything," says Mack Harvey, Assistant Athletic Director and Head Athletic Trainer at Dutch Fork. "They saved the data and the cardiologist went back later and reviewed it once more to make sure he didn't miss anything. Luckily, everybody was negative."

Dutch Fork conducted a second screening the following fall, but attendance was low so the school hasn't planned any since. However, Harvey will help athletes get a more thorough exam if a PPE turns up signs of trouble.

AT THE READY
Rather than screening all athletes with echos or EKGs, some schools are opting to have the technology on hand at physicals, allowing them to immediately test athletes who raise red flags. This had been the practice at Nevada since its scares.

"Our physical exam process starts with family practice physicians and residents, and now we also have a cardiologist present with a portable EKG machine," says Paul. "If a physician picks up an abnormality on an athlete's exam, they immediately send the athlete over for an EKG. The cardiologist reads it right there. If they see something and we need to do an echo, it's arranged, and the athlete can go to the cardiologist's office the next day.

"Before we had the EKG machine at our physicals, we'd have to call ahead and schedule an EKG a week or so down the road," Paul continues. "In the meantime this kid is sitting here with a lot of anxiety."

A Nevada team physician arranged the expertise, Paul says. "She knows a lot of cardiologists from a particular group in town," he says, "and she told them, 'We've had these incidents come up, and we'd really like for you to be here.' They volunteer their time."

Spring Valley High School, another school in central South Carolina, follows a similar protocol. It took up the offer of a nearby hospital's sports-medicine outreach program to provide two portable echocardiogram machines and technicians for a voluntary, one-time heart screening event. Athletes who answered yes to one or more questions about their personal and family heart histories during PPEs were tested, explains Ron Caldwell, Head Athletic Trainer. Thirty-five student-athletes turned out on a Saturday morning, and after the questionnaires were administered, 13 were given echocardiograms.

General-practice physicians and orthopedists were present, but the echocardiograms were analyzed later by an off-site cardiologist. The hospital didn't charge, but the school collected $10 from each student as a fundraiser for its sports-medicine program. "We're going to do it again," Caldwell says. "The parents who came to the clinic were very impressed. I'm sure it was worth the money and time."

SMALL STEPS
For schools that choose not to use any echos or EKGs, there are still ways to improve the cardiac exam during PPEs. The first step is to simply make the testing area quieter. At Dutch Fork, there is a quiet room set aside where doctors can better listen for murmurs or other audible indications of trouble, Harvey says.

The second step is to use an extensive history questionnaire. Many of the major heart disorders that can prove dangerous to athletes are hereditary. Thus athletes and their parents should be asked if any relatives have a known heart condition or have died suddenly of anything heart-related before age 50. Athletes should also be asked if they've experienced shortness of breath, chest pain, dizziness, or a rapid or erratic heartbeat during or immediately after exercise. A "yes" can be a red flag warranting further investigation.

Georgia Tech has developed an extensive personal- and family-history questionnaire for all incoming student-athletes that's now a separate page in its pre-participation medical form. To encourage athletes' parents to help with the family-history section, the form is sent by mail to incoming athletes' homes before the year starts. (See "Heart History" at the end of this article.)

One more option is to have a cardiologist on hand, even if they don't have their best tools with them. Camden (S.C.) High School decided not to screen everyone with a high-tech device, but instead have a specialist from the local cardiology practice present at preseason physicals. The specialist steps in when the general-practice physicians notice something amiss while listening to an athlete's heart through a stethoscope, or when a student-athlete's history form turns up something out of the ordinary.

DIALOGUE NEEDED
Because there are more questions than answers when it comes to choosing the best way to conduct cardiac screenings, the key is to discuss the options within your own department. "There are a lot of doctors who feel that if there is no family history of cardiac problems, you're wasting your money," says Blackburn. "There are still a lot of questions.

"But that's why it's good to debate the issue and to have some dialogue," he continues. "Some of the cost-benefit studies aren't necessarily taking into account that here at Brookland-Cayce, we're screening athletes for $50 and it's voluntary. If it gets to the point where routine testing can be done for even less, the cost-benefit argument goes right out the window. We may be ahead of the curve, but we just feel, especially with what happened in our state, that we want to be proactive and offer this."

A version of this article is also appearing in Training & Conditioning, a sister publication of Athletic Management.

Sidebar: HEART HISTORY
Georgia Tech uses the following questions in its personal- and family-history questionnaire.

• Has anyone in your family had a heart attack before age 55?
• Does your heart ever beat fast or skip a lot of beats?
• Have you ever passed out or fainted during exercise?
• Have you ever had chest pain, tightness, pressure, or any discomfort during exercise?
• Have you ever been told you have high blood pressure?
• Have you ever been told you have a heart murmur?
• Have you or any relative been diagnosed as having marfan's syndrome, Hypertrophic Cardiomyopathy, or IHSS?
• Have you ever been told that you have a "heart problem?"
• Have you ever been restricted from sports competition?
• Have you ever been hospitalized for any non-orthopedic reason?
• Please list any supplements or herbs you take other than vitamins.

Sidebar: LEGAL ISSUES
Along with understanding the various options for screening athletes, administrators should know the legal implications of heart testing and clearance-to-play procedures. When an athlete dies, a lawsuit can easily follow.

First, it's imperative that you review your PPE procedures. They should state that an athlete cannot participate until their PPE form is signed. And the form must not be signed until all clearances are confirmed.

For example, in one recent lawsuit, a physician's assistant detected a heart murmur in a junior-college basketball player. The player was referred for an echocardiogram, and the cardiologist recommended the player stop playing basketball. But the clearance form had already been signed, and he kept playing, only to collapse and die. In another case, the PPE was put off, and a high school football player with a known heart murmur and an abnormal EKG died on the second day of preseason practice.

Second, you should not feel pressured to give medical clearance to an athlete with a heart condition, even if it is the family's wishes. Courts have set precedents that schools may bar athletes from their athletic programs if the risk of death from a heart condition is too great. A federal appeals court sided with Northwestern University when a basketball player sued after he wasn't cleared to play. In a similar case, an Ohio high school student and his parents were willing to sign a waiver of liability to get clearance in spite of heart concerns, but the court sided with the school in not agreeing to the waiver.

When deciding whether to give medical clearance, doctors may refer to a document known as the "Bethesda Conference." This is the November 2004 consensus opinion of experts convened by the American College of Cardiology regarding clearance decisions for athletes with heart conditions. It outlines cardiac and circulatory conditions that may affect athletes and gives detailed protocols for deciding when to limit participation, For example, the document advises that athletes with confirmed HCM be held out of competitive sports except possibly low-intensity activities such as bowling, golf, and rifle.

Finally, you should make clear to athletes and their parents that any testing you do is not foolproof. At Brookland-Cayce High School in Cayce, S.C., an extensive consent form spells out that because the tests can't catch every condition, a negative result should not be seen as proof that an athlete has no serious problem. "We tell them up front this is not the test to end all tests," says Head Athletic Trainer Brian Blackburn.