Can pre-competition ECG testing save young athletes’ lives?


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Mark Link, M.D. (left) and Benjamin Levine, M.D.

It’s rare for a student-athlete to die suddenly on the playing field. But anytime we hear news of sudden cardiac death in a young athlete – whether it’s in Alaska, New York, or here in Texas – we worry about our own children.

Can anything more be done to prevent such deaths? That’s the question we’re trying to answer with the help of students and parents in two North Texas school districts. UT Southwestern and Texas Health Resources are partnering to conduct a pilot study with to examine whether electrocardiograms (ECGs, also known as EKGs) can be useful in identifying high school student-athletes who may be at risk of suffering sudden cardiac death. An ECG is a quick, non-invasive electrical tracing of the heart.

The use of ECGs for athletes has been a controversial topic in recent years. No major U.S. medical, government, or sports organizations recommend mandatory pre-sports ECG screening in children. However, some groups advocate adding the screening in an effort to save young lives. In fact, Texas lawmakers in 2015 discussed making the state the first in the nation to require pre-participation ECG testing for public high school athletes. The measure didn’t pass, but the debate continues.

In general, Americans tend to think that more advanced screening equals better preventive care. However, that’s not always the case. Over-screening can lead to unnecessary further tests, procedures, and anxiety. While uncommon, some athletes also may be inappropriately excluded from competition because of their screening results.

The benefits of kids participating in sports overwhelmingly exceed the low risk of sudden cardiovascular incidents. The pluses of sports participation include improved cardiovascular function, better weight management, decreased incidence of Type 2 diabetes, and the value of learning to work cohesively as a team, to name but a few. When a sudden cardiac death occurs in an athlete, an underlying heart condition is almost always the culprit. Sports participation is nearly never to blame for sudden cardiac death in athletes, though there are rare instances when the heart can stop due to blunt force to the chest during sports (called commotio cordis).

Right now, there are no definitive data that show whether the potential benefit of ECG screening (saving lives) outweighs the potential risk (false-positive test results preventing otherwise healthy kids from competing in sports, and the risk of unnecessary and potentially dangerous treatment). With the community’s help, we can start to determine whether these tests should or should not become standard medical care for our children.

How the study will work

We’re inviting student-athletes and marching band members at high schools in the Richardson and Keller Independent School Districts to take part in the North Texas ECG Pilot Study. Marching bands, like sports teams, practice cohesively together under a band director who functions similarly to a coach. We’ve included band members in this study not only because their intensive practices and team setup are similar to a sports team, but also to serve as a baseline for whether standard ECG screening should be performed on all kids, and not just student-athletes.

At half of the high schools, students who volunteer will get the standard history and physical required for participation in school sports. At the other high schools, volunteers will have an ECG performed in addition to the history and physical.

The ECG should take five to 10 minutes to complete. Only the investigator, student, and parents will have access to the results. Schools will not see them, and the results will play no role in determining sports and band participation. If a student’s ECG results are abnormal, we’ll provide a free evaluation with a board-certified cardiologist.

The pilot study includes long-term monitoring of the student volunteers. Every six months for four years, we’ll send all volunteers a text message with a link to a two-question survey inquiring about their health.

The goal of the study

The goal of the pilot study is not to definitively answer the question of whether ECG screening should be made mandatory. To do that, we would need 100 times the participants of this study. But to get funding for such a large study, we need to show that people will volunteer, that we can follow them, and that consistent ECG screening is feasible across different cities and school districts. Ultimately, though, the goal is to keep our children healthy.

If we can prove our methodology works, we plan to apply for funding for what could be the largest randomized prospective study in the history of medicine. We hope to conduct that future study here in Texas. It’s a large-scale effort, but it’s an important issue for the kids in our community and our country.

Should I let my child participate?

Community support is vital to the success of this study. If ECG screening truly saves lives, we need to make it standard medical practice. If it doesn’t save lives, or if it keeps kids out of sports needlessly or exposes them to unnecessary risk, we need to know that as well.

We’re pleased that community members and philanthropic organizations from both sides of this sometimes contentious debate are engaged and participating in this study. Many of these people are strong advocates for widespread training and use of automated external defibrillators (AEDs), which are vital for resuscitating young people who suddenly collapse during sports events.

Still, we can’t do this pilot study without parents and students. While designing this study, we hosted a focus group for parents during which two main questions emerged:

  • Will the ECG screening keep my child from participating in sports?
  • What happens if the ECG results are abnormal?

We resolved the first question by separating the ECG part of the study from the school’s decision to allow kids to participate. Schools will not have access to the screening results. They will make their participation decisions as they always have.

The second question is a little more difficult. We know some parents are worried about the potential financial costs associated with abnormal ECG results. That’s why we decided to include a free evaluation by a cardiologist if a child has abnormal results. If a serious medical problem is still suspected after that evaluation, the parents and insurance companies will be responsible for further testing.

There’s also a potential emotional burden. Around four percent of ECG tests will come back positive for heart abnormalities. But only about 0.5 percent of patients with an abnormal reading will actually have something wrong – the rest will be false-positives. Our hope is that the free evaluation by a cardiologist for participants with abnormal results will minimize unnecessary further testing and anxiety. Some subsequent tests needed after an abnormal ECG are expensive and, like all medical procedures, they bear their own risk of complications. In the likely event that the abnormal reading was a false-positive, all of that worry, expense, and risk would be for nothing.

What’s next?

Independent of the study, if you have questions about sudden cardiac death in athletes, don’t hesitate to reach out to our cardiologists. We’re invested in the health of our young people, and we want to share resources and information to help keep kids safe on and off the field.

If your child attends a high school in one of the school districts participating in the study, you will receive a letter and consent form from the school. If you and your child would like to volunteer, simply fill it out and return it. If you have any questions about the pilot study, speak to your child’s trainer or coach. If they can’t answer your questions, they can contact the research team and put you in touch with someone who can.