Screening for Heart Defects in Young Athletes
by Dr. Wesley Covitz
How can it be that a seemingly healthy 16-year-old can fall and die right there on the basketball court just as the ball leaves his hands? And why didn’t anyone know that the 8-year-old who lived to play football had a heart defect that made the game a deadly sport?
We’ve known about sudden cardiac deaths among young athletes since I first trained in pediatric cardiology more than 30 years ago. We knew then about the rare heart defects that cause them. The shock and anguish haven’t changed much either. I’ll tell you what has changed. Parents. They are more educated than ever – and more insistent that their children be screened and protected.
A father in Greensboro had coached his son for years in basketball, and now that the boy was 15 and played varsity ball, the father still hung around the court during practice to watch. Last year he noticed that his son, always so fit and strong, was having trouble during practice catching his breath. He could still hit his shots but he couldn’t keep up with his team.
This wasn’t the boy the father knew.
First the father took his son to a lung specialist. That doctor found that the boy’s lungs were clear. Then he brought the boy in to see me. I suspected a heart defect called hypertrophic cardiomyopathy and confirmed the diagnosis with a sonogram that showed a thickening of the wall between the left and right ventricles of the heart. The defect is the most common cause of sudden cardiac death.
We implanted a defibrillator, which will automatically shock his heart if the defect ever causes cardiac arrest. Patients with the defect can lead active lives, but the most strenuous sports still pose a danger. I told my patient that he couldn’t play varsity level sports, because at that level the game is simply too strenuous. But he’s back playing club basketball and thriving so well that I feature him when I give medical talks about sudden cardiac death.
Sudden cardiac deaths among young athletes are rare, but that doesn’t make them any less shocking. Heart defects are more common in boys than in girls. And basketball seems to be the riskiest sport, we think because of the quick sprints. There is no central registry for these deaths. Studies suggest that in the U.S. fewer than 70 young athletes die of sudden cardiac death each year. So the risk is minuscule. Fewer than 1 out of 100,000 young athletes -- .6 to be more precise – will collapse and die playing sports.
Hypertrophic cardiomyopathy accounts for half of these sudden deaths. The condition is inherited but often develops when the patient is in his late teens or early twenties. Some patients report an arrhythmic heartbeat or shortness of breath. But often there are no symptoms. We don’t know exactly why the defect leads to death, but we believe that under exertion blood can’t reach the vessels in the thickened wall and the heart stops.
There are other, even rarer, defects. Some children are born with defective coronary arteries. In a normal heart, the two coronary arteries branch off the aorta and carry oxygen rich blood back to the two ventricles in the heart. When the arteries are defective, they start as the same branch from the aorta, with the left artery then branching from the right or the right from the left. The defect leads to kinks, which means that blood flow to the heart is interrupted. Other defects affect the aorta, and can be just as deadly. Often there are warning signs. Athletes may pass out in the middle of practice or during a game. Some report arrhythmic heartbeats.
Routine health exams don’t pick up these defects. In Italy, all athletes are screened with electro cardiograms, or EKGs. Some medical experts pressed for a similar requirement here, but EKGs miss many of these defects and produce so many false readings in children that in my view they create more confusion than answers.
I’ve seen the confusion caused by EKGs in my own practice at Brenner Children’s Hospital. About a year ago, a study found that children on medication for ADHD were at higher risk for heart trouble. My office was flooded with referrals. About a third of EKGs sounded a false alarm. In the end none of the patients we screened were diagnosed with heart disease.
Overall, most children referred to me turn out to be fine. In most cases, I find a benign explanation for shortness of breath, fainting or chest pain. But when I do find a defect the diagnosis can save a life. One recent patient fainted taking a jump shot. A CT scan showed one of those rare coronary heart defects I mentioned earlier. Heart surgeons here at the children’s hospital repaired the defect and today he’s fine.
I believe in striking a balance between saving lives and expensive screening measures. I don’t believe it’s practical to screen all athletes playing youth sports with sonograms and CT scans. But I do recommend screening children with symptoms, whether that’s chest pain or shortness of breath. Children in families with a history of heart defects in children should also see a cardiologist. But heart disease in adult relatives generally is not a risk factor for heart defects among children in the family. And certainly any young athlete who collapses without warning should be screened for heart problems. Finally, it’s important that children and teenagers see a pediatric cardiologist. We’re trained to diagnose these rare defects in children, often missed by routine physicals and tests run on adults.
Don’t panic next time you hear about a sudden death on the ball court. But play it smart. The dad I told you about from Greensboro did. He noticed his son’s shortness of breath and I believe he saved his son’s life.