Cardiologist clarifies mistakes in NYT article about screening young athletes

When a news source as powerful as The NY Times publishes an article about sudden cardiac death in young people, one expects accurate information. It’s far too important a topic to write about imprecisely. This piece, entitled Should Young Athletes Be Screened for Heart Risk, included numerous inaccuracies and failed to tell important facts about the complexities of widespread screening of athletes. It was a really bad post.

I’d like to help clarify things.

Let’s state the obvious first. Few events in medicine–and life–pull at your heart more than the sudden death of a young person. As a Dad, it hurts just thinking about it. I accept that the tragic nature of the problem can cloud thinking on the matter.

As a heart rhythm doctor, I am tasked with diagnosing and treating conditions that could cause life-threatening arrhythmias. This is a tough problem. One reason is the rarity with which sudden death occurs in the young and outwardly healthy. Another is that sudden death rarely gives second chances. Its finality, therefore, motivates medical people to strive for 100% effective treatment. Again the obvious: whenever one strives for 100% efficacy, over-diagnosis and over-treatment become more likely. Never missing anything has steep costs.

Now, let’s get to the specifics of the Times’ misstatements:

On the incidence of sudden death:

As stated by author, Mr. Anahad O’Connor:

“Once thought to be exceedingly rare, sudden cardiac death is far more prevalent among young athletes than previously believed, recent research has shown.”

Not exactly. The two scientific papers described as ‘recent’ were published in 2001. In fact, the lead sentence in the referenced policy statement from the American Academy of Pediatrics states, “in the [US], there is no centralized or mandatory registry for pediatric sudden cardiac arrest (SCA)…Available data generally are collected through media reports, from lay SCA advocacy groups, or from peer-reviewed publications, often from major referral medical centers.” In other words, we have no idea whether sudden cardiac death is becoming more prevalent in the young.

On who is at risk:

“While it can strike those who are sedentary, the risk is up to three times greater in competitive athletes.”

This statement makes athletics sound dangerous. Given our crisis in youth health, that seems unwise. Here’s another way of stating the known facts. The best peer-reviewed estimate available (Circulation, 2009) for sudden death incidence (US) in young people are that approximately 100 competitive athletes die suddenly per year. Considering the tens of millions participating, the actual death rate is 0.6 per 100,000 person-years. Keeping the things that threaten our youth in perspective, and even if we agreed on a three-fold increase in risk from competitive athletics, tripling the risk to 1.8 per 100,000 person-years hardly seems dangerous. The bottom line, which should have been written clearly, is that sudden death in the young is exceedingly rare—and three times rare is still rare.

At the risk of sounding unsympathetic to Ms. Varrenti, a grieving mom who started a foundation dedicated to sudden death after her teen died, I disagree strongly with her statement that…”it [sudden death] happens all the time.”

On ECG screening:

The rarity of sudden death in the young person directly impacts our ability to prevent it. Enter the debate about screening ECGs, which I have written about previously. This is where the Times gets it really wrong. First, on simple facts, they are way off on the price of an ECG. Just trust me: no one charges 1400$ for an ECG. Most often, it’s below 100$.

More importantly, the article overstates the benefits of the ECG as a screening tool. Though it is true that an expert electro-cardiographer may detect abnormalities in many of the underlying conditions (hypertrophic cardiomyopathy, Long QT syndrome and myocarditis) predisposing to sudden death, this doesn’t mean that’s what will happen in the real world. I respectfully disagree with family physician, Dr. Drezner, who stated that newer methods of ECG interpretation are better. If anything, ECG skills have worsened. The very human skill of ECG reading has gone the way of the physical exam. It’s not taught, appreciated or desired anymore. And despite what you may have read, computers cannot interpret ECGs accurately. (Not even iPhones) The under-detection of ECG abnormalities combined with the sharp rise in over-investigating normal findings will negate the rare finding of a potential abnormality.

Can we screen all athletes?

Dr. James WIllerson, the head of Texas Heart Institute, and beneficiary of a five million dollar private grant to screen 10,000 Houston-area kids, says “if we save even one life, it would be worth it.” That’s hard a statement to argue with. And it’s certainly easier to strive for such lofty goals with 5-million-dollar grants.

Here are some questions that Dr. Willerson should have been asked:

• How would you know whether finding an ECG abnormality saved a life?
• How do you measure the emotional costs of holding a kid out of sports?
  
• Does prohibiting a kid from sanctioned athletics prevent him (or her) dying on a playground or at home?
• Will you tell us how many extra heart tests (and complications thereof) will be done in the name of saving one life?

The Times should correct (or add too) this terribly flawed story. It’s important for the youth and parents of America to have accurate information about sports-related death.

I’m no journalist, nor a precise writer, but it’s really important that educators of the public understand what we were taught in medical school: No data is better than bad data.

JMM

P.S. I am not against the use of the ECGs in individual cases in which a doctor and patient understand the pre-test likelihood of abnormalities. Rather, these comments pertain to the widespread screening of low-risk populations.

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