Cardiac Safety and Screening in Teen Sports: A Q&A With Dr. Cory Noel

Dr. Cory Noel is a pediatric cardiologist in Anchorage at Seattle Children’s Pediatric Cardiology of Alaska.

How common is cardiac death in teen sports?

Dr. Noel: Sudden cardiac death is a rare occurrence, making it a challenge to get accurate numbers. Studies show different rates depending on what they’re looking at, what ages they cover and whether or not the children survived. A general estimate is 1 occurrence in every 80,000 to 100,000 children per year. However, when accounting for sudden cardiac arrest, that number is lower, at approximately 1 in 20,000.

The most common cause of sudden death in young competitive athletes is the inheritable condition hypertrophic cardiomyopathy (HCM), but other causes include a variety of congenital coronary artery anomalies, myocarditis, dilated cardiomyopathy and aortic dissection, as well as rhythm disturbances such as long QT syndrome (LQTS), arrhythmogenic right ventricular cardiomyopathy (ARVC) and catecholaminergic polymorphic ventricular tachycardia (CPVT).

How helpful are sports clearance screens in spotting at-risk kids?

Dr. Noel: They’re helpful, but there’s unfortunately not yet a gold standard for cardiac screening. Identifying at-risk athletes in the sports clearance process is like trying to find that needle in the haystack. These athletes often appear perfectly healthy and have no known family history of cardiac problems.

Is an electrocardiogram (ECG or EKG) recommended for back-to-sports screening?

Dr. Noel: Not officially. In the United States today, the standard sports clearance process includes taking a thorough personal and family history. The American Heart Association specifically recommends a 14-point cardiovascular screen that includes both a history and physical exam designed to tease out the signs, symptoms and physical abnormalities that would prompt a more thorough evaluation with a cardiologist.

The 14-point cardiovascular screen includes:

MEDICAL HISTORY (Parental verification recommended for middle/high school athletes)

• Personal History

1. 1. Exertional chest pain/discomfort
   2. Exertional syncope or near-syncope
   3. Excessive exertional and unexplained fatigue/fatigue associated with exercise
   4. Prior recognition of a heart murmur
   5. Elevated systemic blood pressure
   6. Prior restriction from participation in sports
   7. Prior testing for the heart ordered by a physician

• Family history

1. 1. Premature death – sudden and unexpected before age 50 years due to heart disease in one or more relatives
   2. Disability from heart disease in a close relative under 50 years old
   3. Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy, LQTS or other ion channelopathies, Marfan syndrome or clinically important     arrhythmias

• Physical exam

1. 1. Heart murmur* – exam supine and standing or with Valsalva, specifically to identify murmurs of dynamic left ventricular outflow tract obstruction
   2. Femoral pulses to exclude aortic stenosis
   3. Physical stigmata of Marfan syndrome
   4. Brachial artery blood pressure (sitting, preferably taken in both arms)

*Murmurs that intensify with Valsalva or standing abruptly from a squatting position are particularly concerning for hypertrophic cardiomyopathy.

An EKG is not part of the screen. However, studies show the EKG is a much more sensitive measure to detect underlying cardiac conditions than family history and a physical exam alone. A group of researchers, including Seattle Children’s pediatric cardiologist electrophysiologist Dr. Jack Salerno, conducted a study several years back comparing an EKG with just the 14-point questionnaire. It concluded overwhelmingly that the added sensitivity of the EKG did aid in diagnosing underlying cardiac conditions that could be potentially lethal for an athlete. It also showed that using a specific set of criteria in interpreting the EKG could dramatically decrease unnecessary testing.

• Read about the study

Incorporating an EKG into sports screening is becoming more accepted in the United States for athletes considered higher risk, and is standard in some other countries, including Italy, as well as different organizations such as the International Olympic Committee, where they have been shown to significantly improve detection. In some cases, such as Italy, this may be due to differences in their population having certain groups at higher risk for arrhythmia.

There is some debate within the American medical community right now about adding EKGs to sports screenings. We know it can help us spot kids who would otherwise be missed. On the downside, cost is a big factor because of the extra financial burden it would place on some families. It could also lead to more unnecessary testing and be an added burden to the people and facilities doing the tests. This was such a key feature of the article by Dr. Salerno because the group demonstrated they could significantly minimize the number of additional tests.

Why do you encourage EKGs in sports screenings?

Dr. Noel: In our practice, we have a sports cardiology clinic, and we screen all athletes with an EKG. I always say a serious athlete should have an EKG, purely in terms of the added sensitivity in detecting cardiac problems. Being active and playing sports are to be encouraged, particularly as we continue to see rising preventive cardiac disease and obesity in childhood, and at the same time we want to be sure kids are playing safely — particularly those involved in high-intensity training in their high school years.

In my earlier work as a pediatric cardiologist in Texas, we ran a multiyear program that screened thousands of regular teen athletes — not previously diagnosed heart patients — using a combination of history, exam and EKG. It resulted in a handful of kids with life-threatening cardiac issues being identified. I remember two who had hypertrophic cardiomyopathy and two with anomalous coronary arteries, all of which are high-risk conditions. These kids may have slipped through a standard history/exam screening.

Which young athletes need that extra level of EKG screening?

Dr. Noel: This is a difficult question; because sudden cardiac arrest is such a rare occurrence, it is difficult to really risk-stratify. However, there are some sports in the United States like basketball, football and soccer that have a higher propensity for cardiac death than other sports like tennis, lacrosse or swimming. I have a lower threshold for ordering EKGs for athletes in these higher-risk sports and, really, on any kids who are participating in high school athletics with intense training. For these athletes, I always recommend taking that next step and getting the EKG and having it read by a pediatric cardiologist. Additionally, anyone with a family history of cardiac issues warrants special attention; many heart diseases are inheritable.

I always make sure to tell pediatricians that if a child has even mild abnormalities or if there’s even the smallest question in the back of their mind about whether the child is safe to play, we welcome the opportunity to see those kids to make sure they’re safe.

What happens in a follow-up cardiac screening exam?

Dr. Noel: We do a thorough family history, examine them and do an EKG. We try to keep any time away from their sport to a minimum. I emphasize to my athletes not to hold back on their answers. They sometimes feel a certain degree of apprehension. They might worry that if they say they’ve had chest pain, they’ll never play again. I tell them that I know they want to play, I want to make sure they’re safe and it may just be a single additional test, but we can probably do it all in the same day and get them back to playing. For many of the common complaints we see, we can feel comfortable giving clearance the same day as the visit.

Do athletes need a referral for a cardiac sports screening?

Dr. Noel: Yes, a referral from a primary care provider is required. Parents calling to schedule should request a cardiology clinic visit for the purpose of sports clearance. Their child will be scheduled for the next available appointment or for a sports clearance clinic day if there is one upcoming.

What can PCPs tell their young athletes about cardiac care?

Dr. Noel: I think it comes down to this: overall, we want teens being active and playing sports and doing it in as safe a way as possible. We also need to be advocates for safety in athletics, and with that comes verifying. Just like we might use the doctor visit to ask about guns in the home, we want to be taking the same steps in looking out for cardiac safety. Ask if their school has an automatic external defibrillator (AED) action plan, whether they practice it and whether they have a trainer onsite who knows how to use the AED. Not having an AED or having one but not knowing what to do with it can lead to delayed response, neurological injury or even death. A properly executed AED action plan is one of the most effective ways to prevent sudden cardiac death.

And it’s always good to emphasize the connection between a healthy heart and hydration. Educate athletes about the importance of proper hydration, especially in hot weather or when playing in the sun. Proper hydration for an event should absolutely begin the day before. Athletes should be drinking at least 100 to 120 fluid ounces a day during competition. Kids playing a sport should have 12 ounces of water 30 minutes before the activity begins, then at least 10 gulps every 20 minutes during the activity, plus at least 10 gulps every 20 minutes in the first hour after the activity.

At what point does insurance cover an EKG?

Dr. Noel: It depends because insurance can be so variable. There is an ICD code for sports clearance, but all insurance may not cover that. But that is why an answer on any of the screening questions can be helpful; murmur, shortness of breath, chest pain and family history of cardiovascular disease should all justify an EKG.

Where does Seattle Children’s offer cardiac sports screening?

Dr. Noel: We offer designated sports clinic days throughout the year; coming up are clinics in Anchorage on Aug. 10 and 17, 2020. Alternatively, families can schedule a cardiac clearance visit with any of our cardiologists at the hospital or regional clinics at any time. The screening performed is the same either way.

Additional resources for cardiac sports screening:
• Nick of Time Foundation: offers EKG Youth Heart Screening
• UW Sports Cardiology

What is your reaction to recent news reports about cardiac problems in athletes who had COVID-19? 

Dr. Noel: Any time you have a fairly new disease, it is a learning process, which is clearly evident, as we begin to understand the pathophysiology, associated complications, and the vulnerable populations. With COVID-19, we are beginning to understand the potential cardiac complications, particularly in the pediatric population. We are seeing some patients who have had an infection with COVID-19 have a subsequent cardiac dysfunction complication, similar to myocarditis. Myocarditis is a known pathology, and accounts for roughly 10% of sudden cardiac death in athletes. In fact, there has been one major league baseball player who will miss this season for this very pathology after having COVID-19.

It is this association with myocarditis that is giving many university athletic departments pause about fall sports. Just as we see when it comes to sports screening in general, there is variability in how to approach athletes that have had a previous case of COVID-19. Some of the data that has come from the limited studies has shown that this is a real issue. It seems one commonality among all of the different universities and from assessing their athletes, is that those who previously had symptoms with COVID-19 are being screened with at least an ECG. There are some universities that are going further with blood tests and echocardiograms, but I would say an ECG is a very good place to start. In light of this information, I would recommend that any athlete who previously had symptoms from COVID-19 see a pediatric cardiologist and have an ECG performed, and depending on that visit and those results, additional testing before resuming athletic competition. For those athletes who were asymptomatic from COVID-19, I would recommend being highly vigilant with regards to sports clearance, and keeping a low threshold for referring to a cardiologist.

For your patients and families: Read “Returning to Sports Safely During COVID-19.” Our athletic team outlines questions families can ask and information to look for so that they can make the most informed choices around re-engaging their child safely into sports. This article compiles recommendations from the Centers for Disease Control, Washington State Department of Health, Washington Interscholastic Activities Association, National Federation of State High School Associations, and Korey Stringer Institute.