Medical experts recommend ensuring children are healthy enough to play sports
BY ELLEN MITCHELL
Special to Newsday
October 10, 2006
On March 25, 2000, Louis Acompora died on the playing field at Northport High School. He was 14 years old, full of life and playing lacrosse, his favorite sport.
The ball slammed into Louis' chest. It was a routine shot, not at high speed, and Louis was wearing a chest protector. But the impact came in a split second between heartbeats, striking in just such a way as to cause a fatal arrhythmia. The teenager's life and the lacrosse ball collided at precisely the wrong time in the wrong place.
"This was Russian roulette," said Karen Acompora, Louis' mother. "It's disgusting terminology, but that's what it was."
The arrhythmia that killed Acompora's son is called commotio cordis, which translates as commotion of the heart. It is the second leading cause of death in young athletes.
On Sept. 27, 2005, at a Merrick Little League practice, 9-year-old Robbie Levine was running the bases. He had been playing baseball since he was a preschooler. On that fateful day, he collapsed at home plate and died. Robbie's father, Craig, the team manager, tried to revive his son to no avail. Robbie died of some form of cardiac arrhythmia, for which - despite an autopsy and the passage of time - his parents do not yet have a precise name.
Once, several months before his death, Robbie felt dizzy and faint while playing baseball. A pediatric cardiologist did tests and declared Robbie had "the healthiest heart he had ever seen," according to Robbie's mother, Jill.
Could either of these boys still be alive today? In Louis' case, perhaps if a defibrillator had been accessible, his heart could have been shocked back into a regular rhythm, and he might have survived. In Robbie's case, his problem might have been detected earlier if the doctor had performed more tests, in particular a stress test, when Robbie first complained of dizziness while playing ball.
Could more be done?
The tragedies call into question whether enough is being done to screen young athletes and try to identify those who may have heart problems and who could be at risk, and then to provide emergency treatment on the athletic field in the event of a sudden cardiac attack.
According to the American Academy of Family Physicians, of the estimated 10 million to 15 million athletes who participate in organized sports in the United States yearly, fewer than 300 die of sudden cardiac-related causes. Most studies say roughly one high-school-age male per 100,000 and one female per 300,000 suffer sudden cardiac death on the playing field.
Those are very low numbers ... unless it's your child, in which case it's "heartbreak for everyone," said Dr. Russell Schiff, director of pediatric cardiology at Winthrop-University Hospital in Mineola.
Schiff is among physicians who believe not enough is being done in the screening of young athletes. Winthrop is developing a pediatric program that will provide cardiopulmonary stress tests with treadmills and bicycles as well as other testing. The intent is to prevent cardiac deaths and to determine to what level children with known cardiac abnormalities can safely participate in sports.
Writing in the July 2006 issue of Cardiology Review, Dr. Daniel Montellese, a senior cardiology fellow at Stony Brook University Hospital, said most young people who suffer sudden cardiac death on the athletic field show no sign of symptoms or abnormalities before their deaths, and few undergo any form of pretesting to evaluate their risk.
Montellese said guidelines from such groups as the American Heart Association recommend that a family history and physical exam including blood pressure reading be taken, but they do not include an electrocardiogram or echocardiogram (which uses ultrasound), and surely not a stress test prior to allowing a young person to compete in athletics.
By contrast, Montellese said, in 2005 the European Society of Cardiology issued a statement mandating that every young competitive athlete undergo a standard, 12-lead EKG before participating in sports.
Schiff added that in a study done in Italy, which has had a formal national screening program mandating such an EKG since 1982, about 2 percent of would-be athletes were disqualified, and among athletes the rate of sudden deaths had fallen 89 percent since that time.
A disclaimer
However, though experts agree the Italian results are impressive, they say Italy and the United States cannot be compared, because the Italian population is more homogeneous and far smaller.
The American College of Cardiology recently said similar national obligatory screening would be difficult in the United States because of the huge number of young athletes here, the major cost-benefit considerations and the fact that it is impossible to eliminate all risks associated with competitive sports. EKGs can also yield a substantial proportion of false positive test results. The Italian study found a 9 percent rate of false positives. In this country, experts say such false positives could represent a burden to athletes and their families.
The cardiologists interviewed for this article said that although an EKG would not detect all cardiac problems, it could raise suspicion of some potentially fatal conditions. Among them is the most frequent cause of sudden cardiac death in young people, hypertrophic cardiomyopathy. In this usually genetically transmitted condition, the heart muscle of the left ventricle is abnormally thickened and may obstruct the flow of blood out of the heart.
"In the age group from ninth to 12th grade, I'd say a third to 40 percent of sudden cardiac deaths are from hypertrophic cardiomyopathy," said Dr. Frederick Bierman, chairman of the department of pediatrics at Schneider Children's Hospital in New Hyde Park. Bierman said hypertrophic cardiomyopathy may not always be apparent on an EKG and is usually not detectable by testing before the age of 14. But, he said, after that age an EKG could add information and may help identify the condition.
At Schneider, there is a special program that provides EKG prescreening for young athletes from several high schools in the vicinity. Bierman knows of no other area hospital doing this.
Slipshod requirements
The cardiologists said ideally a physician should do a detailed medical and family history, a general physical exam including an EKG, and an echocardiogram. However, some school districts require nothing more than a cursory medical questionnaire and a brief exam by a school nurse.
Montellese said any prescreening and history taking should involve parents. Asking a 12-year-old if there is any history of cardiac death in his or her family is "laughable," he said.
Dr. Stanley Weindorf of Woodbury Pediatric Associates in Plainview is a general pediatrician who for the past year and a half has been performing EKGs on all teenage athletes in his practice. He said no school districts request that he do so. "You have to realize a lot of coaches are just thinking of getting their kids fit to play in the game. They're not thinking of any medical consequences," Weindorf said.
However, the National Athletic Trainers Association, which represents some 30,000 members, just this year developed guidelines on dealing with sudden cardiac arrest during high school and college athletic practices and competitions. They recommend that all schools have an emergency action plan, with a defibrillator and a first responder trained in cardiopulmonary resuscitation on site. The association, however, does not have any formal recommendations on prescreening for high school students, according to representative Robin Waxenberg.
Weindorf, meanwhile, said he is finding "more and more" cardiac conditions, which he refers to pediatric cardiologists. It is "frightening, disconcerting" he said, that EKGs are not mandated for student athletes.
The physicians agreed that the cost of universal testing for so many millions of athletes, and the low numbers of cardiac problems that would be found, are the prime reasons prescreening EKGs are not regularly done in this country.
"Some of the HMOs refuse to reimburse for a routine EKG that is not recommended by the American Academy of Pediatrics," Weindorf said. "But we're not talking a lot of money when you think of the repercussions of even one major heart event."
"In the U.S., everything we do deals with cost-benefit analysis, how much it is going to cost, and who'll pay for it," Schiff said. "But if you can save even one life, that can't be disregarded."
Liability issues
Schiff said there also is fear on the part of the medical community. "What if I or someone else performs a test and misses something?" And, he said, he has known parents who "when things are going well" choose to avoid medical tests for children for fear of jeopardizing a possible college sports scholarship.
Bierman questioned who should or should not be screened. "What about the young girl who plays the violin and doesn't pick up a tennis racket? Probably the risk is slightly higher for those who participate in highly competitive sports, but you have sudden death in individuals who are not doing competitive sports. So how do we manage universal screening? That's a difficult question to answer," Bierman said.
Today, the Acompora and Levine families are trying to educate the public that the lives of young, seemingly healthy athletes can be taken suddenly. They are advocates for EKG prescreening and for placement of defibrillators in schools and at athletic events.
The two families are planning to hold an EKG screening session, possibly in January, which will be open to all children, because any child can harbor a silent heart condition.
Because of lobbying efforts through the Louis J. Acompora Memorial Foundation, New York State has Louis' Law. Signed in 2002, the law mandates that public schools have an automated external defibrillator on site and easily accessible at school athletic events. The law further requires that a staff person trained to render emergency aid using the AED be readily available.The AED, as Bierman explained, is not difficult to operate. It has a recording that talks the first responder through the process. Pads are applied to the victim's chest, and the machine takes and interprets an EKG. If there is evidence of a life-threatening rhythm, the device will automatically react and, hopefully, shock the heart back into regular rhythm. On the evening of Oct. 14, the Acompora Foundation is holding a Save-a-Heart Benefit at the Crest Hollow Country Club in Woodbury to raise funds for distribution of AEDs. The event will include the raffling off of three 2007 Mercedez-Benz sedans.
At Robbie's 5k Run last April in Merrick, the Levine family raised $35,000 to buy and distribute AEDs. They are now producing a short video, which they will give to Little League chapters throughout Long Island in hopes team leaders will see fit to have AEDs on the playing fields. Levine said most chapters she's contacted in the past have showed little initial interest.
But some chapters have taken the initiative on their own. About five years ago, Joe Heid, president of the Huntington-Tri-Village Little League, first ordered that an AED be available at games.
"We house the defibrillator in the field house," said Andy Terc, safety officer for the chapter. Terc trains all the directors and board members to use the AED, which, he said, "we've never had to use in five years - and, God willing, we never will."
While the Levines and the Acomporas say the public is receptive once they understand the gravity of the problem, and certainly as each tragic death receives mass media attention, sudden cardiac death in a young athlete is, for most people, "one of those things, if you don't think about it, it won't happen," Levine said.
RESOURCES
The Louis J. Acompora Memorial Foundation
631-754-1091
The Robbie Levine Foundation
The National Athletic Trainers' Association
214-637-6282
Information on the AED mandate in New York State public schools
Cardiology Review
July 2006, Vol. 23, No.7
