The Screening Debate

by Whitney Harding
Jan 27, 2010

Doctors point out that not all athletes with enlarged hearts are at risk of heart failure, the unexpected cause of death of Chicago Bears defensive end Gaines Adams earlier this month.

But as a result, the NFL Cardiovascular Committee is considering the possibility of making echocardiogram heart scans mandatory for all players, starting with potential draft picks this year.

“NFL [Players Association] medical director Thomas Meyer told ESPN that the medical examiner who performed an autopsy on Adams stated the enlarged heart that led to his death could have been detected by an echocardiogram,” said Chris Mortensen, reporting for ESPN.

But just because someone has an enlarged heart, it does not mean they have a fatal heart condition, emphasized Dr. Mark Hutchinson, professor of orthopaedics and director of sports medicine at the University of Illinois at Chicago.

Any athlete in any sport could have an enlarged heart from their conditioning and endurance training. The heart, in common with any other muscle, is going to get bigger if you give it a constant workout, doctors said.

The most common heart condition seen in these sudden deaths of athletes is called hypertrophic cardiomyopothy (HCM) – a condition where the walls of the heart are too thick. This causes the heart to pump less efficiently and work harder. When the effort is too great, young, healthy people can have heart attacks or go into cardiac arrest.

“While HCM does lead to an enlarged heart, an enlarged heart by itself is not HCM,” Hutchinson said. “It is like the flawed logic that poodles are dogs; therefore all dogs are poodles. One does not imply the other.”

The echo is “the most sensitive, non invasive test we have” for detecting HCM, said Dr. Kousik Krishnan, a board certified cardiac electrophysiologist and assistant professor of medicine at Rush University Medical Center. However, just because it is the best scan available does not mean it is fool-proof.

With athletes, pictures can be deceiving and then things get complicated.

“It’s like lifting weights makes your biceps bigger,” said Dr. Robert Bonow, chief of cardiology at Northwestern Memorial Hospital. “So if you’re a super athlete, your heart is going to get bigger.”

The fact that professional athletes may already have larger hearts than the normal population is what makes detecting HCM tricky.

“A number of those patients are going to not have a problem,” but they may be considered at risk as a result of the screening, Hutchinson said. “Then, they do a cardiac injection – they put dye into the heart and see how it works. So now, you’re more invasive for a false positive.”

Another problem with detecting HCM is the symptoms. A few of those clues are chest pain, shortness of breath, unexplained dizzy spells or passing out. While the more serious end of the symptoms may seem more obvious, the less obvious symptoms could be construed as something else. For instance, a coach may think the athlete isn’t in good enough shape.

“These people don’t have a lot of symptoms,” Krishnan said. “I mean, Gaines Adams was at the highest condition – how could he have anything wrong? Symptoms are subtle, so people blow them off.”

An example of this was seen in marathon runner Ryan Shay at the 2008 Olympic trials in New York. Shay collapsed five miles into the race and died. His condition was slightly different than HCM – he suffered from an irregular heartbeat caused by an enlarged heart and had scar tissue in his heart. He had shown symptoms but those were attributed to the flu. Sorting out symptoms related to several conditions is another challenge.

So where to go from here? Should all professional athletes have to undergo full screening? What about college and high school athletes? The answers are varied.

“This has been a debate for a long time and I would be cautious saying one answer is the right answer,” Hutchinson said. “The best recommendation is a strong screening history, and that is what everyone does across the NCAA. Once positive, if those people have symptoms, then they go for further testing.”

Krishnan said the screening process as it is, does not do enough and more echoes need to be done.

“Clearly at the highest levels, spending money on these screens shouldn’t be a problem,” he said.

But then, there’s the legal issue of athletes’ rights to refuse testing to protect their careers.

“You may have an enlarged heart from being an athlete and not have a problem,” Krishnan said. “But if it comes back enlarged, no one will want to sign you. So there may be some legal issues where these pro organizations can’t screen anyone, because athletes want the right to be screened or not.”

HCM is not a disease that is growing in the United States. Krishnan said that simply, when a healthy athlete dies, it gets a lot of publicity. But nothing about the disease itself has gotten worse over the years.

Hutchinson said to look at the bottom line, that very few athletes have this condition and the cost of echocardiograms for all athletes at this point is over the top. He believes that more research is needed and not a hasty decision.

“The key here is we can’t really in all honesty say one football player dies and jump in and say everyone needs this,” he said. “What I would say is when these things happen, that should alert us to go look at the science and not make a dropkick decision.”

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