While it is the death of a high-profile college or professional athlete such as Hank Gathers or Reggie Lewis that defines sudden cardiac death in sports for the general public, most of the victims are high school and junior high athletes. Their deaths are local tragedies, isolated traumas that can leave small towns reeling in pain for years. Because there are noninvasive procedures that can identify most of the young people at risk, the question of comprehensive screening inevitably arises in the wake of each new incident.
Unfortunately, any exploration of the screening issue quickly runs into the double roadblock of cost and practicality. "True broad-based screening in this country is not going to happen," says Dr. Barry J. Maron of the Minneapolis Heart Institute Foundation, who is preparing a paper on the subject for the American Heart Association.
An echocardiogram, the best test for identifying hypertrophic cardiomyopathy (HCM), the most common cause of sudden death in young athletes, generally costs around $600. Since about seven million junior high and high school students participate in interscholastic sports in the U.S., performing echoes on all of them would be prohibitively expensive.
The practical alternative to echocardiograms and other sophisticated testing for young athletes is the traditional combination of a physical exam and a medical history, the latter usually requested in a form that must be filled out by a student's parents. This can pick up some life-threatening conditions—including heart abnormalities that generate heart murmurs—but its effectiveness varies widely from program to program. As part of his study, Maron has been surveying screening programs around the country, and he has discovered a stunning variety of deficiencies. "You could argue that in a majority of our states, we cannot be sure that the screening process has any efficacy," he says. His examination of the preparticipation forms in the 39 states that require them, for instance, found these serious omissions:
•Only 20 states ask if the student's family has a history of sudden death of a young member.
•Only 21 states ask about a history of fainting.
•Only 17 ask if the student has a heart murmur.
•Only one asks if there is a family history of Marfan's syndrome, a known cause of sudden cardiac death.
"This system is not adequate to identify, with a high degree of reliability, the diseases that we know cause sudden death," Maron says. "It's not completely worthless, but it's not the best way to do it. On the other hand, the problems of practicality and cost seem insurmountable."