The Athlete Heart Research Study: Investigating the Use of Ultrasound and EKG as Screening Tools for SCD in Young Athletes

Santosh Menon, MD, FACC, Medical Director, Carl and Edyth Linder Heart Failure Treatment Center, The Christ Hospital, Cincinnati, Ohio
Santosh Menon, MD, FACC, Medical Director, Carl and Edyth Linder Heart Failure Treatment Center, The Christ Hospital, Cincinnati, Ohio

The number one cause of death for today’s youth athlete might surprise you. 

While concussions receive nationwide attention, sudden cardiac death (SCD) is taking the lives of young athletes at an alarming rate. SCD affects more young adults than widely perceived, with a young athlete dying once every three days in the U.S. (6 per 100,000). Tragically, SCD happens in an instant and, most commonly, without any warning signs. 

Today, the screening tests young people undergo prior to engaging in athletic activity involve a standard physical and a basic review of family history. Many times these evaluations miss underlying, previously undetected heart conditions that can result in a horrible on-field death. Keeping in mind the tragic outcome and devastation these unexpected events have on the victims and their families, friends and communities, we must do something more to keep our young athletes safe.

As a heart failure specialist with a son who is a highly competitive rower, I had a unique opportunity to research what other screening tools could be used to help prevent SCD. Specifically, electrocardiograms (EKG) and echocardiograms (echo) have both shown promise as effective tools at diagnosing the conditions that lead to SCD.

Screening High School Rowers with EKG and Ultrasound

Over time, my son and I noticed a pattern in his competitive rowing teammates. Most of the athletes participate in only one sport per year and tend to be about the same size and fitness level. The sport also uniquely involves aerobic and resistance training. This group of athletes appeared to be the perfect sample for a study on cardiac indications for SCD and what the hearts of highly trained athletes look like. After we reviewed the literature, we found a paucity of data on this particular group of athletes.

While there is quite a bit of research on adult athlete SCD, there is surprisingly little data on youth athletes. For instance, professional athletes like NBA players undergo a thorough cardiac evaluation that includes both EKG and echo. Other countries also have more rigorous screening than the U.S.; for example, Italy requires all young athletes to have an EKG. 

While the extra costs and rate of false-positive results are cited as reasons that the EKG and echo aren’t used for screening in this country, I was in a position to conduct research on their effectiveness.

In collaboration with The Christ Hospital Health Network, The University of Mississippi Medical Center, Cincinnati Children’s Hospital Medical Center and USRowing, we recently began a research project to screen for SCD in high school rowers. We set out on the project with three distinct goals in mind: 

  1. Define and enhance the data on what constitutes a young athlete’s heart. The rigorous training that high-performing athletes undergo creates changes in the heart that are different than average. Many times, doctors mistake these natural changes as problems, which can result in false-positive outcomes. This study will help distinguish what is considered normal for athletic hearts versus the real presence of heart abnormalities.
  2. Evaluate the efficiency of EKG and echo as screening tools for SCD and determine their cost-effectiveness.
  3. Determine what changes occur naturally in a young athlete’s heart after two to three years of consistent aerobic and resistance training.

With the objectives established, we needed a fairly large group of rowers who could be examined with EKG and echo. As with any top-level athletes, and particularly high school-aged kids, the demands on their time from coaches, school and parents made it difficult to find time for the screening. 

Therefore, we set our sights on the USRowing Youth National Championship, held in June 2013 in Oak Ridge, Tennessee. This regatta is the top competition for high school-aged rowers — it offered a perfect set of potential athletes to image.

After consulting with USRowing, the organization agreed to participate in the study and sent information to their coaches on SCD, the screening tests we would perform and a place for athletes to register at the event. We very quickly had 45 participants signed up — the maximum we could image in one day of competition. 

In the meantime, we imaged 10 local athletes in Cincinnati to establish protocols and prepare for the screening at the National Championship meet.

During this testing, we evaluated the athletes for the most common indicators of SCD: left ventricular hypertrophy beyond the normal thickening in athletes, left and right ventricular dilatation, abnormal left and right ventricular ejection fraction, and any irregular strain patterns. 

Phase one of screening 10 local athletes found some abnormalities that resulted in further follow-up examinations.

Imaging the 45 athletes in the midst of the biggest competition of the year was no easy feat. We partnered with Toshiba America Medical Systems, Inc., who provided two of its Aplio500 CV systems, their most advanced cardiac ultrasound system. We also rented a truck and set up a tent to image the athletes. After the athletes completed their competition and were inactive for a minimum of six hours (to ensure a resting state and hydration), we performed the EKG and echo. 

It is also worth mentioning the role that the latest ultrasound technology played in the imaging of these athletes. The Aplio 500 CV delivered beautiful image quality, advanced visualization capabilities and workflow automation tools in a compact, easy-to-use design. The system’s 2D Wall Motion Tracking technology provided quantitative analysis of myocardial wall motion. In addition, the system’s screen was able to reduce the glare of imaging outdoors and made it possible to image these athletes quickly and accurately.

During the screenings on-site, we found a handful of abnormalities that resulted in follow-up care, including an athlete with left ventricular hypertrophy and dilated ventricles, a case of long QT syndrome, and two instances of athletes with bicuspid aortic valves. Beyond those preliminary findings, we are now in the process of performing a more detailed analysis of the data. 

Additionally, we imaged a handful of rowers who were just starting out in the sport. We plan to follow up with them in three years to compare changes with the baseline results. This will help determine the type of cardiac changes athletes experience over a set period of consistent, rigorous cardiovascular training.

With the largest registry of high school rowers in the country, we will be able to more accurately distinguish what changes are considered normal for athletic hearts versus the true presence of heart abnormalities that may cause SCD. Our analysis will also hopefully establish additional data and guidelines on the benefits of EKG and echo as effective and cost-efficient screening tools for athletes. 

Summary

SCD is a traumatic and devastating killer of youth athletes, and occurs far more often than it should. Beyond rowing, any sport with significant physical activity increases a young athlete’s risk of SCD by two to three times. 

Utilizing screening tools such as EKG and echo, which offer more detailed information on the cardiac state, is proving effective in finding indicators for SCD based on our initial evaluation. Most importantly, these early results are encouraging signs that more can be done to prevent SCD and help make youth sports safer for our children.

Initial results will be published this year in the Journal of Cardiac Failure

Looking toward the future, we strive to expand our research into SCD, which we feel is more preventable than current screening methods are accomplishing.

For more information, please visit The Christ Hospital's website.

 

Disclosures: Dr. Menon reports receiving a grant from the Lindner Research Center for funding of this study. 

Also Involved in the Athlete Heart Research Study:

Michelle Grenier, MD, University of Mississippi Medical Center Kailas Menon, Cincinnati Country Day School Echo Techs: Brian Volz, Roberta Brown, Jennifer Westrich Front Desk: Barbie Orman