Screening fails to predict most heart deaths in young soccer players

(Reuters Health) - Examinations of more than 11,000 adolescent soccer players in the UK over 20 years have found that routine heart testing prevented very few sudden heart-related deaths during exercise.

One in 266 players were found to have a heart problem that might cause sudden death. Just 1 in 1,396 died suddenly from some form of heart disease, totaling eight cases. But six of those eight athletes had passed the one-time heart screening, which used both electrocardiograms (ECGs) and ultrasound.

The cost of screening: $3.8 million or $342 per teenager from 1996 through 2016. The cost of identifying any child with heart disease: $16,167 per case.

Lead author Dr. Aneil Malhotra of the University of London, said the study is the first to give a reliable estimate of the risk. He said it does not suggest that screening is not worth the expense.

In fact, the English Football Association, which helped fund the study, has intensified its call for testing, he told Reuters Health in a telephone interview. The association is now recommending both tests at age 16 with follow-up ECGs at ages 18, 20 and even 25 because heart problems can develop in young adulthood.

“Cynics would say perhaps screening is not effective because six of eight deaths were missed,” said Malhotra. But the argument could be made that the heart problems that caused the deaths had not developed at the time of screening and “some may have displayed an abnormal ECG later on down the line.”

“This is very important and informs us that a one-off screen in an adolescent may not be sufficient and that serial assessments may be necessary,” the study’s senior author, Dr. Sanjay Sharma of the University of London, said in an email.

“These are elite-level soccer players” Malhotra said, so when all children who play soccer are included, “we think this is a minimum estimate of cardiac death. This is the tip of the iceberg.”

But Dr. Naomi Kertesz, a pediatric cardiologist at The Heart Center at Nationwide Children’s Hospital in Columbus, Ohio, who was not involved in the research, said the findings show that “screening once isn’t going to do it for you. And these are not inexpensive tests.”

She argued in a phone interview that emphasis should be redirected toward a better solution - making automated defibrillators (AEDs) for restoring a normal heart rhythm widely available in areas where a player is likely to collapse, along with making sure lots of people know how to use them in conjunction with performing simple push-on-the-chest cardiopulmonary resuscitation (CPR).

“Over 80 percent of the time the rhythm you’re going to die from is something I can fix with an AED. But you have 3 to 5 minutes to fix it,” she said. “No child is allowed to play football unless you have a mouthguard, yet none of the coaches have an AED with them” because the devices are often stored minutes away in a gym or somewhere else in the school.

And most staff don’t know how to use them because there’s little training, a problem that extends to schools in general, not just on the playing field, she warned. “We have to run fire drills and active shooter drills. Once a year, you can’t run a sudden cardiac arrest or emergency medical drill?”

Nonetheless, Kertesz characterized the new research, published in the New England Journal of Medicine, as “an incredibly important study because there has been a discussion on the utility of screening that has been going on for a long time.”

The heart risk faced by athletes has been hard to estimate because there is no systematic registry of such deaths, the study authors note.

The new data came from the English Football Association, which began its mandatory cardiac screening program for promising young soccer players in 1997.

Many of the heart problems that were uncovered were considered minor, such as a misfiring valve. In all, 2.4 percent of the screened children had some type of heart condition.

Just 42 players, or 0.38 percent, were identified as having a problem capable of causing sudden death. Most made it back onto the field with treatment. Two continued to play against medical advice and both died from sudden cardiac arrest.

“We cannot predict what would have happened to the other 42 if they had not been identified but it is possible that the screening program may have prevented some fatalities,” Sharma said.

SOURCE: The New England Journal of Medicine, online August 8, 2018.