The Physician and Sportsmedicine
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[NEWS BRIEF]

THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 9 - SEPTEMBER 2021


Portable 'Echo' Devices Offer PPE Possibilities

In past years, arguments against the use of echocardiography screening in the preparticipation physical exam (PPE) setting revolved around cost and the number of false positives. However, the recent introduction of portable echocardiography devices has decreased the cost from about $400 to between $2 and $39 per athlete (1), renewing the debate about echocardiography's role in the cardiac exam.

What Do the Guidelines Say?

Noninvasive tests such as echocardiography and electrocardiography have been discussed as ways to enhance the detection of identifiable conditions that may cause sudden cardiac death, such as hypertrophic cardiomyopathy (HCM), in athletes. Overall, sudden cardiac death is estimated to occur in 1 in 200,000 to 1 in 300,000 high school and college athletes per year (2). Though rare, HCM is the most common cause of sudden cardiac death in young athletes in the United States.

Several practical considerations have impeded regular screening with echocardiography. A 1996 American Heart Association (AHA) statement on the cardiovascular PPE (3) listed the limitations of echocardiography screening, which included the potential for false-positive and false-negative results and the heavy emotional, financial, and medical burdens created by uncertainty and additional testing. The authors also noted that evidence of HCM may not be evident in some athletes, particularly those younger than 15.

AHA guidelines (4) published in 1997 list asymptomatic competitive athletes as a class 3 indication for echocardiography screening, meaning that that there is no evidence or agreement that the procedure is useful.

New Devices in the PPE Setting

Two portable echocardiography devices (also called point-of-care ultrasound devices) are marketed for cardiac screening in the PPE—the OptiGo (Philips Medical Systems, Andover, Massachusetts) (figure 1A: not shown) and the SonoHeart (SonoSite, Inc, Bothell, Washington) (figure 1B: not shown). The devices allow users to perform an initial limited exam using the parasternal long-axis view. Operators can follow up on an abnormal initial reading with additional measures and views. The devices weigh about 5 lb and cost around $12,000.

In a study (1) of portable echocardiography screening in high school students, researchers from the University of California at San Diego reported that two cardiologists performed limited echocardiography with the devices on 197 students in 125 minutes (average time, 1.3 min/exam). HCM was excluded with initial evaluation in 74% of the students. Frozen diastolic images were made on the remaining 26%; none of the students had a septal wall thickness of 15 mm or greater. In calculating the cost of portable echocardiography screening, researchers used a 5-year depreciation of a $15,000 portable device, a $400 to $800 charge for a full echocardiogram when referral was needed, and physician labor costs of $100 per hour. Average costs of the screening examination were calculated for various referral cutoffs (>12 mm, $21 to $39/student; >13 mm, $8 to $14/student; >14 mm, $4 to $6/student; and >15 mm or if no referral was required, $2/student).

Bruce J. Kimura, MD, lead author of the study, says staffing questions still need to be resolved. Currently, screening is performed by cardiologists on site, but with the new technology it may be possible for them to interpret the screening results off site. "Eventually, it may be possible that the appropriately trained noncardiologist will be able to perform this in a primary care setting," says Kimura, who is director of noninvasive cardiology at Scripps Mercy Medical Center in San Diego.

He says physicians should not equate the results of screening with the new devices with those of traditional echocardiography. "That is why I believe it should not be called an 'echo,' " he says. "It can enhance the physician's physical examination." He compares ultrasound screening for cardiac problems to finger stick glucose measurement for the detection of diabetes. "It's portable, at the point of care, fast, and reasonably accurate, but not definitive."

Renewed Debate

Paul D. Thompson, MD, director of preventive cardiology at Hartford Hospital in Hartford, Connecticut, and professor of medicine at the University of Connecticut School of Medicine in Farmington, Connecticut, cowrote the AHA's statement on cardiovascular preparticipation screening (3). He notes that despite their convenience and lower cost, there is no evidence that the devices actually save lives, and they may unnecessarily exclude a number of athletes.

Thompson, an editorial board member of The Physician and Sportsmedicine, pointed to an Italian study (5) that showed that the cardiac death rate was higher in Italian athletes who were cleared for competition after extensive screening than for American male athletes who underwent less screening (6). Only 4 of the 365 Italian athletes who were excluded from competition died of a cardiac condition. "Consequently, instead of supporting extensive screening, these results actually raise questions about its effectiveness," Thompson says. Another concern is that there are many unanswered questions about HCM. "Many people have mild forms that don't seem to do much damage," he says. "I fear we will wind up excluding lots of folks unnecessarily. Will the ultimate benefit be good or ill? I really don't know."

Aaron Rubin, MD, director of the Kaiser Permanente Sports Medicine Fellowship in Fontana, California, says despite the lowered costs of portable echocardiography, he is still struck by the high cost-versus-benefit ratio. "Instead of looking for the needle in the haystack with our hands, we're using an expensive magnet," says Rubin, who is an editorial board member of The Physician and Sportsmedicine. He also worries that affluent school districts will be able to afford a higher standard of care than less affluent districts.

Still, the isolated cases of sudden cardiac death in young athletes will continue to make news headlines, prompting physicians, parents, and athletic administrators to consider putting more resources into expanding cardiac screening efforts. In California, a nonprofit organization has formed to provide free portable echocardiography screening to high school and college athletes. The organization, A Heart For Sports (https://www.aheartforsports.org), based in Yorba Linda, California, coordinates regional community outreach programs and staffs the screening sessions with its own sonographers who are supervised by cardiologists.

Lisa Schnirring
Minneapolis

REFERENCES

  1. Kimura BJ, Sklansky MS, Eaton CH, et al: Screening for hypertrophic cardiomyopathy in the preparticipation athletic exam: feasibility and cost using a hand-held ultrasound device, abstracted. J Am Coll Cardiol 2021
  2. Maron BJ: Cardiovascular risks to young persons on the athletic field. Ann Intern Med 192021;129(5):379-386
  3. Maron BJ, Thompson PD, Puffer JC, et al: Cardiovascular preparticipation screening of competitive athletes: a statement for health professionals from the sudden death committee (clinical cardiology) and congenital cardiac defects committee (cardiovascular disease in the young), American Heart Association. Circulation 1996;94(4):850-856
  4. Cheitlin MD, Alpert JS, Armstrong WF, et al: ACC/AHA guidelines for the clinical application of echocardiography. Circulation 1997;95(6):1686-1744
  5. Corrado D, Basso C, Schiavon M, et al: Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 192021;339(6):364-369
  6. Van Camp SP, Bloor CM, Mueller FO, et al: Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27(5):641-647


Field Notes

Fly Fishing: Sports Injuries Run Through It
Fly fishing seems like a low-impact activity performed in a serene setting; however, a researcher found that participants experience some of the same injuries as golfers, tennis players, and baseball players.

Keith Berend, MD, chief orthopedic resident at Duke University Medical Center (DUMC) in Durham, North Carolina, surveyed 131 participants about their health and fishing habits and found that 69% reported low-back pain, about 25% had pain in the hands and wrist, shoulder, or knee, and 18% had elbow pain. Berend reported his findings in July at the annual meeting of the Southern Orthopedic Association. Details of his study were issued in a DUMC press release.

Shoulder, elbow, and wrist pain appeared to stem from the repetitive motion required to keep the fly active to mimic a live insect. A number of causes seemed to contribute to leg and back pain, including prolonged standing on rocky, uneven surfaces and overloaded or unevenly loaded fishing vests. Berend believes that improper casting technique, along with properties of the rod itself, might contribute to shoulder pain. He noted that he's planning to do a biomechanical study to better understand the demands of casting and to devise strategies to reduce pain and improve physical performance.

Berend, himself an avid fly fisherman, advises participants to take the same basic injury precautions as for other sports: stay in good general shape, focus on proper technique, and use the right equipment.

HCM Findings Can Surface in Adults
Patients were once thought to be safe from hypertrophic cardiomyopathy (HCM) if heart size was normal upon reaching adulthood. However, new findings reported in the August issue of the Journal of the American College of Cardiology (JACC) confirm that heart enlargement associated with HCM can appear even in middle age.

Barry J. Maron, MD, director of the HCM clinic at the Minneapolis Heart Institute Foundation, and colleagues studied 119 relatives of people who had HCM. Of this group, 12 were adults who had cardiomyopathy-causing mutations in the cardiac myosin-binding protein C gene but no sign of cardiomyopathy. Researchers used echocardiography to assess changes in 5 of the patients' hearts over 4 to 6 years and found that 3 developed enlarged hearts in midlife.

Michael Sole, MD, a cardiologist at Toronto General Hospital, who commented on the study in a press release from the American College of Cardiology, noted that the new findings may influence the diagnosis given to adults who exhibit late-developing cardiac hypertrophy. He said this group is often classified as having acquired hypertrophy from unstable hypertension or other forms of heart disease.

Genetic mutations responsible for HCM are more common than previously suspected, according to a study by German researchers that appeared in the same issue of JACC. Their study of 110 unrelated, consecutive patients with HCM identified 13 mutations of the cardiac myosin-binding protein C gene, 11 of them for the first time.


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