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New York Times
June 3, 2007
Phys Ed
The Not-So-Tell-Tale Heart
By GRETCHEN REYNOLDS
Sue Cox says that her 17-year-old son, Tim, “started playing sports practically in the womb.” A standout on junior-league basketball and Pop Warner football teams in Hudson, N.H., he was, by high school, among the top basketball players in the state as well as a starting safety on the football team. “I lived for sports, you could say,” Tim says.
But could he also have died from them? Last July, at his parents’ insistence, Cox had an electrocardiogram, which measures electrical activity in the heart. It’s the same test his father had 15 years ago, after experiencing some shortness of breath. That EKG and follow-up tests showed hypertrophic cardiomyopathy (HCM), a thickening of the heart muscle. Cox’s grandfather had been diagnosed with the same condition and died at age 63. But Cox, with the insouciance of youth, was sure that his own heart was fine. He was therefore stunned when the test came back positive. He would never be allowed to play competitive sports again, his cardiologist told him flatly. “It was a terrible time,” says Cox’s father, also named Tim. “We wanted to keep our son alive, but to do that, we were taking away everything that he loved most in life.”
Athletes, particularly young athletes, don’t worry too much about dropping dead from heart failure. But it happens. The 1990 death of the Loyola Marymount University basketball star Hank Gathers, who had been diagnosed with cardiac problems after a fainting episode but was allowed to continue to play, made headlines around the country. So did the deaths of 27-year-old Reggie Lewis of the Boston Celtics in 1993, and the 28-year-old ice-skating Olympic gold medalist Sergei Grinkov in 1995. In 2005, Atlanta Hawks center Jason Collier died at 28 of an undiagnosed heart abnormality; that same year, three N.C.A.A. basketball players also died. Just three months ago, in February, Damien Nash of the Denver Broncos died not long after playing in a charity basketball game. By sad coincidence, the game was to raise money for heart-transplant research — Nash’s older brother had had a transplant, after passing out during a basketball game.
Though exercise-induced sudden death most commonly affects recreational athletes over 35, cardiologists are realizing that more young people die of heart failure than was previously thought. “We used to see figures saying there were 20 cases or so a year,” says Barry Maron, the director of the Hypertrophic Cardiomyopathy Center at the Minneapolis Heart Institute Foundation. But a national database that Maron has helped compile suggests a much higher prevalence. “We’ve documented around 125 cases a year of sudden cardiac death among young competitive athletes,” he says. “That represents about one death every three days in the U.S. And that number is almost certainly an underestimate.”
The incidence is alarming enough that this season the N.B.A. began mandating echocardiograms (ultrasounds of the heart) for all of its players, along with electrocardiograms. The International Olympic Committee recently began recommending EKG’s for its athletes. And the European Society of Cardiology issued a report in 2005 calling for all European athletes, including teenagers, to pass an EKG before being cleared to play. (EKG’s are generally cheaper and easier than echocardiograms and so are the test of first resort. Since each test provides different information, some sports organizations think it’s safest to have both.)
In the United States, the push for mandatory cardiac testing of athletes has been slower and much more contentious. In March, the American Heart Association issued its first new guidelines in a decade for the cardiac screening of competitive athletes. The conclusion was that requiring EKG’s would be expensive — costing about $500 million nationwide, not all of which would necessarily be covered by insurance — and result in too many false readings.
Cardiac arrest in those under 35 typically results from an undiagnosed heart abnormality. The most common — accounting for about one-third of all sudden cardiac deaths in young competitive athletes in the United States — is HCM, in which the heart muscle thickens, leading to possible disruptions in the heart rhythm. There may be a known family history, as in the Cox family, or there may not be. It can be accompanied by symptoms, like chest pain or shortness of breath, but isn’t always. Even if it is, an athlete might not recognize the symptoms. As Tim Cox says: “I was running up and down the basketball court all the time. Of course I had shortness of breath. We all did.”
Other frequent causes of sudden death due to heart failure include Marfan syndrome, a disorder affecting the body’s connective tissue (Marfan is commonly found among the tall and lanky — some believe that Abraham Lincoln had it); and Long QT syndrome, in which heart rhythm can suddenly become erratic. Again, these conditions may or may not cause obvious cardiac symptoms.
Doctors are not absolutely sure why heavy exertion sets off arrhythmias in people with these conditions, but it does. “A child with HCM could, of course, die in the library,” says Paul D. Thompson, the director of cardiology at Hartford Hospital in Connecticut and one of the authors of the new American Heart Association guidelines, “but they tend to die out on the playing field.”
As the poets say, the heart is a thing of mystery. Some of these cardiac abnormalities, particularly HCM, can be almost indistinguishable from robust good heath on an EKG or echocardiogram. In HCM, the walls of the left ventricle grow thicker. The same thing can happen to an extremely fit athlete. This can be part of a benign condition known as “athlete’s heart,” which is often typified by an increase in the overall size of the heart’s chambers and a slowing of the heart rate, sometimes to 40 beats per minute. “It’s a normal physiological adaptation to sustained, heavy exercise,” says Adolph M. Hutter Jr., a professor of cardiology at Harvard Medical School and the team cardiologist for the Boston Bruins and the New England Patriots. Hutter points out that about half of the EKG’s of well-trained athletes look unusual when in fact there is nothing wrong.
Even common heart disease, such as atherosclerosis — hardening of the arteries — can be hard to diagnose in a fit athlete. Atherosclerosis is by far the leading cause of death among older athletes. Intense exercise can cause fatty deposits to rupture, forming clots that block coronary arteries and stop blood flow. Jim Fixx, author of the seminal 1977 best seller “The Complete Book of Running,” died that way. “A very fit, middle-aged athlete can harbor severe, asymptomatic atherosclerosis,” Thompson says. “Exercise helps reduce heart disease, but it’s not absolute protection.” A fit athlete could pass a stress test despite having arteries that are larded with plaque. “Then a week later, he has a heart attack,” Thompson says. “This happens far more often than we would like to acknowledge.”
Just as stress tests are not foolproof, neither are EKG’s for younger athletes. For that reason, experts like Thompson and Hutter are skeptical of mandatory testing, especially if it’s done by those who aren’t experts in sports cardiology. “It costs too much and you get too many wrong answers,” Thompson says. “I know of an N.B.A. player who’d been told he had heart disease, but almost certainly did not. He lost probably millions of dollars during contract negotiations because of it.”
The American Heart Association has an easier, cheaper — if much less sophisticated — way to identify those with heart problems: give every athlete a decent physical.
For years, the A.H.A. has recommended that doctors use a basic screening as part of every athlete’s regular physical exam. It consists of eight medical-history questions and four simple tests, including checks for high blood pressure and heart murmurs. A positive answer to any of the questions or a hint of medical irregularity in the physical exam should prompt a further round of tests, often beginning with an EKG or echocardiogram. (For more about the 12-step screening, go to americanheart.org.)
But to date, the screening has been adopted only sporadically, even at the professional level. A 2006 survey by Adolph Hutter and others found that none of the major sports leagues in the United States followed every step of the 12-part test.
“Every kid who goes in for a sports physical should get it,” says Jonathan Drezner, an associate professor of family medicine at the University of Washington in Seattle and the lead author of a recent paper about how to combat sudden death in young athletes. “This kind of screening is easy, it’s inexpensive and it could probably catch many heart abnormalities early, before the athlete dies.”
Dealing with the consequences of a positive finding are nowhere near as straightforward. “There’s a big gray area here,” Thompson says. “Just because an athlete has a heart condition does not mean he will die from it. Maybe he’d be fine, even competing. Maybe if he hadn’t known, he could have played out his whole career without a problem. Maybe he still could.”
Few schools or teams will allow athletes with a confirmed heart condition to participate because of liability concerns, although exceptions have been made (remember Hank Gathers). In some instances, the athletes will be fitted with a defibrillator or pacemaker, which would shock the heart automatically if it went into arrest or fell out of rhythm. Doctors might advise some athletes to stop exercising altogether, while others might be told to switch from competition to more casual, recreational sports. “I’ll tell an athlete, ‘You can’t race anymore,’ ” Hutter says. “ ‘But you can run, you can ride. You just have to back off if you feel anything unusual.’ ”
Easy to say, difficult to accept. “We still agonize about whether it was the right thing to have Timmy tested,” Sue Cox says. “His father is O.K., even with HCM. So maybe Timmy wouldn’t have had any problems.” Had he never been tested, had his condition never been discovered, he wouldn’t have been pulled from his teams. He might, she thinks, have helped his school’s basketball squad make it to the state tournament. He might have been offered a college scholarship.
Instead, he attended practices, watching but not playing. “He’s a different boy,” his mother says. “It makes me so sad.”
But if they hadn’t had him tested and his heart had failed? “How could we have lived with ourselves?” she asks. “But when I see him standing on the sidelines, looking so sad, I wonder if we did right.” .
June 3, 2007
Phys Ed
The Not-So-Tell-Tale Heart
By GRETCHEN REYNOLDS
Sue Cox says that her 17-year-old son, Tim, “started playing sports practically in the womb.” A standout on junior-league basketball and Pop Warner football teams in Hudson, N.H., he was, by high school, among the top basketball players in the state as well as a starting safety on the football team. “I lived for sports, you could say,” Tim says.
But could he also have died from them? Last July, at his parents’ insistence, Cox had an electrocardiogram, which measures electrical activity in the heart. It’s the same test his father had 15 years ago, after experiencing some shortness of breath. That EKG and follow-up tests showed hypertrophic cardiomyopathy (HCM), a thickening of the heart muscle. Cox’s grandfather had been diagnosed with the same condition and died at age 63. But Cox, with the insouciance of youth, was sure that his own heart was fine. He was therefore stunned when the test came back positive. He would never be allowed to play competitive sports again, his cardiologist told him flatly. “It was a terrible time,” says Cox’s father, also named Tim. “We wanted to keep our son alive, but to do that, we were taking away everything that he loved most in life.”
Athletes, particularly young athletes, don’t worry too much about dropping dead from heart failure. But it happens. The 1990 death of the Loyola Marymount University basketball star Hank Gathers, who had been diagnosed with cardiac problems after a fainting episode but was allowed to continue to play, made headlines around the country. So did the deaths of 27-year-old Reggie Lewis of the Boston Celtics in 1993, and the 28-year-old ice-skating Olympic gold medalist Sergei Grinkov in 1995. In 2005, Atlanta Hawks center Jason Collier died at 28 of an undiagnosed heart abnormality; that same year, three N.C.A.A. basketball players also died. Just three months ago, in February, Damien Nash of the Denver Broncos died not long after playing in a charity basketball game. By sad coincidence, the game was to raise money for heart-transplant research — Nash’s older brother had had a transplant, after passing out during a basketball game.
Though exercise-induced sudden death most commonly affects recreational athletes over 35, cardiologists are realizing that more young people die of heart failure than was previously thought. “We used to see figures saying there were 20 cases or so a year,” says Barry Maron, the director of the Hypertrophic Cardiomyopathy Center at the Minneapolis Heart Institute Foundation. But a national database that Maron has helped compile suggests a much higher prevalence. “We’ve documented around 125 cases a year of sudden cardiac death among young competitive athletes,” he says. “That represents about one death every three days in the U.S. And that number is almost certainly an underestimate.”
The incidence is alarming enough that this season the N.B.A. began mandating echocardiograms (ultrasounds of the heart) for all of its players, along with electrocardiograms. The International Olympic Committee recently began recommending EKG’s for its athletes. And the European Society of Cardiology issued a report in 2005 calling for all European athletes, including teenagers, to pass an EKG before being cleared to play. (EKG’s are generally cheaper and easier than echocardiograms and so are the test of first resort. Since each test provides different information, some sports organizations think it’s safest to have both.)
In the United States, the push for mandatory cardiac testing of athletes has been slower and much more contentious. In March, the American Heart Association issued its first new guidelines in a decade for the cardiac screening of competitive athletes. The conclusion was that requiring EKG’s would be expensive — costing about $500 million nationwide, not all of which would necessarily be covered by insurance — and result in too many false readings.
Cardiac arrest in those under 35 typically results from an undiagnosed heart abnormality. The most common — accounting for about one-third of all sudden cardiac deaths in young competitive athletes in the United States — is HCM, in which the heart muscle thickens, leading to possible disruptions in the heart rhythm. There may be a known family history, as in the Cox family, or there may not be. It can be accompanied by symptoms, like chest pain or shortness of breath, but isn’t always. Even if it is, an athlete might not recognize the symptoms. As Tim Cox says: “I was running up and down the basketball court all the time. Of course I had shortness of breath. We all did.”
Other frequent causes of sudden death due to heart failure include Marfan syndrome, a disorder affecting the body’s connective tissue (Marfan is commonly found among the tall and lanky — some believe that Abraham Lincoln had it); and Long QT syndrome, in which heart rhythm can suddenly become erratic. Again, these conditions may or may not cause obvious cardiac symptoms.
Doctors are not absolutely sure why heavy exertion sets off arrhythmias in people with these conditions, but it does. “A child with HCM could, of course, die in the library,” says Paul D. Thompson, the director of cardiology at Hartford Hospital in Connecticut and one of the authors of the new American Heart Association guidelines, “but they tend to die out on the playing field.”
As the poets say, the heart is a thing of mystery. Some of these cardiac abnormalities, particularly HCM, can be almost indistinguishable from robust good heath on an EKG or echocardiogram. In HCM, the walls of the left ventricle grow thicker. The same thing can happen to an extremely fit athlete. This can be part of a benign condition known as “athlete’s heart,” which is often typified by an increase in the overall size of the heart’s chambers and a slowing of the heart rate, sometimes to 40 beats per minute. “It’s a normal physiological adaptation to sustained, heavy exercise,” says Adolph M. Hutter Jr., a professor of cardiology at Harvard Medical School and the team cardiologist for the Boston Bruins and the New England Patriots. Hutter points out that about half of the EKG’s of well-trained athletes look unusual when in fact there is nothing wrong.
Even common heart disease, such as atherosclerosis — hardening of the arteries — can be hard to diagnose in a fit athlete. Atherosclerosis is by far the leading cause of death among older athletes. Intense exercise can cause fatty deposits to rupture, forming clots that block coronary arteries and stop blood flow. Jim Fixx, author of the seminal 1977 best seller “The Complete Book of Running,” died that way. “A very fit, middle-aged athlete can harbor severe, asymptomatic atherosclerosis,” Thompson says. “Exercise helps reduce heart disease, but it’s not absolute protection.” A fit athlete could pass a stress test despite having arteries that are larded with plaque. “Then a week later, he has a heart attack,” Thompson says. “This happens far more often than we would like to acknowledge.”
Just as stress tests are not foolproof, neither are EKG’s for younger athletes. For that reason, experts like Thompson and Hutter are skeptical of mandatory testing, especially if it’s done by those who aren’t experts in sports cardiology. “It costs too much and you get too many wrong answers,” Thompson says. “I know of an N.B.A. player who’d been told he had heart disease, but almost certainly did not. He lost probably millions of dollars during contract negotiations because of it.”
The American Heart Association has an easier, cheaper — if much less sophisticated — way to identify those with heart problems: give every athlete a decent physical.
For years, the A.H.A. has recommended that doctors use a basic screening as part of every athlete’s regular physical exam. It consists of eight medical-history questions and four simple tests, including checks for high blood pressure and heart murmurs. A positive answer to any of the questions or a hint of medical irregularity in the physical exam should prompt a further round of tests, often beginning with an EKG or echocardiogram. (For more about the 12-step screening, go to americanheart.org.)
But to date, the screening has been adopted only sporadically, even at the professional level. A 2006 survey by Adolph Hutter and others found that none of the major sports leagues in the United States followed every step of the 12-part test.
“Every kid who goes in for a sports physical should get it,” says Jonathan Drezner, an associate professor of family medicine at the University of Washington in Seattle and the lead author of a recent paper about how to combat sudden death in young athletes. “This kind of screening is easy, it’s inexpensive and it could probably catch many heart abnormalities early, before the athlete dies.”
Dealing with the consequences of a positive finding are nowhere near as straightforward. “There’s a big gray area here,” Thompson says. “Just because an athlete has a heart condition does not mean he will die from it. Maybe he’d be fine, even competing. Maybe if he hadn’t known, he could have played out his whole career without a problem. Maybe he still could.”
Few schools or teams will allow athletes with a confirmed heart condition to participate because of liability concerns, although exceptions have been made (remember Hank Gathers). In some instances, the athletes will be fitted with a defibrillator or pacemaker, which would shock the heart automatically if it went into arrest or fell out of rhythm. Doctors might advise some athletes to stop exercising altogether, while others might be told to switch from competition to more casual, recreational sports. “I’ll tell an athlete, ‘You can’t race anymore,’ ” Hutter says. “ ‘But you can run, you can ride. You just have to back off if you feel anything unusual.’ ”
Easy to say, difficult to accept. “We still agonize about whether it was the right thing to have Timmy tested,” Sue Cox says. “His father is O.K., even with HCM. So maybe Timmy wouldn’t have had any problems.” Had he never been tested, had his condition never been discovered, he wouldn’t have been pulled from his teams. He might, she thinks, have helped his school’s basketball squad make it to the state tournament. He might have been offered a college scholarship.
Instead, he attended practices, watching but not playing. “He’s a different boy,” his mother says. “It makes me so sad.”
But if they hadn’t had him tested and his heart had failed? “How could we have lived with ourselves?” she asks. “But when I see him standing on the sidelines, looking so sad, I wonder if we did right.” .
