Electrocardiogram (EKG) and echocardiogram tests could reduce the risk of sudden cardiac death in college athletes, according University of Washington researchers. Their study on the incidence of cardiac fatalities in college sports, led by sports medicine specialist Dr. Kimberly Harmon, appears in the April 4 online edition of the journal Circulation. (The abstract of the study is available to the public; a subscription is required to view the complete study.)

Each year, 9 NCAA student athletes die from cardiac incidents. (Photo: iStock)

The new study concludes that sudden cardiac death is the leading medical cause of death in NCAA student-athletes. On average, 9 NCAA athletes a year suffer sudden cardiac death.

The study looked only at college athletes whose schools and teams are recognized by the National Collegiate Athletic Association (NCAA). Records showed that there were 45 deaths from cardiac incidents during the five years (2004 – 2008) covered by the study. Deaths were most likely to occur among NCAA basketball players and swimmers.

“Young athletes are not supposed to die doing what they love,” Dr. Jonathan Drezner, a co-author of the study, told the Associated Press.

The Associated Press reports that the American Heart Association currently recommends that student athletes have a medical exam that includes a review of family medical history, but the association does not recommend an electrocardiogram or echocardiogram because of the cost of the additional screenings. The European Society of Cardiology and the International Olympic Committee both recommend that student athletes have an EKG test. In a press release about the new study, the American Heart Association said that the data from the study suggests that “more extensive screening might be practical if targeted at high-risk groups — for instance, basketball players.”

Just minutes after Wes Leonard shot the game-winning basket for Fennville High School, he lay lifeless on the floor of the court. A spectator began CPR, 911 was called, but it is not clear if the school had an automated external defibrillator (AED) or if one was used before paramedics arrived on the scene. When the ambulance arrived, Leonard was taken to a nearby hospital where he was pronounced dead later that evening.

The story of the 16-year-old basketball star, who died March 3, is the latest chapter in the book of young athletes who have suffered sudden cardiac arrest while playing high school or college sports.

The Ottawa County coroner’s report revealed that Leonard had suffered from hypertrophic cardiomyopathy, a heart condition that increases the chances of sudden cardiac arrest.

No one suspected the Fenville, Michigan, teenager had a thing wrong with him. Leonard was the very model of a healthy young man, playing football and basketball for his high school teams.

Leonard’s death comes at a time when groups are working to mandate the presence of automated external defibrillators at school gyms and community ballfields and when some communities are offering cardiac screening for young athletes, using EKG tests and other tools to diagnose hypertrophic cardiomyopathy and other heart conditions. AOL columnist Greg Couch is calling for cardiac screening for school athletes, saying that Leonard’s death proves the need for systematic preventive measures, pointing out that Leonard’s death comes just death of Loyola-Marymount player Hank Gathers, who also suffered cardiac arrest at a game.

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Source Diagnostics is a company in a growing field — mobile medical diagnostics. Their technicians take on-call diagnostic testing services — X-ray, ultrasound, electrocardiogram (ECG), and Holter monitoring — to patients nursing facilities and hospital home-care programs in Ohio and Indiana.

When Source Diagnostics’ management went looking for replacement ECG equipment last year, they discovered something new and different that suited their needs: our CareCenter MD, a diagnostic workstation weighing less than six ounces but able to produce digital test results and send them, wirelessly, to a laptop.

At first, Source Diagnostics bought one CareCenter MD from us to try in their Cleveland mobile service. At the time, their technician was carrying an 11-pound ECG machine into each nursing facility and lugging it from patient to patient.

“The CareCenter MD was so much smaller than what we had before,” said Adrienne Ziroe, a manager with Source Diagnostics. “Even with the laptop included, the equipment still weighs less than regular ECGs, and of course that’s important to us as a mobile service.”

The first CareCenter MD worked so well that the company purchased six more of them.

“Some techs were set in their ways and weren’t sure about using the new equipment,” Ziroe explained. “But as soon as they started working with CareCenter MD, we got a great response. People are saying, ‘It’s so easy!’”

Ziroe says what makes CareCenter MD so user friendly is the way it performs in a clinical environment.

CareCenter MD is a success for mobile diagnostic company Source Diagnostics.

“You can do what needs to be done without have to consult a 16-page pamphlet on how to do it,” she says. “We had a half-page ‘cheat sheet’ to get people started and I don’t think anybody even looks at that any more.”

When problems arise with ECG leads, CareCenter MD provides valuable, time-saving feedback. “If there is a bad connection, CareCenter MD actually lets you know where the lead issue is,” Ziroe says. “The other ECG machines just told us there was a failure, and we were left trying to figure out how to fix it.”

Ziroe describes the digital test results as “absolutely beautiful.” While doctors generally read the tests online, Source Diagnostics faxes the images to nursing facilities that want paper copies for their charts.

“That took care of their needs and those look so much better than the old printouts we used to send,” Ziroe said.

The CareCenter MD diagnostic workstation is presently available in the US only.

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Editor’s Note: What should clinicians do when they need more diagnostic information than an initial exercise stress test can provide? A recent article in the journal Circulation looked at that question. (Selecting a Noninvasive Imaging Study After an Inconclusive Exercise Test. Blankstien, Ron, MD. DeVore, Adam, MD. Circulation. Vol 122. October 12, 2010.)

The American Heart Association recently updated their Appropriate Use Criteria statements. These are nuclear testing guidelines based on usage patterns that emphasize correct testing indications. As an adjunct they also published a nice clinical update summarizing noninvasive cardiac stress testing options. Use this information for:

Selecting the Right Cardiac Stress Test

1. Low risk, asymptomatic patients may not need further testing after an exercise stress or stress echo, unless test results are definitively positive for suspected coronary artery disease (CAD) or worsening CAD.
2. In low-to-intermediate risk patients Coronary CT scans can be used to rule-out severe coronary artery disease (CAD).
3. High-risk patients with known CAD will benefit greater from nuclear perfusion-based imaging.

Exercise Stress Testing

• It’s a good initial test for patients with known or suspected CAD.
• It’s a safe and inexpensive way to get valuable prognostic and diagnostic information.
• In addition to ST changes, testing gives info on important clinical markers such as functional aerobic capacity (FAC), symptomatic, hemodynamic and other ECG (arrhythmias or rate-dependant conduction defects) responses to physiological stress.

Exercise Stress Testing Limitations
Inconclusive tests are commonly due to:
• Insufficient workload or chronotropic incompetence (no heart rate increase)

• Inadequate BP response (<25mmHg increase)
• Baseline or resting ST depression > 1mm

• Baseline Left Ventricular Hypertrophy (LVH) (deep S-wave in V1 with a tall R-wave in V4, V5 or V6.

• Patients with physical limitations or certain arrhythmias like Wolf-Parkinson-White Syndrome (WPW) are not candidates.
• Diagnostic uncertainty still exists with both equivocal and positive test results.

To increase diagnostic accuracy additional testing modalities are often useful. Understanding the clinical strengths and limitations of the testing options is essential and keeping up with current clinical efficacy data can be challenging or confusing, even for cardiologists.

Stress Echocardiography

• Accuracy relies on visual confirmation of wall motion abnormalities (rest vs. stress).
• Increases specificity for CAD detection and valvular function without radiation exposure.
• For chronotropically incompetent patients or those unable to exercise a pharmacological (dobutamine) stress echo can be done.

Stress Echo Limitations
• Images are limited in patients with obesity or obstructive lung disease.
• Accuracy is reduced in patients with resting wall motion abnormalities (prior MI, paced rhythms, very poor EF% or certain cardiac surgeries).
• And although it’s accurate at detecting significant coronary disease, the test does not detect non-blood flow-limiting coronary blockages.

Single Photon Emission Computed Tomography (SPECT) Scan – Nuclear

• Robust prognostic value based on clinical risk correlation to severity of perfusion defect caused by CAD.
• Test results are valuable in determining the need for medical therapy vs. coronary intervention (angioplasty, balloon or stent placement).

SPECT Limitations
• “Attenuation” (scan irregularities due to fatty tissue) increase false-positives.
• Global ischemia (or “balanced” ischemia in all coronary arteries) can fool the camera and cause false-negatives.
• Cannot detect non-obstructive coronary blockages.

Positron Emission Tomography (PET) Scan — Nuclear

• Superior image resolution and better attenuation correction.
• Better diagnostic accuracy.
• Faster radiotracer results in lower radiation exposure.
• High reimbursement.

PET Limitations
• Significant portion of high reimbursement is consumed by very expensive PET camera and radiotracer costs.
• Current PET protocols cannot be performed with exercise stress, only pharmacological stress.

Cardiac Magnetic Resonance Imaging (MRI)

• Produces images of stress-induced wall motion abnormalities, cardiac structures, ventricular function and other forms of heart disease or inflammation (pericarditis, myocarditis) without radiation exposure.
• Pharmacological stressors (adenosine or dobutamine) are used to promote visual confirmation of ischemic areas.
• Similar diagnostic accuracy to SPECT, but without the annoying attenuation artifacts.

MRI Limitations
• Complex, limited availability and cannot be performed with exercise stress, only pharmacological stress.
• Can’t be done on patients with claustrophobia or patients with ICDs. Stents are ok.
• Occasional transient dark rim artifacts can show false-positives.

Coronary CT Angiography

• Produced high resolution images of coronary arteries.
• Has a high negative predictive value (those who don’t have CAD), but poor positive predictive value (those who have severe CAD).
• Better at identifying non-obstructive blockages. This helps direct medical therapy.

CT Limitations
• Requires normal kidney function and a low resting heart rate.
• Few studies done on the diagnostic accuracy.
• Has trouble detecting severe calcified blockages.
• Testing can be combined to utilize the diagnostic advantages of each modality.
• The combined diagnostic accuracy of these tests is currently the subject of many on going clinical studies.

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The Burdick ECG 8000 Series is feature-rich, easier to use, and EMR ready

Bothell, WA – December 9, 2010 – Cardiac Science Corporation, a global leader in automated external defibrillator (AED) and diagnostic cardiac monitoring devices, today adds two electrocardiographs (ECGs) under its Burdick brand, known for its accuracy, reliability, and ease of use. The ECGs, available only in the U.S., deliver built-in, bi-directional communication so customers can connect to leading EMRs. Click to view the video.

The Burdick 8500 ECG features a friendly user interface, multi-angle 7-inch widescreen, adjustable protocol settings, and color display to make reading the continuous waveform data easy. With the Burdick 8500 ECG, customers can:

• View continuous 3-, 6-, and 12-leads of data on the color display.
• Adjust the unique 7-inch adjustable widescreen color display for contrast and viewability.
• Store up to 300 digital ECG records; enjoy on-screen QuickTips.
• Reduce typing mistakes and save time by downloading patient information from your electronic medical record (EMR/HIS) system.
• Eliminate the hassle of scanning and filing.
• Enjoy an industry-leading, four-year warranty and service program for worry-free usage.

The Burdick 8300 offers similar performance, connectivity, reliability, and workflow in an economic package.

Both ECG devices clean the ECG waveform before it is measured and analyzed by the Glasgow Royal Infirmary (GRI) algorithm. With more than 30 years of continuous refinement, the GRI algorithm is the first and only to consider five clinically significant variables – including gender, age, race, medication, and classification – to interpret patient data.

Six Product Introductions in 2010

Cardiac Science introduced six new cardiac monitoring products (available only in the U.S.) in 2010. Information is available on the cardiacscience.com website.

• The Burdick ECG 8500;
• The Burdick ECG 8300;
• The CareCenter MD diagnostic workstation, multimodality PC-based wireless diagnostic workstation with both PC ECG and PC stress test modalities;
• The Quinton 9500 cardiac stress system, a unique wall-mounted cardiac stress system with wireless capabilities between patient and workstation;
• The Quinton 9550 cardiac stress system, similar to the 9500, in a convenient mobile cart with ample storage space; and,
• The Microvolt T-Wave Alternans for Quinton Q-Stress, creating the most comprehensive, reimbursable cardiac-risk profiling system in the industry.

This fall in the Chicago area, privately funded ECG testing for high school athletes once again protected student lives.

The Daily Herald reports that Konrad Mueller, a football and lacrosse player, didn’t think he needed an ECG test. He was astonished when a test his freshman year revealed that he had a heart problem — the sort of undetected heart abnormality that triggers sudden cardiac arrest in more than 7,000 children a year.

Mueller owes that life-saving discovery to one of several heart-screening programs funded by private organizations, including Midwest Heart and the Max Schewitz Foundation. The tests they offer at Chicago-area schools are purely voluntary, and parents must sign a consent form before a student is tested. The Schewitz Foundation was started by Mary Beth Schewitz and friends after her 20-year-old died from sudden cardiac arrest as the result of an undiagnosed heart condition.

Cardiologist Joe Marek of Midwest Heart predicts that, in coming years, ECG testing for high school athletes will become a standard of care, paid for by insurance. But currently it must be paid for by students’ families unless it is underwritten by a foundation program. Midwest Heart has provided subsidized testing for more than 50,000 students.

Dr. Raymond Kawasaki, who tests students through a similar program created by Advocate Good Shepard Hospital in Barrington, Illinois, told the Daily Herald that the screenings are intended to find underlying conditions that have no symptoms — until a student athlete collapses from sudden cardiac arrest.

“Some people believe as long as you’re not symptomatic, it’s not necessary to do these tests on patients, and that’s not correct,” Kawasaki told the paper. “It’s very important.

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A new research study about to launch in Australia will test the effectiveness of intravenous cold saline treatment, administered by paramedics, to reduce brain injury in victims of sudden cardiac arrest.

In the RINSE (Rapid Infusion of Cold Normal SalineE) study, Mobile Intensive Care Ambulance (MICA) paramedics will administer cold saline solution during resuscitation.

The program is slated to run for more than 2 years and involve more than 2500 adult patients, half of whom will receive the experimental cooling treatment. The study is a join effort by researchers at Monash University and MICA, funded by the National Health and Medical Research Council. It will involve ambulance services in Victoria and in parts of South Australia and Western Australia.

Victoria health officials told HealthCanal.com that Victoria is a leader in improving outcomes for those sudden cardiac arrest victims who can be treated using an automated external defibrillator (AED).

“In 2003-2004, 39 per cent of cardiac arrest patients presenting with a shockable rhythm survived to hospital and 14 per cent got to go home. In metropolitan Melbourne, that figure has now jumped to 60 per cent of patients arriving at hospital with vital signs and almost one in three patients surviving to discharge,” according to the HealthCanal.com report.

In Queensland, The Westerner reports the story of a group of parents have formed an organization to raise awareness of Sudden Arrhythmic Death Syndrome (SADS), a hereditary condition that is one of the causes of sudden cardiac arrest. Three local children died of SADS, including Tara Fielding, an athletic 18-year-old. Tara’s mother, Cheryl Fielding, is a cardiac nurse but said she had never heard of SADS until it claimed her daughter.

Cheryl Fielding aims to increase public awareness of the hereditary heart condition and what can be done to prevent SADS-related deaths. The group, SADS Australia, is campaigning to have cardiac screening for school children and athletes and to have AEDs placed in schools and sports facilities.

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Heart Safe news: Our weekly update on what’s happening in the world of heart safety and noninvasive cardiology

Reducing firefighters’ risk of sudden cardiac arrest

Seattle’s KING 5 reports that University of Pittsburgh researchers are testing two high-tech cooling techniques to reduce the incidence of sudden cardiac arrest among firefighters.

Smoke, toxic fumes, searingly hot temperatures, and exertion while wearing as much as 70 pounds of gear are factors in sudden cardiac arrest, the leading cause of death for on-duty firefighters.

While fighting a fire in a burning building, a firefighter’s body temperature can rise to 104 degrees. This can increase the risk of a serious heart incident. The Pittsburgh researchers are testing both vests (designed to cool the body’s core) and portable chairs with cooling arm rests. These solutions are being compared to the traditional cool down for firefighters, which is simply taking a break.

After losing son to sudden cardiac arrest, New York mom campaigns for AEDs, cardiac screening

17-year-old Dominic Murray died of sudden cardiac arrest while playing basketball. (Photo: DomHeart21.org)

Melinda Murray wants to see automated external defibrillators (AEDs) at stadiums, ballfields, and gyms — plus cardiac screenings for students before they can play school sports.

That’s because a year ago her 17-year-old son, Dominic, collapsed on the basketball court of sudden cardiac arrest, from which he later died.

New York Post sportswriter Dylan Butler wrote Sunday about Dominic’s death and his mom’s crusade to protect other student athletes. Dominic, who died while playing basketball at Farmingdale State College, had an undiagnosed heart condition called hypertrophic cardiomyopathy. Cardiac screening involving electrocardiogram (ECG) and echocardiogram tests can diagnose hypertrophic cardiomyopathy and other heart conditions that render children vulnerable to sudden cardiac arrest during sports. Melinda Murray is working with state legislators to draft a bill to requiring cardiac screenings for student athletes.

Murray has established the Dominic A. Murray 21 Memorial Foundation (the 21 refers to the number her son wore at Farmingdale). The foundation provides free cardiac screenings for high school student-athletes and promotes CPR/AED training and awareness.

“The only thing that may have saved Dominic’s life was an automated external defibrillator (AED). Sadly, help arrived too late,” the foundation’s website notes. “Equipping places where youth congregate with AEDS, along with the help of CPR/AED-trained individuals, can give youth stricken by SCA another chance at life.”

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University of Miami offensive line coach Jeff Stoutland was a busy man — so busy that when he experienced tightness in his chest and other symptoms of cardiac problems in May, he ignored them for as long as possible.

A treadmill stress test may have saved Jeff Stoutland's life. (photo: University of Miami)

But, as a story in the Palm Beach Post relates, it was just a matter of weeks before the symptoms were so painful that Stoutland was unable to do his regular workouts.

“I was getting crushed,” Stoutland told the paper. “I couldn’t go any longer.”

The 48-year-old coach made an appointment for a cardiac stress test. The results of the treadmill stress test were so dramatic that Stoutland was taken off the treadmill mid-test and admitted to the hospital. Just a few hours later, he underwent open-heart surgery to clear three blocked arteries.

Research at Columbia University Medical Center found that stress testing can be a life-saver for people like Stoutland who have chest pain but are not suffering a heart attack. Every year, more than 5 million people seek medical care for chest pain. Those who are having heart attacks can be diagnosed using electrocardiograms (EKGs), but for the rest, chest pain is often attributed to anxiety or physical activity.

The Columbia study, published in the June 15, 2003, issue of the American Journal of Cardiology, found that patients with chest pain who undergo a stress test have a significantly lower death rate that those who are not given a stress test. One of the reasons for the difference is that treadmill stress tests, which reveal blood flow deficiencies, can identify underlying coronary artery disease — blockage such as what Stoutland suffered.

The results of the study led to the creation of a chest-pain protocol, which includes recommendations for stress tests, at Columbia University Medical Center, NewYork Weill Cornell Medical Center and the Allen Pavilion at NewYork-Presbyterian Hospital.

Stoutland is now back at work coaching the Hurricanes. He advises others to do what he didn’t: Take care of their health, and visit the doctor if they have chest pains.

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The American Heart Association recommends that cardiac stress testing preceded exercise programs for certain sedentary patients.

One of the toughest tasks for primary care physicians is getting sedentary middle-aged patients off the path to cardiovascular disease and onto the path for health. A Clinician Update in the June 15, 2010, issue of Circulation has advice for doctors on when and how to prescribe exercise, including when to start the process with a treadmill stress test.

The article recommends that physician conduct a preparticipation screening to rule out any conditions, such as existing heart problems, that would make exercise risky. The authors note that some authorities recommend that certain sedentary patients get a cardiac stress test before embarking on an exercise program:

The American College of Cardiology and American Heart Association recommend exercise treadmill testing for asymptomatic patients with diabetes mellitus, men older than 45 years of age, and women older than 55 years of age before they undertake vigorous exercise, with the decision to incorporate myocardial imaging based on the baseline ECG and the pretest probability of coronary artery disease.

Unless the preparticipation screening reveals cardiac problems, physicians are urged recommend a moderate form of exercise, such as walking 5 times a week, to start, with resistance training to be add after the patients is exercising for 30 minutes in each session.

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