May 3rd, 2012

The Dark Side of EKG Screening in Athletes

CardioExchange welcomes this guest post from Dr. Westby Fisher, an electrophysiologist practicing at NorthShore University HealthSystem in Evanston, Illinois, and a Clinical Associate Professor of Medicine at University of Chicago’s Pritzker School of Medicine. This piece originally appeared on his blog, Dr. Wes.

They sat nervously with their son in the doctor’s office, wondering why they were there. John was, after all, the picture of health and had just received a scholarship to Stanford University to play soccer. His mother and father had been to every soccer match throughout his formative years, enduring the travel schedule with its weekends away from home, long hours, horrible weather. John was staring at his iPhone, his mother clutching a Kleenex. John’s father stared out the window. It was raining.

The door opened.

“Hello, I’m Dr. Kiljoy. They asked me to see your son about a finding on his EKG.”

“Hello,” they said back.

“As you know, we’ve been looking into EKGs in athletes because we have suspected for some time that an EKG will help us better detect students who might be at risk for sudden cardiac death while participating in sports. You know, even if we can prevent one death in these young people, it would be worth it. None of us want a young person to die. That New York Times article yesterday… dang… with that crying family and all right there at the top… poor boy collapsed, people had no clue what happened at first, people thought he overheated, then waited… only later did they find that AED. Then it didn’t work ’cause the battery was dead. So sad! We really are trying to prevent that from ever happening. Seriously. Sad as hell. And to think we could have caught this if that teenager had just had an EKG…”

“Yes, of course!” said John’s mother. “I’m SO glad you did this! We’ll be so reassured to know that John’s going to be okay. ”

A pause filled the room…

“He IS going to be okay, isn’t he?” she asked.

“Well, Mrs. Smith, we’re not sure, we have to run some other tests. You see, he had a slight elevation to his ST segments in these leads here, see? Then look at his heart rate, it’s so slow! And that voltage here, it’s more than we usually see… It’s probably okay, but I’m going to order an echo to look at his chamber sizes.”


“And then I’m going to have one of our EP people see him to make sure he doesn’t have a congenital ion channel disorder…”

“A what?”

“A channelopathy — a genetic defect of some ion channels in his heart – the most common form is called Brugada Syndrome…”

“How do you spell that?” She waited with pen and paper to jot it down…

“B-R-U-G-A-D-A. Look, he’s probably okay, but we want to be absolutely sure, especially with that ST segment elevation in those leads…  We’ll also check a stress test to make sure his heart rate comes up appropriately with exercise and that there aren’t any funny EKG changes with exercise that might suggest an anomalous coronary artery – I’ve seen three people die like a dog with that one!”

“How often does that happen?” she asked.

“Well, it’s pretty uncommon, but if it’s there, sometimes we have to do open heart surgery to reimplant it so that it won’t get pinched between the pulmonary artery and aorta when he exercises.”

“But he’s never had a problem! And no one has ever died suddenly in our family – ever!”

“Mrs. Smith. Remember why we’re doing this: John’s safety. This is all about John’s safety.”

“And if you find something in all these tests, then what?”

“Well, he wouldn’t be able to play soccer.”

John’s eyes suddenly lift from his cell phone. “What did you say?” he asked.

“You won’t be able to play soccer,” Dr. Kiljoy repeated.

“Mom, what the f#$*!? If I don’t play soccer, I don’t go to Stanford. If I don’t go to Stanford, I’ll never play soccer again! Are you serious?”

The father, sensing his son’s concern, returns to the room from his window transcendental meditation.

“Son, let’s just get the tests. Your mother’s concerned.”

“Mom’s concerned? What the hell do you mean ‘Mom’s concerned?’ What about me? I never wanted to get this frickin’ EKG anyway! Look, I’m FINE. I never so much as farted wrong. We have no family history of heart disease. I’ve never felt my heart race, I’ve never passed out, I’m faster than everyone else on my team and we just won the State Championship! How’s THAT for a stress test? I’ve worked my ass off for YEARS to get this scholarship. And now, just because of this EKG with bull—- findings that don’t pertain to kids my age they’re going to do a million tests just to be sure? Seriously? Honestly, Dad, you gotta be kidding me… How much is all this gonna cost, huh? And maybe I’ll lose my scholarship, too? How much is THAT worth?”

“John, honey, it’s for your safety,” his mother whispers, tears streaming down her cheeks. “We love you so. We just don’t want anything bad to happen to you…”

“Your Mom’s right, John. We just want to be sure… Really…” Dr. Kiljoy continued.

John looked up at Dr. Kiljoy, and said slowly, painfully, with tears in his eyes:

“Doctor, f*&% you.”


P.S.: For more, please see Dr. John M’s take on the New York Times’ abysmal reporting on this issue.

4 Responses to “The Dark Side of EKG Screening in Athletes”

  1. Alain Efstratiou, MD says:

    I could easily write the opposite story about the athlete who collapses and autopsy shows a septum measuring 22mm which could easily have been detected by an ECG and confirmed with an Echo. And this proves what?
    Yes, we will restrict unnecessarily from sports some people like millions are treated with statins who will never have a heart attack. As long as both parties understand what is proposed I see no problem.

  2. Michael Mirochna, MD says:

    The problem is, how many people will be held out of sports/exercise/live with the thought of a taking time bomb to potentially save a life? How many people have hocm and have died of other causes?

    Doctors don’t understand false positives, etc… How will the lay population understand testing just to be sure, what that actually means and what it takes to actually be sure?

    Nice post.

  3. Tim Noonan, none says:

    Preventing people from engaging in organized sports is the same as taking statins?

    We would probably have far less perceived need for statins if we could encourage more physical activity.

    The responsible approach to treating with statins is to try exercise first. Should we screen everyone for rhabdomyolysis, ALS, and Guillain Barre because they might be at greater risk for these than the risk of SCA that a student athlete faces?


  4. I am grateful to John Mandrola – . SCA/SCD is by far more complex than an extremely rare (“sole”) ECG finding. By the way, is everyone reading this topic sure not to miss any slight anomalies in ECG in case the ECG had been indicated for some other reason? Event if one finds Brugada type 2 or 3 (not so rare), it does not necessarily mean SCD.