In 2004 and 2005, the European Society of Cardiology and the International Olympic Committee began recommending universal EKGs for athletes less than 35 years old. ("Athletes" means people participating in "competitive activities"; some argue that it includes anyone exercising regularly at high intensity.) Yet in 2007, the AHA issued guidelines that broke with their European counterparts and failed to endorse routine EKGs. Of course, scientific disagreements over evidence occur frequently. However, the guidelines offered a baffling, non-evidence-based justification for inaction. In a tortured passage, the American Heart Association argued primarily that "the framework" for EKG screening doesn't exist since screening would "have to be unusually efficient to process thousands of athletes"—an excuse that ignores the fact that Italy now screens millions of athletes routinely. The AHA claims that sudden deaths of athletes are "unlikely" to "achieve sufficiently high priority when competing with a myriad of other public health issues." The U.S. health care system, they conclude, is "already overburdened."
That's an odd argument from an organization that recommends all manner of fabulously expensive therapy for heart attacks, cholesterol problems, and other conditions. The AHA's rationale inflamed Dr. Robert Myerburg, chair of cardiovascular research at the University of Miami, who co-wrote a devastating critique of the guidelines. "We need to lead," he recently told me, "and get away from the idea [that] screening isn't feasible." In particular, Myerburg assails cost-effectiveness figures of the AHA, whose estimated hospital costs fail to factor in any discount for mass screenings. Nor do the estimates take into account the potential savings of modern automated reading technology. Like opponents of drug treatment for AIDS in poor countries, he implies, the AHA has cooked the books to suit an anti-screening agenda.
Consider how the savviest, and wealthiest, organizations now protect their athletes. Ninety-two percent of American professional athletes get screening EKGs. Following the death of Atlanta Hawks center Jason Collier in 2005, all NBA players get a cardiac ultrasound—an even more reliable, if expensive, test than an EKG—to exclude causes of sudden death. Several college sports programs, such as those at Purdue, Ohio State University, and Georgia Tech, also perform echocardiograms. Anecdotal evidence suggests that some private high schools have begun offering routine EKG screening for athletes, since the AHA guidelines explicitly say they are "not intended to actively discourage individual local efforts." This contradiction between the AHA's population-wide and individual recommendation inevitably will lead to a two-tier approach to young athletes. (Already, more than half of all young athletes who die are African-American.)
Why does the AHA really oppose screening tests, even though their statement plainly asserts that the tests "would have benefit?" Though not stated explicitly, widespread screening with EKGs, or even echocardiograms, threatens traditional, lucrative fee-for-service norms for expensive cardiac testing. According to Medicare reimbursements, an EKG scores about $50, though it takes only minutes to obtain and a few seconds to read. An echocardiogram gets roughly $400. What would happen if these tests were subjected to market pressures and economies of scale? Consider what Purdue's athletic department did: They contracted with local cardiologists to perform focused two-minute echocardiograms for only $35 instead of $400. Such creative solutions might save lives—but could also dispel the mystique (and monetary rewards) of many cardiologists' work.
Widespread screening, whether it's mammograms, blood pressure measurements, or other tests, is often complicated and not always helpful. But the debate over expanded EKG testing largely concerns the politics, not the science, of the test. Ultimately, it would be better for America's young athletes if the scientists stuck to the science, the politicians handled the politics, and the entrepreneurs tackled the franchising.
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