Testimony by Wilson Lam, MD
House Public Education Committee
House Bill 3476 — Mandatory ECGs for Student Athletes
April 11, 2017
Thank you, Chairman Huberty and Public Education Committee, for the opportunity to share my testimony. My name is Wilson Lam, and I am a cardiologist from Houston trained in adult cardiology, pediatric cardiology, and electrophysiology (or rhythm disorders including sudden cardiac death). I work in the Texas Medical Center and am involved in medical education. I am here representing myself, the Texas Pediatric Society, and the Texas Medical Association.
I want to thank Representative Huberty and the Stephens Go Big or Go Home Memorial Foundation for their desire to reduce sudden cardiac death in University Interscholastic League athletes. However, as a cardiologist aware of the most recent medical literature, I have to oppose House Bill 3476, which would mandate a screening electrocardiogram, or EKG, for participation in school athletics.
The electrocardiogram is an imperfect screen. It is rarely grossly abnormal and often can have subtle variations or mild abnormalities. It is neither sensitive nor specific for cardiac disease. In other words, abnormalities on EKG can be present in a normal heart, sidelining a healthy athlete and adding angst and expensive confirmatory testing such as an echocardiogram or cardiac MRI. For the leading cause of sudden death in the United States, hypertrophic cardiomyopathy — present in 1 in 500 individuals — for every 50 electrocardiograms read as abnormal thickness only one corresponding echocardiogram follow-up will identify the condition. While EKGs are relatively inexpensive, echocardiograms can be very expensive, ranging from $1,000-$2,000 each.
Likewise, normal EKGs can be present in hearts with significant disease that can lead to sudden death. The electrocardiogram gives us only 10 seconds of a person’s rhythm and can fluctuate based on general constitution, race, gender, and technicalities such as lead placement. When looking at the major causes of sudden death in competitive athletes, we see that around 40 percent of those would have had a condition presenting with a normal EKG. (These major causes include anomalous coronary arteries, myocardial bridging, premature coronary artery disease, mitral valve prolapse, indeterminate hypertrophy, aortic rupture, channelopathies like CPVT, structural conditions like ARVC, and even 3 percent of normal hearts — a condition called commotio cordis). Some conditions might start with a normal EKG and develop into an abnormal EKG later in life, giving a false sense of security.
There are insufficient numbers of cardiologists (Texas has more than 1,700 cardiologists but fewer than 200 pediatric cardiologists) to interpret and sift through the normal variants. With an estimate of 500,000-750,000 high school athletes per year and $15 per EKG, that’s $7 million-$11 million to get high school athletes screened each year. Additionally, you would need every pediatric cardiologist in the state to read 3,000 more EKGs each year.
The October 2014 Scientific Statement from the American Heart Association and American College of Cardiology states:
Mandatory and universal mass screening with 12-lead ECGs in large general populations of young healthy people 12 to 25 years of age (including on a national basis in the United States) to identify genetic/congenital and other cardiovascular abnormalities is not recommended for athletes and nonathletes alike (Class III, no evidence of benefit; Level of Evidence C).
If funding for EKGs was used instead for automated external defibrillators at sporting events and gymnasiums, and for sports team travel, we could treat all comers via the final common pathway of sudden death, which is fatal arrhythmia. Even the 3 percent of normal hearts that would have passed an EKG screen would benefit from a defibrillator on site. Even older bystanders with higher sudden death risk would benefit from these.
Thank you again for your commitment to reducing sudden cardiac death in our young people. I hope we can devise a high-value coordinated plan to protect our children. Please do not let Texas become the first state to go against recommendations from the two largest cardiology organizations in the United States by mandating EKG screenings.
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