Why Are 12-Leads Not Required For School Physicals

[18G]

I think it's time to mandate 12-leads as a standard part of a school physical. This is happening way too much.

http://www.foxnews.com/us/2011/10/0...l-cheerleader-collapses-dies/?test=latestnews

 

[JPINFV]

Is it occurring more or just being reported more?

 

[medicdan]

Although the minority of these cases are sensationalized in the news, what is the real rate of cardiac abnormalities in those less than 30, especially high school athletes? Do we know what actually happened here? How do we know this wasn't a drug interaction or commino cordis (sp?)?

Is it worth the additional expense to the healthcare system for the testing and analysis? What is the rate of "false positives" requiring additional testing? At what point does the benefit outweigh the costs?

Can you pull up any epidemiological data describing the rate of congenital abnormalities? Do you believe this event to be a result of CAD in a high school cheerleader?

 

[JPINFV]

Although the minority of these cases are sensationalized in the news, what is the real rate of cardiac abnormalities in those less than 30, especially high school athletes? Do we know what actually happened here? How do we know this wasn't a drug interaction or commino cordis (sp?)?

If I was a betting man, I'd bet on hypertrophic cardiomyopathy, of which one of the leading presenting symptoms is cardiac arrest in young adults.

 

[Imacho]

Are you saying the government should pay for this? Or when student athletes get their physical screening, the 12 L is part if it paid by their insurance?

 

[Aidey]

I will try and find it, but last year someone did an analysis for how useful 12 leads would be as a routine part of a school physical. There was a significant concern about false positives and the number of students that needed to be tested to find one legit case was pretty high.

 

[usafmedic45]

I think it's time to mandate 12-leads as a standard part of a school physical. This is happening way too much.

http://www.foxnews.com/us/2011/10/0...l-cheerleader-collapses-dies/?test=latestnews

Because of low diagnostic yield. Many of the things that cause sudden cardiac death in young athletes are not likely to be picked up on a 12-lead. Hypertrophic cardiomyopathy will show up, but it's not specific because of the hypertrophy that naturally happens in well trained athletes so you're going to wind up referring a lot of kids out for echos that don't need them and, in many cases, can't afford them. Most cardiac dysrhythmias that you see in young people (outside of Brugada in some cases and LQTS) are not going to show up on a resting 12-lead. Cardiac valve issues, abnormal origin of the coronary vessels, myocardial bridging or even frank coronary atherosclerosis or vasospasm are not going to be picked up. Granted, it's a cheap and easy test but you asked why it's not done. All of the reasons above are why.

 

[18G]

These are perfectly healthy, young kids who should not be dying. If a 12-lead can potentially pick up on a cardiomyopathy or prolonged QT or some other risk factor for sudden death than I think it needs to be happening. It's very simple and takes no time at all to do.

Even if the 12-lead shows something suspect and the child needs an echo, so what. If it can prevent one child from dying than it is worth it in my opinion. I'm aware that a 12-lead won't pick up everything but if it can be used as a screening tool to help reduce SCA it should be employed.

I did a 12-lead on myself at work that showed LVH which I wasn't real concerned about but it was still a little concerning. I went to my doctor for another problem and told him my finding. He ordered an echo with no questions asked. Insurance paid for the echo.

Parent's need to be paying attention to these media reports and requesting 12-leads during physical's for their kids if they are not going to be mandated. States should also be mandated to have AED's in schools and at the sidelines of all sporting events.

 

[usafmedic45]

what is the real rate of cardiac abnormalities in those less than 30, especially high school athletes?

It's not all that high but it's considered to be more significant because of the age and popularity of the person. You can look on Pubmed for the actual numbers as this has been studied to death. If it were members of math bowl team suffering a berry aneurysm rupture during intense calculations or the drama geeks suffering spontaneous tension pneumos while singing in school musicals, I don't think it would get as much attention. Just my two cents....

 

[18G]

I highly doubt only the popular students get their deaths reported.

 

[usafmedic45]

If a 12-lead can potentially pick up on a cardiomyopathy or prolonged QT or some other risk factor for sudden death than I think it needs to be happening. It's very simple and takes no time at all to do.

That's the problem. It can't in most people.

These are perfectly healthy, young kids

Technically, no they are not, otherwise they would not be dead.

I did a 12-lead on myself at work that showed LVH which I wasn't real concerned about but it was still a little concerning.

Would it surprise you that simply misplacing the leads can produce that? Also, even with perfect placement, about 30-40% of adult men are going to show up with LVH based off of electrocardiographic criteria.

I went to my doctor for another problem and told him my finding. He ordered an echo with no questions asked. Insurance paid for the echo.

Yeah, good on you that you have insurance. A lot of people don't. You want to pay $500 for an echo that in all likelihood is going to be clear? Also do you want to backlog the echo techs even further keeping people who really need echos from getting them just so you can assure that Susie Q. Cheerleader will be able to keep her mouth firmly on someone's jock until she's too battered and worn for anyone to want her anymore?

Even if the 12-lead shows something suspect and the child needs an echo, so what. If it can prevent one child from dying than it is worth it in my opinion.

So then by your logic, let's require rear facing passenger seats in all cars, buses and airplanes. Let's switch from using gasoline to using something like JP-5 (the Navy's version of jet fuel) which is less flammable but more expensive. I mean, it's inconvenient and expensive but hell, if it saves a single child's life then it must be worth it right?

Why is a teenage athlete's life worth more than a non-athlete or an older person? Why not just screen all teens? The ones with more going for them than a minor physical skill are more likely to contribute something to this world and anyways, their sedentary lifestyles put them at greater risk of real cardiac threats both in the short and long term.

 

[usafmedic45]

I highly doubt only the popular students get their deaths reported.

There's a statistical difference in the reporting of lightning fatalities between immigrant workers and American workers in Florida as we identified in a study that we did looking at the accuracy of reporting. The National Weather Service actually uses newspaper articles to track them (yeah, seriously....) and if you start comparing it to other sources of data (death certificates, autopsy reports, etc) you start to see trends where folks who aren't white, young and/or otherwise sympathetic victims do not appear in the data set as often. If you need another example, there's always this: http://en.wikipedia.org/wiki/Missing_white_woman_syndrome


I can't see why other biases would not exist.

 

[18G]

Would it surprise you that simply misplacing the leads can produce that? Also, even with perfect placement, about 30-40% of adult men are going to show up with LVH based off of electrocardiographic criteria.

And that is why I said I wasn't too concerned. But I'm not going to assume that the high voltage criteria and ECG finding were from misplaced leads or is a benign finding. I placed the leads so I knew they were not misplaced.

My oldest son takes a stimulant ADHD med daily and has for years. A potential cardiac effect exists in children who takes these meds daily. And because it was requested, my son has a 12-lead performed annually as ordered by his pediatrician. As a parent you need to take control and be informed of all things that can harm your kids as much as possible. These media report's should be making parents perk up.

And by using your logic, these incidents are so rare and these kids are that unimportant that we should not invest thousands of dollars into AED's for school's?

 

[Tommerag]

And that is why I said I wasn't too concerned. But I'm not going to assume that the high voltage criteria and ECG finding were from misplaced leads or is a benign finding. I placed the leads so I knew they were not misplaced.

My oldest son takes a stimulant ADHD med daily and has for years. A potential cardiac effect exists in children who takes these meds daily. And because it was requested, my son has a 12-lead performed annually as ordered by his pediatrician. As a parent you need to take control and be informed of all things that can harm your kids as much as possible. These media report's should be making parents perk up.

And by using your logic, these incidents are so rare and these kids are that unimportant that we should not invest thousands of dollars into AED's for school's?

Sure if the parent wants to take control and be informed then have them take their kid in for it, but it should not be required for every student.

 

[Handsome Robb]

Sure if the parent wants to take control and be informed then have them take their kid in for it, but it should not be required for every student.

Oy! look who it is!

18g I'd love to hear more about this medication. I personally have been taking stimulant ADHD meds since I was younger.

PM me if that's ok with you.

 

[usafmedic45]

But I'm not going to assume that the high voltage criteria and ECG finding were from misplaced leads or is a benign finding.

You know more than 95% of the board certified cardiologists out there? Very few people get kicked to an echo for asymptomatic EKG findings of LVH. Usually, it's done in those cases only to shut up those patients who are either hypochondriacs and/or have spent too much time watching House or reading WebMD.

My oldest son takes a stimulant ADHD med daily and has for years. A potential cardiac effect exists in children who takes these meds daily

And that pertains to your picture of a "perfectly healthy" child how? Are we talking about screening everyone or just those with known but likely insignificant risk factor? Hell, taking aspirin regularly leads to a potential gastrointestinal hemorrhage...should we start screening every member of this forum for ulcers simply to avoid Tommerag or Chimpie eventually going bloody version of The Exorcist on their surroundings from a complication of stress-induced headaches? The risk of bleeding complications with aspirin is a lot higher than the risk of cardiac effects from properly prescribed (pun intended here) ADHD medication.

As a parent you need to take control and be informed of all things that can harm your kids as much as possible

But not to the point of subjecting them to every medical test under the Sun simply to allow the parents to sleep better at night. You can't make life perfectly safe and we breed neurosis and insecurity in our children by trying to give them an allusion of perfect safety. Welcome to why your child is likely on psych meds. We've turned kids who doesn't get smacked frequently or hard enough when they misbehave into a clinical diagnosis.

And by using your logic, these incidents are so rare and these kids are that unimportant that we should not invest thousands of dollars into AED's for school's?

I didn't say that and there is a high risk population at schools. They are called "adults". You really aren't very good at intellectual debate, you know that right?

 

[usafmedic45]

18g I'd love to hear more about this medication. I personally have been taking stimulant ADHD meds since I was younger

There's a risk of premature atherosclerosis with prolonged use of stimulant medications and some concern over the risk for the development of cardiomyopathies associated with them as well. Do a PubMed search for "methylphenidate, cardiovascular disease" and you should learn a lot more than you would otherwise.

 

[Handsome Robb]

Good thing I don't take methylphenidate.

 

[18G]

There's a risk of premature atherosclerosis with prolonged use of stimulant medications and some concern over the risk for the development of cardiomyopathies associated with them as well. Do a PubMed search for "methylphenidate, cardiovascular disease" and you should learn a lot more than you would otherwise.

Both the AHA and the American Academy of Pediatrics find it acceptable for physicians to screen kids who are on ADHD meds with an ECG.

If your one of the many parents who want to leave your kids to chance than good for you. That's your choice. I do not take that approach however, and will assure my kids are screened with risks minimized as much as possible.

 

[usafmedic45]

Both the AHA and the American Academy of Pediatrics find it acceptable for physicians to screen kids who are on ADHD meds with an ECG.

Yes and it is because of the low risk involved, but this discussion wasn't about that. It was about screening kids with no risk factors. Do try to stay on topic and not bring in unrelated information to try to win the debate.

If your one of the many parents who want to leave your kids to chance than good for you. That's your choice. I do not take that approach however, and will assure my kids are screened with risks minimized as much as possible.

There's a difference between minimizing appropriate risk and being overprotective and borderline paranoid. It's not a matter of leaving things to chance but simply the difference in where one chooses to deem risk existing.