Why Are 12-Leads Not Required For School Physicals

[Aidey]

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?

So in other words your son has a risk factor aside from just being a kid? Funny how that works.

Schools are not closed systems, there are a number of people besides children at them. Especially when you consider how big high school sports are in some areas of the country.

You sound a lot like the people who got drop side cribs banned. I did the math one time, it came out to something like .0000000068%* chance a child would die in a drop side crib.

I bet the numbers are similar for the percentage of deaths that would be prevented with a 12 lead. There are millions of school athletes, and how many cases of SCA are publicized each year? 6-8? Even if there are twice that many deaths there is no guarantee that all of them would be caught by a 12 lead ahead of time.


*I took the total number of cribs recalled, assumed each crib was used by 2 children, and those children slept in them for 12 months and divided that by the total number of deaths. Crude, but puts the numbers into perspective.

Edit: As usual USAF beat me to the punch.

 

[18G]

USAF..Actually I dont even consider this a debate and don't care if I convince you or not. I have my own informed opinion and life experiences on the subject and that is what I am relaying.

The ADHD med and ECG screening is kinda related to the routine screening of student athletes. The ECG screening is deemed reasonable BEFORE starting the ADHD med and while taking the med. These meds are stimulants which can aggravate underlying heart conditions just the same as catecholemine release can aggravate heart conditions during extreme physical activity. So, if were gonna screen for one than how is the other not even remotely reasonable? I see a relation

Hmmm.... stimulant ADHD med... may aggravate an unknown cardiac abnormality... lets use the ECG as a risk reduction tool.... deemed REASONABLE.

Hmmm.... high exertional state during sports activity - extreme catecholemine release... may aggravate an unknown cardiac abnormality in a similar way as an ADHD med.... lets NOT use the ECG as a risk reduction tool. MAKES NO SENSE TO ME.

No conclusive evidence has been found to say one way or the other on the benefit of routine 12-lead testing. I think it is very reasonable for a child to receive a routine 12-lead prior to sports participation. How many kids have t go unscreened and die before studies can say for sure if these deaths can be prevented. It is known that a 12-lead can catch some abnormalities that will pose a threat to a student athlete so it is prudent to perform these until direct evidence says other wise.

If nothing else... to the parents on the forum... consider it for yourself and spread the word to other parents so they too can be informed and make a decision that may potentially save their child's life.

 

[usafmedic45]

USAF..Actually I dont even consider this a debate and don't care if I convince you or not. I have my own informed opinion and life experiences on the subject and that is what I am relaying.

I don't care if I convince you or not, but I am not about to let groundless supposition and illusory correlations based on what is- at best- a questionable grasp on the subject matter to rule the day so long as I have anything to say about it.

Hmmm.... high exertional state during sports activity - extreme catecholemine release... may aggravate an unknown cardiac abnormality in a similar way as an ADHD med.... lets NOT use the ECG as a risk reduction tool. MAKES NO SENSE TO ME.

It's a piss poor reduction measure and likely to simply result in the same rate of deaths and, if anything a false sense of security. If you'd pull your head out of the cavity in which you have it lodged and actually read what I am saying then you would see that. It's like saying that having an normal RBC count rules out anemia when it does nothing or the sort. If you need me to explain how that one works, let me know.

If nothing else... to the parents on the forum... consider it for yourself and spread the word to other parents so they too can be informed and make a decision that may potentially save their child's life.

Why don't you just change your screen name to Jenny McCarthy because you have about the same burden of proof standards as she does.

No conclusive evidence has been found to say one way or the other on the benefit of routine 12-lead testing.

Low specificity and high sensitivity is a pretty good bit of evidence. Just because it doesn't fit your standards doesn't mean that it's not relatively conclusive to a reasonable person.

The ADHD med and ECG screening is kinda related to the routine screening of student athletes. The ECG screening is deemed reasonable BEFORE starting the ADHD med and while taking the med. These meds are stimulants which can aggravate underlying heart conditions just the same as catecholemine release can aggravate heart conditions during extreme physical activity. So, if were gonna screen for one than how is the other not even remotely reasonable? I see a relation

Because there's a difference between the effects of periodic exercise and the effect of more or less continuous up-regulation? Your oversimplification of this and false analogy isn't going to stand up before anyone with even a moderate knowledge of physiology and pharmacology.

"Education is the discovery of one's own ignorance"

You'd be well advised to spend more time reading your own signature. There is nothing more dangerous than sincere ignorance or conscientious stupidity, to quote Martin Luther King, Jr. I'm pretty sure you meet the criteria for both of those based upon your statements here in this thread.

 

[18G]

Your entitled to your opinion which is fine. I simply raised a question for discussion and gave my input. You however want to hijack the thread and make it a pissing contest like you do the majority of times.

I never said a 12-lead is an absolute solution and realize it's short comings in the issue at hand. I also know they're are physicians who advocate for it and those who advocate against it.

Excerpts from the article:
http://savingyounghearts.org/?p=1125

"As more high schools and colleges require that athletes get an EKG to detect potentially deadly heart defects, an international group of experts has issued recommendations to help make the test more reliable. "

“It’s an excellent effort to try to give guidance” that should minimize false-positive and false-negative results, said David E. Haines, director of the Heart Rhythm Center at Beaumont Hospital in Royal Oak, Mich., who was not part of the current study.

His hospital conducts mass screenings of high-school athletes in the community. The program has screened 6,685 students over four years, with 41 told to stop exercising pending further medical evaluation and another 663 sent on for follow-up but not told to stop exercising."

"A study published in April in Circulation found that 45 NCAA student athletes suffered sudden cardiac death between 2004 and 2008. That translated to one student out of every 43,770 participants each year, a greater incidence than previously thought."

"Some individual colleges require screening, though, and hospitals are increasingly offering community screening programs for high-school athletes.

And this.... http://today.msnbc.msn.com/id/41392...etes-sudden-deaths-spur-call-heart-screening/

So I'm really the only ignorant one advocating and giving support to routine ECG's for student athletes????

Your obviously being antagonistic intentionally so your not worth my time in this discussion. You really sound like a reinvented VentMedic.

 

[usafmedic45]

So I'm really the only ignorant one advocating and giving support to routine ECG's for student athletes????

I didn't say you were the only one. But the problem with that reference is it doesn't give us a measure of how many actually turned out to have a real problem and how many were false positives.

Your obviously being antagonistic intentionally so your not worth my time in this discussion

No, I'm disagreeing with you because you have nothing to substantially back up your argument. I am being intentionally antagonistic. The only way I could not be doing so is to agree with you and you haven't given me anything to base agreement with your stance upon. Learn to debate and you'll see why where you see someone spitting in your face, someone with an academic background sees someone demanding proof. This isn't a bar room debate over whose fantasy football team is better. It's a debate on medical science. I'm treating it as such. You think I'm being nasty, you should see how ugly debates like this at conferences can get between PhDs and between MDs.

Just for clarification, I'm not against screening. I just think 12-leads are a poor way of doing it. Screen for symptoms or family history and find those with high risk and refer them for echos. Better yet, find someone with money to burn and the need for a tax write-off and hire echocardiographers such as myself to scan everyone.

 

[Akulahawk]

USAF..Actually I dont even consider this a debate and don't care if I convince you or not. I have my own informed opinion and life experiences on the subject and that is what I am relaying.

The ADHD med and ECG screening is kinda related to the routine screening of student athletes. The ECG screening is deemed reasonable BEFORE starting the ADHD med and while taking the med. These meds are stimulants which can aggravate underlying heart conditions just the same as catecholemine release can aggravate heart conditions during extreme physical activity. So, if were gonna screen for one than how is the other not even remotely reasonable? I see a relation

Hmmm.... stimulant ADHD med... may aggravate an unknown cardiac abnormality... lets use the ECG as a risk reduction tool.... deemed REASONABLE.

Hmmm.... high exertional state during sports activity - extreme catecholemine release... may aggravate an unknown cardiac abnormality in a similar way as an ADHD med.... lets NOT use the ECG as a risk reduction tool. MAKES NO SENSE TO ME.

No conclusive evidence has been found to say one way or the other on the benefit of routine 12-lead testing. I think it is very reasonable for a child to receive a routine 12-lead prior to sports participation. How many kids have t go unscreened and die before studies can say for sure if these deaths can be prevented. It is known that a 12-lead can catch some abnormalities that will pose a threat to a student athlete so it is prudent to perform these until direct evidence says other wise.

If nothing else... to the parents on the forum... consider it for yourself and spread the word to other parents so they too can be informed and make a decision that may potentially save their child's life.

Kids with ADHD that might be or will be put on a stimulant... is a relatively small population (one at a time) and that stimulant use is a known risk factor. Athletics is a MUCH larger population. You're asking for a couple HUNDRED athletes to be screened via 12-lead, all at once. While each student may get clearance from their personal physician, that physician isn't likely to be knowledgeable in the stresses of athletic competition. We also know that generally, athletics (exercise) is good for you. The stresses on the heart are normally a very good thing for you.

Now, add in the fact that these physicals are not cardiac stress tests. Given that athlete hearts are already somewhat enlarged because of the stresses put on them, you're going to get a LOT of false positives. It's possible that even an echo might not pick up on anything.

A school athletics department would do MUCH better to purchase a couple AED units and have them available at every school-sponsored sporting event. Often the only presenting symptom is the athlete dropping dead... However, since these events happen to athletes only a few times per year, schools may not even consider doing that because of the cost. So they require that all the coaches and athletic training staff be CPR trained and at certain events, they pay for an ambulance stand-by.

This is a prime example of risk-benefit analysis...

Personally, I like the idea of having an AED unit at every sporting function, designated for use on the team. It's just that they're expensive.

 

[usafmedic45]

Often the only presenting symptom is the athlete dropping dead... However, since these events happen to athletes only a few times per year

It's roughly twice the lifetime risk of being killed by a crashing airplane....when you're not on it. It's tragic, a minority of them are preventable but as you said, risk/benefit analysis.

 

[18G]

USAF45...And you have yet to provide absolute proof that this screening tool is absolutely useless and worthless. All I've heard you spew is speculation based on some limited data in which you are trying to disparage me with. Your the one spouting the absolute, not me.

I'm simply saying I feel there is a great benefit and for the time being it is better than nothing as an attempt to save some of these kids. If years down the road after routinely doing these ECG's the data say's something else, than let's reexamine.

Italy mandates routine ECG's for students and have found a reduction in student deaths. How about that? Are they idiotic too and have flawed numbers???

The point is this.... evidence does suggest benefit and I also see the other side of false positives and the limited evidence and groups that say it's not worth the effort (although I don't agree).

But standing back and doing nothing to screen for these lethal abnormalities is certainly not good practice. I would rather have a false positive and a kid not play a sport than to have that same kid dead on a football field.

And this is a discussion for raising points... its not about who's wrong and who is right. And further, I am not here for a scientific debate. It is 12:21am, I am bored, and is a simple forum on the Internet!

 

[18G]

Kids with ADHD that might be or will be put on a stimulant... is a relatively small population (one at a time) and that stimulant use is a known risk factor. Athletics is a MUCH larger population. You're asking for a couple HUNDRED athletes to be screened via 12-lead, all at once. While each student may get clearance from their personal physician, that physician isn't likely to be knowledgeable in the stresses of athletic competition. We also know that generally, athletics (exercise) is good for you. The stresses on the heart are normally a very good thing for you.

Now, add in the fact that these physicals are not cardiac stress tests. Given that athlete hearts are already somewhat enlarged because of the stresses put on them, you're going to get a LOT of false positives. It's possible that even an echo might not pick up on anything.

A school athletics department would do MUCH better to purchase a couple AED units and have them available at every school-sponsored sporting event. Often the only presenting symptom is the athlete dropping dead... However, since these events happen to athletes only a few times per year, schools may not even consider doing that because of the cost. So they require that all the coaches and athletic training staff be CPR trained and at certain events, they pay for an ambulance stand-by.

This is a prime example of risk-benefit analysis...

Personally, I like the idea of having an AED unit at every sporting function, designated for use on the team. It's just that they're expensive.

You bring up good points.

Implementing this type of program requires planning and I would expect wouldn't happen with ordinary visits and office schedules. Why couldn't student's be scheduled for ECG's in large sessions a few times a month? Where on certain day's all that happens is student ECG screenings? That doesn't seem like a huge hurdle to clear.

Certain places already do this so obviously it can be done.

 

[18G]

“Good scientific data neither supports nor refutes the benefit of ECG screening,” according to Marek. “We will therefore give the youth in our community the benefit of the doubt and continue with our incredibly successful and efficient Youth Hearts for Life Cardiac Screening model.” - Dr. Marek

http://www.sca-aware.org/sca-news/three-deaths-in-one-week-are-student-athletes-safe-at-school

Exactly what I been trying to say.

 

[Smash]

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.

You do realise that those organizations are essentially lobby groups for their members don't you? What they find acceptable is what improves the lot of their members or makes them more money, and often has no bearing on what is useful, or even safe in real life.

Any test is only as good as your pre-test suspicion that there is something wrong. I presume that, as you assume your child has cardiovascular disease, in the absence of a positive ECG, you would insist upon bloods, or maybe an angio? After all, this is where we need to go in a suspected ACS with a negative ECG.

 

[usafmedic45]

And you have yet to provide absolute proof that this screening tool is absolutely useless and worthless. All I've heard you spew is speculation based on some limited data in which you are trying to disparage me with. Your the one spouting the absolute, not me.

The burden of proof is on the person making the extraordinary claim. You're claiming that the 12-lead is a great tool for this. You have the burden to prove it. I'm not trying to disparage you, I'm trying to make you think before you cram your foot in your mouth by making questionable statements based off of emotion and reflex. If I were trying to disparage you, I'd have simply told you that you're a simpering moron who incapable of learning and left it at that.

Italy mandates routine ECG's for students and have found a reduction in student deaths. How about that? Are they idiotic too and have flawed numbers???

Let's see the actual source of the numbers. The peer-reviewed article on it, not some press release from a group with an agenda to push.

I'm simply saying I feel there is a great benefit and for the time being it is better than nothing as an attempt to save some of these kids. If years down the road after routinely doing these ECG's the data say's something else, than let's reexamine.

...or you apply the data that exists from other studies and save yourself the time, the effort and the expense. Would you rather wait ten years to find out that it doesn't work or maybe save 5-10% of these kids by using more sensitive and specific screening measures? You're talking 45 lives a year nationwide. It's not a huge loss and there are problems much more easily rectified that affect far more people.

And this is a discussion for raising points... its not about who's wrong and who is right.

Then stop getting your panties in a twist every time I raise one and request more than "I feel....". The only person whom I give more than a roll of the eyes to when they start a sentence with that phrase is Kat.

But standing back and doing nothing to screen for these lethal abnormalities is certainly not good practice.

No one is advocating that. You're viewing this as either we do it your way or we're throwing up our hands and saying ":censored::censored::censored::censored: it!". I really hate false dichotomies especially when put forward to save face.

I would rather have a false positive and a kid not play a sport than to have that same kid dead on a football field.

So you're more comfortable falsely consigning a kid to a sedentary lifestyle with the much more realistic risks involved than the infinitesimal risk of an athletic SCA in a teen?

 

[usafmedic45]

Why couldn't student's be scheduled for ECG's in large sessions a few times a month? Where on certain day's all that happens is student ECG screenings? That doesn't seem like a huge hurdle to clear.

Certain places already do this so obviously it can be done.

The issue comes back to "Is the benefit worth the effort?". Inconveniencing thousands of people to maybe prevent one or two deaths a year nationwide isn't going to be practical except to someone who ideologically melded to the idea on grounds other than scientific proof.

 

[Aidey]

18g I read about Italy too. You're leaving out all the details that make their practice not really applicable to the US. They have a significantly smaller population, and thus fewer student athletes. Their pre screening death rate is higher than the US, and consequently their post screening death rate is the same as the US. The practice is not standard nationally because of the cost, and as I said, they are dealing with a lot fewer student athletes.

Other studies have also found that 12 leads really only useful when combined with a thorough pre-screening.

I'll dig the links back up.

 

[18G]

The burden of proof is on the person making the extraordinary claim. You're claiming that the 12-lead is a great tool for this. You have the burden to prove it. I'm not trying to disparage you, I'm trying to make you think before you cram your foot in your mouth by making questionable statements based off of emotion and reflex. If I were trying to disparage you, I'd have simply told you that you're a simpering moron who incapable of learning and left it at that.

Im not making an extraordinary claim or making any statement based on emotion. I've been a supporter of this for a few years now and is a topic I take great interest in. I never said this is the "golden answer" to kids killing over. I never said that at all. You like to put words in my mouth.

They're are quite a few groups of physicians that have the same outlook and support of routine ECG's as I do. And they run the programs that screen kids. Would you tell them they are just as dumb too because they are doing something that numbers don't back up??? I highly doubt that you would.

Think and support what you want. I do. And I believe in programs and physicians that support the routine screening of student athletes with ECG's. They're is some evidence from programs in the US and Italy that show's benefit and also numbers that show the incidence is much greater than once believed.

I believe it is a worthwhile endeavor and Im not trying to convince anyone else of that. It is what it is. Make the decision for yourself.

 

[Aidey]

This discusses Italy and other countries that use 12 leads as part of athlete screening. The end conclusion is that it should not be used as routine screening, and only done when indicated by assessment. There is also an interesting rebuttal at the end.

http://circ.ahajournals.org/content/116/22/2610.full

Something else to note, how many GPs are proficient in differentiating clinical LVH from normal EKG variants and lead placement errors? I think it would be very interesting to see a study comparing the % of students would be referred for an echo after their 12 leads are reviewed by each a GP, a cardiologist, and a pediatric cardiologist.

This link also explains some of the limitations to the Italy study: http://www.theheart.org/article/1270485.do

I think it is also worth pointing out that a screening prior to the student starting sports may not accurately reflect the stress the body is under while in the middle of the season. Especially in highly competitive activities, like wrestling, football, cheerleading/gymnastics, and basketball. High school and college students will do stupid stuff in order to make weight, look good, and improve their game. I could very easily see how someone with a borderline abnormality missed on a 12 lead could drop dead because they fark up their magnesium or potassium by doing something stupid during the season, or even inadvertently due to excessive water intake causing an electrolyte imbalance.

Edit: For those following along who are not paramedics long Q-T syndrome is another cause of SCA that can go undetected, and magnesium deficiency can aggravate it or cause it.

 

[18G]

The issue comes back to "Is the benefit worth the effort?". Inconveniencing thousands of people to maybe prevent one or two deaths a year nationwide isn't going to be practical except to someone who ideologically melded to the idea on grounds other than scientific proof.

I guess it only becomes worth it when its your kid. After your kid dies playing soccer and is found to have cardiomyopathy, than tell me if your opinion is still the same (after the funeral of course).

Maybe it's some people just don't place a whole lot of value on a child's life and losing a few here and there unnecessarily is okay with them?

 

[18G]

This discusses Italy and other countries that use 12 leads as part of athlete screening. The end conclusion is that it should not be used as routine screening, and only done when indicated by assessment. There is also an interesting rebuttal at the end.

http://circ.ahajournals.org/content/116/22/2610.full

Something else to note, how many GPs are proficient in differentiating clinical LVH from normal EKG variants and lead placement errors? I think it would be very interesting to see a study comparing the % of students would be referred for an echo after their 12 leads are reviewed by each a GP, a cardiologist, and a pediatric cardiologist.

If you read the links and articles I posted you would see a new protocol and guideline for physicians to use to distinguish between these variants to reduce false-positives is already being implemented.

 

[usafmedic45]

Im not making an extraordinary claim or making any statement based on emotion. I've been a supporter of this for a few years now and is a topic I take great interest in. I never said this is the "golden answer" to kids killing over. I never said that at all. You like to put words in my mouth.

Well, it sure seems like you're saying that it's a great option but you're not offering any peer-reviewed evidence to substantiate that claim.

They're are quite a few groups of physicians that have the same outlook and support of routine ECG's as I do.

Have any of them published their results in a journal? If they have evidence to support their approach why aren't you trotting it out to make your case?

Would you tell them they are just as dumb too because they are doing something that numbers don't back up??? I highly doubt that you would.

You don't know me very well do you? LOL I have no problem telling someone regardless of their title or degree that I don't simply take their word for it. If someone persists, I will tell them that I think they are full of it. Welcome to being a scientist and not a sycophant.

Think and support what you want.

Will do.

I do.

OK. I'm still waiting to see proof of why you do lest this simply be a reminder of why Churchill once commented that the best argument against democracy was a five-minute conversation with the average voter.

And I believe in programs and physicians that support the routine screening of student athletes with ECG's.

You know that what you're describing is religion and not medical science right?

They're is some evidence from programs in the US and Italy that show's benefit

Then let's see it. You keep mentioning it but until you bring it out for review and to let us see that you're not misunderstanding or wrongfully attributing a downward tick in the death rate to your beloved 12-leads when it might be do to other actions associated with screening, the professionals here are just going to work from the position that you're talking out your *** and are making this stuff up to win a debate that you're thus far not doing so hot in.

and also numbers that show the incidence is much greater than once believed.

Yeah, it's amazing that when you look at a nationwide count that the numbers are going to be higher than in a regional study, right? Totally :censored::censored::censored::censored:ing mind-blowing....didn't see that coming for sure.

 

[usafmedic45]

I guess it only becomes worth it when its your kid. After your kid dies playing soccer and is found to have cardiomyopathy, than tell me if your opinion is still the same (after the funeral of course).

So by the same token do you believe in flying people unnecessarily simply to give the perception that we are doing everything possible? That was the very argument put out in Maryland to keep the MSP helicopter system intact. It's a pretty **** move if you ask me. "I don't have any evidence, but what if it was YOUR child?"

Are you just going through the Wikipedia list of logical fallacies tonight or something?

Maybe it's some people just don't place a whole lot of value on a child's life and losing a few here and there unnecessarily is okay with them?

It's not that at all. I maybe a misanthrope, but kids are the one group I generally have a positive outlook towards. It's the dull intellect of the average adult that makes me question whether the human race has any inherent value whatsoever. That said, I'm realist and recognize that we're not going to eliminate SCA in kids and most of the ones who do die would only be avoided by an angiogram, an echo and genetic screening for LQTS, etc.