Focus on Screenings

Jeff Wiehe
The Journal Gazette
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If anyone can empathize with the University of Southern Indiana and the Chicago Bears, Arthur Snyder can.

The sudden deaths this month of Gaines Adams, a 26-year-old defensive end for the Chicago Bears, and Fort Wayne native Jeron Lewis, a talented 21-year-old basketball player at Southern Indiana, can dredge up dark memories for anyone associated with Indiana Tech, where Snyder is president.

And how could they not, when October 2008 is still fresh in some people’s minds?

That was when Elizabeth Lykowski, a 21-year-old volleyball player, died in her home from a heart defect. Two weeks later, Jasmin Hubbard, a 19-year-old sophomore on the women’s basketball team, collapsed during an intrasquad scrimmage on the opening night of a new season.

“Like any death in the family, we still think about them,” Snyder said.

Attempts to revive Hubbard failed, and she died from a condition different from the one that killed Lykowski, something called hypertrophic cardiomyopathy. In layman’s terms, she had an enlarged heart – the same condition suspected of causing the deaths of Lewis and Adams, according to published reports.

A genetic condition, having an enlarged heart might cause no symptoms and never be detected until someone is lying on an autopsy table. It’s also the leading cause of sudden death in young, seemingly healthy athletes, according to various studies and doctors.

Now, it’s in the national spotlight.

The deaths at Indiana Tech in 2008 sparked intensive screenings of all the school’s athletes for heart conditions, thanks in part to help from Parkview Hospital and Fort Wayne Cardiology.

Still, establishing a testing policy can be tricky for institutions with cost concerns. The condition is not something a typical physical exam picks up, and for many high schools and small colleges, a prudent approach boils down to knowing an athlete’s family medical history before deciding that a more extensive physical is needed.

Tests for condition

Though it’s typically called an enlarged heart, hypertrophic cardiomyopathy can mean the walls of the heart have become thickened. This makes the chambers inside smaller, and the heart might not be able to pump enough blood through the body. That can lead to cardiac arrest during strenuous activity.

The condition affects about one in 500 people, according to the Hypertrophic Cardiomyopathy Association.

About 7,000 to 10,000 athletes between ages 15 and 34 die from the condition each year, a cardiologist for the NFL’s Kansas City Chiefs told the American Orthopaedic Society for Sports Medicine in 2006. About 300 high school athletes die at organized sporting events every year from cardiac arrest, according to the society’s Web site.

Prominent athletes who have died from enlarged hearts include Hank Gathers, a basketball star at Loyola Marymount who collapsed during a game in 1990, and Reggie Lewis of the Boston Celtics, who died at practice in 1993.

John Stewart, a Lawrence North High School basketball player in the 1990s who planned to attend Kentucky, was another victim.

Despite the disorder’s name, a picture of the heart might not reveal the condition.

“Usually, the heart is not terribly large,” said Dr. Mark A. Jones, of Heart Center Medical Group, a cardiologist associated with Lutheran Hospital. “So if you did a chest X-ray, you wouldn’t necessarily see a large heart.”

Tests like electrocardiograms and echocardiograms are some of the best at finding the condition, according to Jones and Dr. Michael J. Mirro, a cardiologist with Fort Wayne Cardiology.

An electrocardiogram – often called an ECG or EKG – measures electrical activity as it moves through the heart during contraction and relaxation, according to www.WebMD.com. An irregular test result could be the first sign of an enlarged heart in someone who shows no symptoms.

An echocardiogram uses ultrasound to create a picture of the heart, according to WebMD.com, and is the main tool doctors use to diagnose hypertrophic cardiomyopathy.

A precursor to those tests many times is a look at personal and family medical histories.

“When we screen athletes, we ask them if anybody in their family died suddenly before the age of 50, and especially 35,” Mirro said. “Those are big warning signals.”

Plus, when an athlete becomes faint unexpectedly or passes out during competition, he or she could be showing signs of an enlarged heart, Mirro said. That could lead to an electrocardiogram test, which typically isn’t covered by insurance and is inexpensive, Mirro said.

An irregular result there would lead to an echocardiogram. Mirro said that echocardiograms are not typically covered by insurance companies unless irregularities are found by an electrocardiogram first.

“The take-home message is, if there’s a family history of sudden death, families need to do an electrocardiogram,” Mirro said.

Genetic testing can also be done to determine whether someone carries the gene for the condition, which can be passed on to family members. Previously, patients were reluctant to follow this course, Mirro said, because insurance companies would not cover someone with the condition or the gene for the condition.

That has since changed because of the federal Genetic Information Nondiscrimination Act of 2008, which went into effect late last year and prevents insurance companies from denying coverage based on family histories or genetic testing.

Who screens?

After the death of Gaines Adams two weeks after his season ended, the National Football League is considering giving every player the more expensive echocardiogram test, according to The Associated Press and ESPN.

Many colleges and universities involved in high-profile sports have extensive screening processes for athletes and might have access to electrocardiograms, according to Mirro. But that is not as common at smaller colleges.

Mirro said electrocardiograms cost $50 to $100 a test. An echocardiogram that Mirro called adequate for a screening runs $200 to $400. A full echocardiogram costs between $1,000 and $1,500, he said.

Still, after the deaths of Lykowski and Hubbard, Snyder, the Indiana Tech president, began looking for ways that the school could test all of its roughly 550 athletes for genetic heart conditions.

“That was the trigger point,” Snyder said. “We wanted to know what we could do to try to address these kinds of issues.

“We could’ve spent a lot of time trying to figure out who owns this issue. Do parents pay for the screenings? Do we? But we didn’t spend too long. We just looked for a way to get it done.”

Soon, Parkview Hospital and Fort Wayne Cardiology, led by Mirro, were offering to do much of the testing for next to nothing, Snyder said.

For the past year, athletes at Indiana Tech have had both electrocardiograms and echocardiograms regardless of family history. It’s something unusual for a school that size, according to Mirro, who hopes to eventually extend the program to athletes at other area colleges.

Typically, Mirro said, many colleges will do extensive family history screenings, and anything unusual will result in further testing. Testing every athlete, though, is generally not recommended because of cost concerns, Mirro said.

As a result, paying attention to family history for high school athletes plays an important role.

For instance, athletes at Fort Wayne Community Schools – which has the most high schools in the area and includes North Side High School, Jeron Lewis’ alma mater – are screened by a doctor before participating in sports, according to district spokeswoman Krista Stockman.

This screening includes a questionnaire that is to be answered by both an athlete and his or her parent or parents.

The form – which the Indiana High School Athletic Association requires – asks, among other things, whether the athlete has ever been dizzy or passed out during exercise; whether someone in his or her family has ever died suddenly before the age of 50; and whether a medical professional has ever told the athlete that he or she has heart murmurs.

“Some parents have gone with extra screening with their family doctor and have the Cardiac Echo Test or Echocardiogram performed,” according to a sample questionnaire provided by FWCS, “but cost does play a factor.”

End of playing days

After an athlete is diagnosed with an enlarged heart, his or her playing career is over, doctors say.

“Some of the athletes aren’t excited about being screened,” said Mirro, who noted that some abnormal test results were found among some Indiana Tech athletes when the screenings at the school were conducted, effectively ending their playing days. “It’s a difficult situation.”

Cuttino Mobley, who played for several teams in the National Basketball Association during an 11-year career, quit the sport in late 2008 after he was diagnosed with an enlarged heart.

According to The Associated Press, Mobley knew he had some type of heart condition, but an electrocardiogram led to an MRI test, which revealed he had the much more serious hypertrophic cardiomyopathy.

But there is a difficulty in testing professional athletes, according to doctors.

“There’s a training effect,” said Jones, the Heart Center Medical Group cardiologist.

Basically, the heart of a professional athlete can appear enlarged because it has adapted to the extra demands placed on it though intense physical competition, Jones and Mirro said. Therefore, tests could confuse what WebMD.com calls an “athlete’s heart,” which has no fatal complications, with an enlarged heart.

Because many colleges weed out athletes with the enlarged heart condition, few typically make it to the professional level, Mirro said. Also, he said, cardiologists are present during the NFL combine – a showcase for the league’s incoming rookies – in Indianapolis every year, making sure there are no problems.

Still, while athletes like Mobley receive the proper diagnosis, some aspiring professional athletes still slip through the cracks.

Mirro holds up the Celtics’ Reggie Lewis as a prime example.

The team’s leading scorer in the early 1990s, Lewis passed out during a playoff game and was later seen by a group of 12 top doctors, according to a Time magazine article written a week after his death.

Diagnosed with a heart that was too thick, he was told to quit basketball. Lewis looked for a second opinion, found it in another group of doctors who told him nothing was wrong, and he continued playing. Months later, he collapsed while shooting baskets. His death was caused by an enlarged heart.

Defibrillator can help

Mirro said that while family history and medical tests are the primary weapons in fighting an enlarged heart condition in young athletes, there is one more thing that can save someone unknowingly suffering from the condition: a defibrillator.

An automatic external defibrillator is on hand at many athletic events throughout the country, according to Mirro. While the Indiana High School Athletic Commission does not require one, it strongly recommends that schools have at least one, according to IHSAA commissioner Blake Ress.

Ress said his organization ran a program a few years ago that allowed schools to buy a defibrillator at a reduced price, and about half the high schools in Indiana took advantage of the program. Now, Ress said, most schools have multiple defibrillators. Every high school in Fort Wayne Community Schools has at least one defibrillator, Stockman said.

Many colleges big and small carry them, according to Mirro. One was used when Jasmin Hubbard collapsed, though it was unable to save her. Still, it is the best shot at keeping someone alive if he or she collapses, and it does no harm to someone not suffering from cardiac arrest.

“It’s a three-pronged approach to preventing sudden death,” Mirro said. “Family history, EKG (electrocardiogram), and then a (defibrillator) at all events.”

jeffwiehe@jg.net

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