In a heartbeat

A small number of athletes die suddenly each year from cardiac complications. Do the deaths justify widespread, and expensive, screening?

The first time Catherine Silva blacked out, she was competing in a high-school swimming meet. It was chalked up to dehydration - until it happened again, when Silva blacked out 18 months later. That time, she was driving home from school and wrapped her car around a telephone pole.

Silva was diagnosed with long QT syndrome, a hereditary disorder of the heart's electrical rhythm that can produce fainting and sudden death, especially during exercise. Silva had a defibrillator implanted to regulate her heart and now, at 24, is poised to graduate from the MGH Institute of Health Professions as a nurse-practitioner.

"I feel very fortunate to be alive," she said. "Studies show a lot of people have these episodes and don't even make it to the hospital."

As students across the country head back to school and competitive sports, two recent studies have reignited a debate about the medical screenings athletes should undergo to reduce the risk, albeit rare, of sudden death from an undiagnosed heart problem. Most specialists have concluded that the small number of deaths does not justify the astronomical cost of a massive system to screen all American athletes - estimated to be as high as $2 billion a year to test all middle- and high-school athletes.

Still, researchers at the University of Wisconsin School of Medicine contend that widespread testing is feasible, but only if organizations are willing to undertake Herculean efforts to line up volunteer physicians and low-cost screening equipment.

The researchers' recent pilot project screened roughly 400 athletes with an echocardiogram, which produces an ultrasound picture of the heart and can pinpoint abnormalities better than a routine sports physical. The tests c ost about $400 each.

In a second study, scientists from the University of Florence, in Italy, also concluded that widespread testing is feasible, but with a different test. Known commonly as an EKG, the electrocardiogram is a much less expensive screening that records the heart's electrical activity.

Previously, the European Society of Cardiology and the International Olympic Committee recommended that all athletes routinely undergo an EKG. To date, Italy is the only European country to mandate such testing for all competitive athletes, at a cost of about $47 per athlete.

"I would love to see all kids get an EKG if even one person could avoid what happened to me," Silva said. But she, too, does not think mandatory testing would be realistic in this country. "There aren't enough primary care providers in Boston and potentially the state to do this," she said.

Roughly 115 athletes die suddenly each year in the United States, and about 70 percent of those deaths are from previously undiagnosed heart disease, according to the Minneapolis Heart Institute Foundation, which has tracked such deaths for more than two decades.

Most organizations that govern high school and college sports require an annual physical that includes questions about family history and health problems that could trigger sudden cardiac arrest. The physical typically also includes an eye exam, and notations of blood pressure, pulse, height and weight.

But most organizations do not mandate more high-tech heart screenings because of the substantial cost and logistics involved. A 2007 study by the American Heart Association concluded that it would cost about $2 billion annually to screen and appropriately evaluate the EKG results of the 10 million American high-school and middle-school athletes who compete each year.

"An [EKG] may identify more athletes with disease, but it also produces many false positives that would create chaos in the system," said Dr. Barry J. Maron, a cardiologist at the Minneapolis Heart Institute Foundation, who led the Heart Association study.

Despite the small numbers of sudden deaths among athletes, the debate is sparked anew nearly every time a seemingly healthy, young athlete dies unexpectedly.

"The advocates for these things either aren't aware of the number of kids participating in high school sports or don't consider the cost, or the logistical problems," said Paul Wetzel, spokesman for the Massachusetts Interscholastic Athletic Association, which regulates most middle- and high-school sports in Massachusetts.

As a growing number of cash-strapped schools impose fees for participating in athletics, Wetzel said that mandating EKGs, in addition to the required sports physical, would likely be wildly unpopular among parents. Those tests are not typically covered by private health insurance unless a problem is suspected.

The families of African-American athletes need to be especially aware of the risk of heart problems, said Dr. Kevin Monahan, a cardiologist and chief of electrophysiology at Boston Medical Center.

"Statistically, when it comes to sudden death, it's young and black," he said. Monahan is a medical adviser to a coalition of schools and athletic groups whose education campaign, called "Close the Gap," aims to raise awareness about racial disparities in heart disease, especially hypertrophic cardiomyopathy, a thickening of the heart that can cause sudden death, often in young, black athletes. Celtics star Reggie Lewis died of the disorder 15 years ago.

Doctors don't know why the condition proves more lethal to African-Americans than to other racial and ethnic groups, but one factor may be that African-American athletes are less likely to be screened for the disease. Specialists also are studying whether genetics, environmental factors, and specific sports play a role, Monahan said.

Massachusetts General Hospital cardiologist Dr. Malissa Wood is hoping her research, using a new echocardiogram that is the size of a laptop computer, may someday lead to affordable screenings of athletes and reduce the number of sudden deaths.

Traditional echocardiogram machines - that's the more expensive, more precise test - are about 400 pounds and the size of a refrigerator.

"The big issue now is can we make a three-minute echo feasible enough to do on all kids?" Wood said.

"We would argue that if we can refine our protocol, that if it can be done very quickly and at minimal cost, it's probably worth doing."

It was through an echocardiogram that Silva, the former competitive swimmer, was finally diagnosed with long QT syndrome. She gave up swimming - which is more likely to trigger irregular heart rhythms than other sports - had the defibrillator implanted, and redirected her passion into running.

"I set out to make 12 New Year's resolutions to prove that someone with a defibrillator at 18 could live a normal life," she said. Top on her list was to run a marathon. The year was 2003, the course was San Diego. Her time: 6 hours, 30 minutes.

"I just remember crossing the finish line and thinking, 'I just did this,' " Silva said. "I felt like I had reclaimed my life."

Kay Lazar can be reached at klazar@globe.com.