Just this once, let’s be more like Florida!
Kudos to the state of Florida for boldly going where no other state has ventured to promote the health and safety of its school children.
Wait! Before I incur the wrath of every Pediatrician in America, let me state clearly:
I’m not talking about immunizations!*
*Disclaimer #1: As a Pediatrician for 40 years I am conditioned to promote immunization as a vital way to prevent serious disease. As a Centrist, I have trained myself to consistently and reasonably challenge my beliefs about everything from religion to politics to social issues to sports allegiance (well, not really that. I’m stubborn about that). That said, I’ve never seen credible evidence that has led me away from putting a needle in my arm or those of my children when it can prevent one of those ailments. Give me the jab!
Back to my point…..
I’m talking instead about the Sunshine State’s “Second Chance” Act, which mandates that starting in the Fall of 2026, high school athletes must have an electrocardiogram (ECG) before competing in an interscholastic sport.
It’s aimed at identifying individuals who seem completely healthy but may be at risk for sudden unexplained cardiac death. We’ve all heard these stories. They seem random – but aren’t, really. And every single occurrence devastates a family and a community.
Florida’s act is the first legislation of its kind in the US, and make no mistake about it, the US is behind the curve on this subject. Many, if not most, of the countries that have a thirst for sports AND a modern medical system have already gone this route in some way.
Italy has led the pack, mandating ECGs for young athletes playing high level competitive sports since 1982. This was done in response to a curious spike in cases of unexpected sudden cardiac death over a three year period in the1970s. Italy has trumpeted that the screening program decreased the sudden death rate by over 90%. That’s a little bit of an exaggeration since it’s based against that exaggerated high-water mark, but unquestionably the screening has saved lives. Currently, athletes have an ECG, a stress test and an echocardiogram before being cleared to compete, and those tests are periodically repeated if the player continues to compete. Wow! Even I think that’s way too much!
Israel was next, starting ECG screening in 1997, and adding stress tests along the way.
Many of what I call the “Soccer Countries” - France, Netherlands, Germany, Spain, Argentina, Brazil - have also mandated pre-participation ECG screening for high level sports.
I have to add Japan, too, which started ECG screening in1973 on a local scale and has developed to the point where not just athletes but all school children have not one but 2 or even 3 ECGs before graduating from high school. They do it the most cost efficient way, by putting ECG machines in the schools and having the school nurse record them. School nurses! They aren’t just for lice checks any more!*
*Disclaimer #2; Pardon my cheekiness, but since this is all about Florida I just couldn’t pass up that reference to the Florida Orange Juice ad campaign of 1979 (“It isn’t just for breakfast any more!”). School nurses -and school trainers - are the first line of defense for everything that could impact the health and safety of our kids during most of their waking hours, for two thirds of the year. They are vital links in the chain of protection for our children and teens.
But as of now in the United States – and five months from now, in 49 of the 50 states – the screening process for sports includes a set of criteria defined by the American Academy of Pediatrics that includes survey for cardiac symptoms, for family history of concerning diagnoses, and for certain physical exam findings like blood pressure and also the absence of a heart murmur specifically when arising from squatting (ring the bell if you remember that happening at your child’s last physical). The ECG isn’t part of it.
You’re probably asking two questions by now:
1. Why should ECGs be added to the screening? (PRO)
2. And why shouldn’t ECGs be added to the screening? (CON)
PRO: You’ve heard these stories before. A young high school or college athlete suffers an unexpected sudden cardiac arrest (I guess that’s redundant. Who would EXPECT a sudden cardiac arrest?) while training or competing. With any luck and with good preparation and support, hopefully they are resuscitated by a bystander, and then recover. Tragically that’s not always the case. Most of those victims will have had an underlying condition that provoked the catastrophe – hypertrophic cardiomyopathy (always #1 on the list), long QT syndrome, Wolff-Parkinson-White Syndrome, Brugada Syndrome, and so on. And most of those – but by no means all of them – may have been identified on a screening ECG. If this happens roughly 2000 times a year in the US, then ECG screening might reasonably be expected to have prevented 1200-1400 of them. Not all of them, but most of them.
One stumbling block is that the second largest group in the US database – individuals with congenital anomaly of the structure of one of their coronary arteries, representing maybe 20% of the cases – will probably have had a normal ECG. That diagnosis requires an echocardiogram (and one that is skilled enough to image the coronary arteries, which is not a given). The difference between an ECG and an echo in terms of availability and cost is significant. I might live long enough to see universal teen ECG screening but I don’t expect to live long enough to see the US adopt echo screening for our young athletes and neither should you. This isn’t Italy!
CON: It all comes down to cost-effectiveness. Believe it or not, there is a formula for that when talking about screening a population for a medical condition, and it is applied – most of the time – whenever a test becomes available for those purposes, like being added to the state blood screening for newborns. That number is…..drumroll, please…….$50,000 per quality year of life saved. If it’s less than that, it’s cost effective. Over $100,000 fails the test. In-between it’s equivocal. So, finding a newborn with Maple Syrup Urine Disease (really a thing) by blotting a drop of blood on a piece of paper and affording them a normal life is a winner. Something that costs a lot and might make a 90 year old live to 95 generally won’t make the grade. I don’t know what cost-effectiveness data says about that colonoscopy I’m supposed to have every five years until the end of time, but my guess is that Gastroenterologists have a better lobby than Pediatricians.
The thing is, over the past couple of decades most measures of cost-effectiveness have shown ECG screening to cost about $40,000 per QYOL. Important things include not only the cost of getting the ECG done and interpreted (that’s why the Japanese school nurse idea is so great), but most importantly the cost of the workup for people with abnormal ECGs. Not only them, though, but also the workup for anybody whose ECG looks abnormal but it turns out they don’t have one of those diagnoses. Minimizing those is the key. American experts have already published criteria to interpret the screening ECGs that we don’t do on young athletes, so as to debunk most of the chatter that might be offered by automated ECG readings. They’re called the Seattle Criteria because they meeting was held a ta Starbucks, or something like that. They’re very similar to criteria published by the European Society of Cardiology, the difference being that in Europe they’re actually used. I apply the Seattle criteria religiously to screening ECGs done by a couple of visionary Pediatric practices in the area, and I’m happy to say that I recommend a referral for less than 10% of the ECGs that say something other than “Normal sinus rhythm. Normal ECG.” Being more lenient would be good business for me. It just wouldn’t necessarily be good medicine.
In the US, certain Pediatric populations are recommended forECGs, or at least it is acknowledged that it is reasonable to consider doing one. The best example is children and adolescents who are being started on stimulant medications for ADHD. The “reasonable to consider” moniker makes it quite OK for a doctor to manage a patient with those meds and without an ECG, but also directs insurance carriers to cover the ECG if the provider orders it. That’s really the heart of the matter, because, really, what parent wouldn’t want the reassurance that anon-invasive 10 minute test might provide before their teen decides to join the crew team? Not a clear path, but at least the lane is open for the ADHD patients*.
*Disclaimer #3: I’m glad that there’s ANY group of Pediatric patients who are certifiably allowed to have an ECG to rule out the silent killers, but I have to emphatically add that the stimulant medications are totally safe from a cardiac point of view. The FDA did a deep dive on this matter and stated simply that there is no link between ADHD meds and sudden cardiac death. Someone with one of these disorders has a greater chance for a cardiac event when they run upstairs to take their meds than when they take their meds.
Why doesn’t cost-effectiveness matter in the countries that do mandate ECG screening? Well, I’m sure it does, but also consider where the cost of screening is directed. In the US we have tied our sports to our schools. So, requiring a medical test to allow a young person to play would essentially be like the government creating a new expense for its schools. But in most of the other sports-focused nations, high level athletics belong not to the schools but to sports federations. The responsibility – and therefore the cost – is passed along to them. If your group exists to try to find and develop the next Lionel Messi, you will not let him get away over the cost of an ECG.
Interestingly, not all tests that we do, or that actually are recommended by the AAP, are shown to be cost effective. Routine lipid screening in children was recommended without any data. After it had been implemented for a decade it was clearly shown that in the absence of a family history of lipid problems or early coronary artery disease, this testing is NOT cost-effective. Not even close. The recommendation stands.
Pulse oximetry screening (measuring the oxygen level using that little band-aid-like device) is not only recommended but has been mandated by every state for newborns before discharge from the nursery for over a decade as well. No cost-effectiveness data was submitted, despite the fact that every baby has to have their own probe, and the actual measurement – which as to be done with the baby calm, and in two limbs – pretty much required every nursery to hire another staff member. After the fact, somebody looked at the real cost and determined that it costs almost exactly that same $42,000 per year of life saved. A win for pulse oximetry, but a loss for ECG!
So then why do we do one and not the other? It has as much to do with emotion as science. Some years ago, a family whose baby succumbed to a congenital heart lesion spoke before a Congressional subcommittee and said that their baby would have been saved if their oxygen level had been noted before they went home and became ill. This may or may not have been true, but it was reasonable enough and more than compelling enough for that committee to recommend screening. Since it’s the responsibility of the states to actually require those measures (which is why not every state tests for Maple Syrup Urine Disease), it took the individual jurisdictions to mandate it. If I recall correctly, New York was first state to require pulse oximetry screening (take that, Florida!), but one by one, in short order, it became a national trend.
So what happened in Florida to spur the Second Chance Act? Exactly the same thing. Advocacy groups largely organized by families of athletes who suffered cardiac arrests, as well as survivors of cardiac arrests and also individuals who have been diagnosed and treated for these conditions without suffering cardiac arrest lobbied their representatives until the law was enacted. Several counties had already enacted ECG screening, and the legislature drew on that to make the rule state-wide.
I expect that within short order, states that border Florida will be pressured to follow suit.
Closer to home, there’s a family on Long Island whose teenager died suddenly while playing hockey and who have created a movement to encourage universal ECG screening in Nassau and Suffolk Counties and hopefully across the state. Their cause is helped, I think, by Florida blazing the trail and creating a blueprint for legislation. It probably helps that Florida, specifically, was first and not some other random state. Does New York need ANOTHER reason for people to move to Florida?
Personally, I’m rooting for them. I’ve looked at this from a lot of angles, over a number of years, and not only my gut but also my reason thinks that ECG screening is going to prove to be an important safeguard for our young athletes. In this country we will be hesitant, I think, to enact screening for just “athletes” because we certainly want all of our young people to engage in exertional activities – not just organized sports, but dancing, going to the gym, just running around for fun and fitness – and the minuscule risk isn’t confined just to formal athletic events. But we’ll probably start with the athletes, and when we find the proper formula for getting the ECGs done efficiently and cost-effectively, then we’ll roll it out more broadly.
True, I’m a Cardiologist, so it’s a little like walking into a bakery and asking the baker if he thinks I need a loaf of bread. But in general I’m not a medical worrywart, and I didn’t let either of my kids leave for their first year of camp without banging out an ECG for peace of mind. I rested a little easier knowing that a large swath of that very small risk had been erased.
So, no, I don’t want New York to start walking backward on immunization requirements. I don’t think New Yorkers should start having dinner at 4:30. We shouldn’t replace “Hamilton” and “Death of a Salesman” with “The Carousel of Progress.”*
But I’m hoping that the Empire State will follow the lead of the Sunshine State in making meaningful strides to decrease the risk of sudden cardiac death in our young people.
What is it worth to remove that needle from the haystack?
*4th and last disclaimer: “Carousel of Progress” has always been my wife’s favorite Disney attraction. It never gets old, or maybe the attraction is precisely that it just really is old, a vestige of the childhood of people who now qualify for Medicaid. When my kids were little, we would all make fun of the Carousel, and every time we sat through it I would assume it wouldn’t be there the next time we visit. But it’s 2026 and not only is it still there, but there’s a huge renovation on tap. So here’s hoping for a “Great, Big, Beautiful Tomorrow!” for teenage athletes in New York.
Yeah, I should have stopped at three disclaimers.
