An apparently healthy high school cheerleader who died after collapsing during a football game this past weekend likely experienced sudden cardiac arrest, a rare occurrence that has again raised questions about the value of widespread screening.
Bystanders at Friday night's game briefly revived Angela Gettis, 16, of George Washington Preparatory High School in Los Angeles, using CPR, but she was pronounced dead at a local hospital after her heart stopped.
Gettis had no known health problems; her family is awaiting results of an autopsy to learn how her life ended so unexpectedly. A member of the Junior Reserve Officers Training Corps, Gettis had planned to major in forensic science in college.
Her death comes on the heels of sudden cardiac deaths among a half-dozen brawny high school football players in Texas, Arkansas, Georgia, South Carolina and Florida as they trained in the suffocating summer heat. The boys had several things in common, including having heavy-set physiques and collapsing early in the practice season, a likely result of pushing themselves when they weren't accustomed to the exertion.
Cheerleaders can be similarly stricken. On April 5, a 16-year-old girl collapsed from sudden cardiac arrest during cheerleading tryouts at North Hunterdon High School in New Jersey. Quick-thinking coaches and parents, who had been trained in CPR and use of automatic external defibrillators, sprang to action and saved her life.
However, in many cases, youngsters don't survive these episodes. Janet Zilinski, an 11-year-old New Jersey girl, died from sudden cardiac arrest after cheerleading practice on Aug. 10, 2006. Her parents, Jim and Karen Zilinski, created the Janet Zilinski Memorial Fund, which is pressing for a New Jersey law requiring AEDs at all public and private schools and sports fields and mandating that schools and sports camps have trained responders as well as emergency action plans.
"The Janet Fund is dedicated to preventing sudden cardiac death in New Jersey's youth through awareness, legislation, AED placement and training. It is our mission to make Automatic External Defibrillators (AEDs) available in every school in NJ and make them commonplace on playing fields," the fund's website says.
Sudden cardiac deaths remain relatively rare, with an estimated one in 100,000 to three in 100,000 young U.S. athletes succumbing annually, said Dr. Kathleen Maginot, a pediatric cardiologist at the University of Wisconsin in Madison. The incidence could be as rare as 1 in 1 million among children from ages 1 to 18, said Dr. Ian Law, a specialist in inherited heart rhythm disorders at the University of Iowa in Iowa City.
Maginot and Law said the No. 1 condition leading to the youngsters' deaths is hypertrophic cardiomyopathy, a congenital problem in which the heart becomes abnormally thickened. Second are abnormalities that impede blood flow through the arteries (not to be confused with artery-clogging accumulations of plaque), Law said.
Other conditions that can set the stage for sudden cardiac death include inherited arrhythmias, in which the heart beats erratically; infection of the heart muscle called viral myocarditis; other heart enlargements that weaken the heart; and inherited heart defects, including those that have been surgically repaired, Maginot said.
Parents and Coaches Should Know Risks, Warning Signs
Before youngsters engage in vigorous sports, their parents and coaches should be aware of cardiac risks such as a family history of sudden death before the age of 50, Sudden Infant Death Syndrome (SIDS), or a history of fainting during exertion. The warning signs include passing out during exercise (which some athletes may try to hide out of fear they'll be told to stop playing), as well as palpitations and chest pain. Maginot also cautioned that episodes that look like seizures may not be epilepsy, but might result from irregular heart rhythms that interfere with blood flow to the brain.
Although an increasing number of schools now monitor athletes' heart rates, which should revert to normal after increasing during exertion, widespread cardiac screening of young athletes has not been adopted by either the American Heart Association or the American College of Cardiologists.
Maginot said cardiac screening "would definitely pick up" abnormalities among some young athletes who died earlier this year, such as those whose inherited cardiac abnormalities put them "at increased risk of arrhythmias after their life-saving surgical repairs." However, she said, had athletes who developed viral infections before their deaths been given typical screening tests last fall, the tests "would likely have been normal since they did not develop their illness until later."
Maginot also cited the low-yield of screening asymptomatic boys and girls without family histories of early cardiac death. "To put this in perspective, the most common cause of death in children (athletes and non-athletes) in this country is automobile accidents; unfortunately many of these children were not wearing adequate safety restraints."
Law said he, too, believes that school systems often could put their money to better use to protect children's health. One of his daughters attends a grade school lacking air conditioning, where doors are left open at lunchtime and there are "bees everywhere." Given that allergic reactions to bee stings occur more frequently among elementary school pupils than fatal cardiac arrests, he said, "the money would be better spent getting air conditioners for the gym and cafeteria."
In areas where emergency medical services can respond to a child's collapse within 3 minutes, "you're probably better off teaching the chain of survival skills, which is CPR and calling EMS," Law said, "especially if you're in an urban area where every police officer has an AED in the car." He said it's much likelier that an AED at a high school "will be used on a parent or grandparent watching the game than it will be used on a high school student."
However, cardiologist Dr. Arthur Garson, director of the Institute for Health Policy at the University of Virginia in Charlottesville, vigorously disagreed with the cost effectiveness argument.
He described the cost of electrocardiograms and echocardiograms as "much less than people think, because the costs frequently are inflated by hospital and physician charges." Dedicated screening programs for youngsters could offer the tests for much less, he said.
To illustrate the value of screening youngsters, he recalled a family he saw when he ran the arrhythmia service at Texas Children's Hospital in Houston.
"When a father brought his 16-year-old son to see me, the week after the 14-year-old daughter had dropped dead during a volleyball game, he said, 'why did she not have EKG screening?'"
Garson told the father that he certainly would have screened the daughter, "but part of the world thinks it is not cost-effective," to which the father responded: "when you're calculating in the cost, you should also factor in the cost of her funeral."
"The point here is the loss of a perfectly otherwise healthy child is so devastating, the effectiveness, even if the cost was high, which it is not, needs to be figured in," Garson said.