The sudden death of a student at a small college is a tragedy felt campuswide. When two such deaths occur within a short period of time from undetected heart conditions in school athletes, the loss raises questions about health screenings for sports participation.

On Oct. 5, Indiana Tech senior volleyball player Elizabeth “Liz” Lykowski, 21, died of what school officials said was a “congenital heart defect.” Twelve days later, sophomore basketball player Jasmine Hubbard, 19, collapsed and died in the school's gym after women's basketball team practice. An autopsy showed she had an “enlarged heart,” school officials said. A defibrillator, kept at the school's gym, was used to try to revive Hubbard, to no avail.

A student-athlete with sudden cardiac arrest is revived in just one of 10 cases, according to a study in the June issue of HeartRhythm Journal. For someone in the general population with sudden cardiac arrest who receives CPR and an electrical shock to the heart (defibrillation) within three to five minutes, the revival rate is 48 percent or greater.

Even if defibrillation isn't given for 12 minutes after collapse, revival rate is 2 percent to 5 percent, according to the American Heart Association. Revival, in which the heart is shocked back into normal rhythm, is not the same as long-term survival.

The No. 1 cause of sudden cardiac arrest in young athletes is hypertrophic cardiomyopathy, or HCM, a genetic condition affecting one in 500 U.S. individuals. It causes the muscle in the heart walls to thicken.

“The blood is reduced in the cavity. Abnormal rhythms develop probably because of scar tissue as the heart changes structure,” said Dr. Scott Mattson, a cardiologist with Heart Center Medical Group, 7916 W. Jefferson Blvd.

The heart with HCM “typically will have murmurs, but some will fall through the cracks,” which is why the required physical for sports participation does not always pick up the problem, said cardiologist Dr. Mark O'Shaughnessy with Fort Wayne Cardiology, 1819 Carew St.

“A lot of times when they do athlete physicals, they will actually do them in stations,” with one for blood pressure checks, another for height and weight, and so on. “I've participated in these and listened to hearts,” he said. “When it's kind of a cattle call, it's less likely to pick up on abnormality.”

Resting electrocardiograms (ECGs) are not part of routine physicals for athletes in this country, although some large universities are beginning to require them.

In 1982, Italy began requiring them by law for competitive athletes. Since then, the incidence of sudden cardiac deaths has decreased 89 percent in one specific region studied from 1979 to 2004.

The findings “suggest that screening athletes for cardiomyopathies is a life-saving strategy and that 12-lead ECG is a sensitive and powerful tool for identification and risk stratification of athletes with cardiomyopathies,” the authors of the Italian study said in their summary, published in October 2006 in JAMA, the Journal of the American Medical Association.

But Mattson, who has looked at the studies, said, the data cannot be compared to U.S. data. Through more aggressive screenings over several decades in that area of Italy, “HCM has been removed from the pool of athletes,” he said.

In other words, a person with a family history of HCM is ruled out for sports competition early on. Then fewer athletes down the line in at-risk families have sought to compete in sports. Certain populations have higher rates for some kinds of heart abnormalities due to ancestry and other factors.

Screenings in school are highly dependent on students' and parents' reports of family health history. A first-degree relative, an older brother who did not compete in sports, for example, may have HCM, and the younger brother trying out for football has no clue. Maybe Grandpa's sudden death at 40 was thought to be a heart attack when it really was HCM, and a grandson is unaware of the link to him.

Many other issues can be raised regarding more aggressive screening: false positives, cost, insurance implications, to name the more significant ones.

“We are talking about an astronomical amount of money,” to screen every middle (school), high school and college athlete,” O'Shaughnessy said. ECGs run about $100 for a resting one to about $400 for a treadmill type. An echocardiogram, a good noninvasive test to show whether heart chambers are abnormally enlarged and some other defects, can be more costly, depending on where it is done.

Who will pay? Insurance companies will not cover routine ECGs for sports physicals without some indication, such as a heart murmur. Screenings in Italy are covered by national insurance.

Dr. Barry Maron of the Minneapolis Heart Institute has researched sudden death in athletes for several decades. The screening issue is not really an economic one, he said, but a staffing problem; he said in Italy, more medical students graduate than the country has jobs for.

“With the excess of doctors in the system, these guys do nothing but this. Are we going to have U.S. medical school graduates who do nothing but screen athletes? It's hard to imagine who would do this in this country,” he said.

Maron oversees the institute's Sudden Death In Athletes national registry, which has tracked more than 1,800 such deaths since its inception in 1982.

Another problem with screenings: The athletic heart mimics the HCM heart because the chambers enlarge from increased blood flow, O'Shaughnessy said.

“Even the ability of a cardiologist to determine if it is an adaptive issue rather than a physiological issue can be a challenge,” Mattson said.

The result is that of the estimated 4 million high school and 500,000 college athletes, a greater percentage will be put at risk by further tests such as MRI, which involves radiation, O'Shaughnessy said, noting, “There are examples of young kids (seeking to play sports) getting heart caths (catheterizations) today, and that's not right.” HCM is also a “spectrum of disease,” he said. An athlete could have a normal echocardiogram at 16, but then develop HCM at 21.

Some suggest the focus should be better blood tests to detect the gene, but even that is not fail-safe because one can carry the gene and never develop the condition. Another problem of genetic testing is that a 14-year-old who tests positive may not get insurance coverage when he's out on his own at 22.

“The testing of these conditions is not as straightforward as you'd like it to be,” Mattson said. “Specialized testing should be reserved to the person found with high family risk or other findings.”

If there is a silver lining to tragic deaths locally and nationally from undetected heart conditions, O'Shaughnessy said, it is that it may be the impetus for family doctors doing sports physicals to “not just simply do them and blow it off. It may make them slow down, ask if there is anybody in the family who has collapsed for unknown reasons or had sudden death. That could lessen the incidence of this.”