Sunday 17 June 2012

Red-flagged for Heart Abnormalities: No combat duty for 1 in 250 men

Study here shows they are exempted after pre-enlistment cardiac screening
By Jermyn Chow, The Straits Times, 16 Jun 2012

ONE in 250 young men here who undergo the pre-national service check-up is eventually exempted from combat training because of heart problems.

Their moderate to severe heart conditions, assessed as likely to cause sudden cardiac death, include irregular heartbeat and leaky heart valves.

The authors of the study which produced this figure say it is in line with international norms. But with some specific heart conditions, the Singapore figures compare favourably: For instance, 0.17 per cent of the pre-enlistees here were found to have a faulty heart nerve, against 1 per cent of their Swiss counterparts.

The pioneering study by eight local cardiologists and doctors was carried out amid public calls for more stringent pre-enlistment screenings after two servicemen died suddenly in 2008.

The issue over whether the check-up is thorough enough has refused to go away. With five servicemen dead this year so far, letters in the Forum pages of this newspaper have renewed the call.

The study was published in February in Europace, the official journal of the European Heart Rhythm Association.

With clearance from the Ministry of Defence, the cardiologists studied 18,476 males, mostly in their late teens and early 20s, who were all given electrocardiograms (ECGs) between October 2008 and May 2009.

Of this number, one in 14 or 1,285 of them had abnormal readings and were sent for additional tests or referred to cardiologists.

Of the 1,285, 84 (6.5 per cent) were red-flagged as having moderate or severe heart conditions that warranted their being medically downgraded.

The rest cleared these additional tests or consultations, despite their abnormal ECGs and were deemed combat fit.

An author of the study, Dr Ong Hean Yee, who heads Khoo Teck Puat Hospital's cardiology department, told The Straits Times that the findings suggest that the medical screening is stringent enough, contradicting even some doctors who say it should be beefed up.

He added that the screening carried out by the Singapore Armed Forces (SAF) in fact errs on the side of caution, in that more pre-enlistees than necessary are sent for further tests.

Of the 988 who were sent directly for an echocardiogram - which produces three-dimensional images of the heart - only nine were found with serious heart conditions and downgraded.

Unlike the ECG, compulsory for pre-enlistees since 2000, the echocardiogram is not mandatory and is carried out only on those suspected to have heart abnormalities. Doctors have said it effectively detects thickening of the heart muscle, a condition known as hypertrophic cardiomyopathy, the No.1 cause of sudden cardiac deaths among American athletes.

Doctors who say the pre-enlistment check-up is not thorough enough argue that the echocardiogram, like the ECG, should be carried out on all pre-enlistees.

This is because some individuals have a normal ECG but have underlying heart disease that can go undetected, said cardiologist Michael Lim of the Singapore Medical Specialists Centre.

But echocardiograms cost more, and take longer than ECGs. The Straits Times found out an ECG costs $12 and takes up to 15 minutes, and an echocardiogram, $500 and up to an hour.

Mindef picks up the tab for all pre-enlistees' medical checks.

Cost aside, Dr Ong pointed out one other burden of over-testing, in the stress on pre-enlistees and their families, who face the possibility of Basic Military Training - and national service - being delayed three months or more.

Colonel (Dr) Kang Wee Lee, SAF's Chief of Medical Corps, said it will continue to review its cardiac screening protocol regularly to ensure it is benchmarked against established clinical best practices and international standards.

What: The study set out to determine how common electrocardiogram (ECG) abnormalities and hypertrophic cardiomyo- pathy (HOCM) were among NS-bound males. HOCM, potentially fatal, is marked by thickened heart muscle.

Who: The 18,476 males given their pre-enlistment medical screening between October 2008 and May 2009 were the study subjects. All were put through an ECG (readings of the heart's electrical activity).

The findings:
- One in 14 or 7 per cent had abnormal ECGs; 
- One in 250 or 0.4 per cent had moderate to severe heart problems such as a leaky heart valve or a large hole in the heart; 
- One in 18,476 or 0.005 per cent had HOCM; SAF has had no reported deaths from this since 2000. 
- 6.5 per cent of the pre- enlistees were referred for an echocardiogram, which gives 3-D images of the heart.

Conclusion: HOCM, the top cause of sudden cardiac deaths among US athletes and soldiers in the Italian military, is rare among NS-liable males here.

Other doctors say: Cardiologist Michael Lim said this could be because HOCM develops and shows up later; in a group of young men, the condition has not manifested yet.

National servicemen undergo rigorous cardiac screening

WE THANK Mr Ang Chin Guan for his letter ('Beef up NS medical checks'; Monday), and his concern for all national servicemen.

The Singapore Armed Forces (SAF) has a robust and systematic cardiac screening protocol.

The protocol starts with the screening for cardiovascular risk factors, such as smoking and a family history of heart diseases, followed by a clinical examination by a doctor and routine resting electrocardiogram for all servicemen.

If required, a serviceman will be referred to a cardiologist for specialist opinion and additional cardiac assessments, such as exercise treadmill tests, echocardiography, Computer Tomography calcium scoring and other cardiac imaging studies.

The SAF cardiac screening protocol is a key component of the baseline medical screening panel for pre-enlistment medical screening, as well as for active and operationally ready national servicemen prior to physically strenuous activities such as the Individual Physical Proficiency Test and other military training for various age groups.

The current SAF cardiac screening protocol was jointly formulated with the SAF Cardiac Screening Advisory Panel, which comprises leading senior cardiologists from public health-care institutions.

The protocol is supported by evidence-based medical best practices and benchmarked against internationally recognised clinical standards, and is specifically tailored to address cardiac screening for a military population.

While there are no screening tests that can fully prevent every instance of sudden cardiac events, the SAF will continue to do its utmost to reduce the risk of such incidents.

The SAF is committed to safeguarding the health of our servicemen. We will continue to review and enhance medical screenings based on clinical best practices to keep our servicemen fit and healthy.

Colonel (Dr) Kang Wee Lee
Chief of Medical Corps
Singapore Armed Forces


Associate Professor Terrance Chua
Chairman SAF Cardiology Specialist Advisory Board
and Deputy Medical Director and Senior Consultant National Heart Centre
ST Forum, 15 Jun 2012

Beef up NS medical checks

SUDDEN cardiac death appears to be getting more common among athletes and national servicemen ('The case for ECG screening'; last Saturday).

With several cases of death during physical exertion in recent years, the routine medical check-up done on Singapore Armed Forces personnel appears inadequate.

The Defence Ministry should consider implementing regular, compulsory electrocardiogram (ECG) screening with treadmill stress tests for both full-time and operationally ready national servicemen, to ascertain their fitness levels before allowing them to embark on physical training and the Individual Physical Proficiency Test.

Pre-enlistees should also be subject to these tests.

Ang Chin Guan
ST Forum, 11 Jun 2012

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