Wednesday, 13 March 2013

Checks 'could not have detected NSF's heart defect'

Mindef: Extra test some doctors are calling for wouldn't have found condition
By Lim Yan Liang, The Straits Times, 12 Mar 2013

MINDEF has said that neither its ECG check nor a more expensive test that some doctors have called for could have detected the heart defect that caused the sudden death of a 21-year-old full-time national serviceman (NSF) last August.

The coroner's inquiry last month into the death of Army Specialist Cadet Ee Chun Sheng has ignited a debate on whether the Singapore Armed Forces (SAF) is doing enough to screen pre-enlistees for heart problems.

Coroner Imran Abdul Hamid noted on Feb 27 that the specialist cadet had, before enlisting, an ECG, which did not detect any abnormality.

But he added that an "echocardiography may be able to detect certain types of cardiomyopathies", referring to the disease of the heart muscle which he ruled killed the NSF.

In an e-mail reply to The Straits Times last week, Mindef said "the autopsy findings showed that his heart was not enlarged and there were no gross cardiac findings indicating disease that could have been detected on either an echocardiogram or an electrocardiogram (ECG)".

It added that "the SAF adopts a systematic, evidence-based medical screening protocol for our pre-enlistees and servicemen".

"For pre-enlistees, this includes clinical evaluation by an SAF doctor and a routine electrocardiogram. Where there is any suspicion of heart disease... further tests such as echocardiography and referral for a cardiologist review are arranged."

But two prominent cardiologists from The Cardiac Centre at Mount Elizabeth are urging compulsory use of echocardiograms - a more detailed test than the ECG.

The price of an echocardiogram (Echo) machine is around $250,000, compared to $7,000 for an ECG machine.

An Echo test also costs up to $400 compared to $12 for an ECG. But the image of the heart it creates through ultrasound can help detect structural abnormalities such as muscle thickening and valve restrictions.

Dr Leslie Lam, who performed the first balloon angioplasty procedure in Singapore in 1988, believes the extra cost is worth it.

"We are richer than them and have a much smaller population, so why should we be led by America or Israel?" he said, referring to the ECG system, which is based on United States guidelines.

"We can lead the world in this."

His colleague Dr Goh Ping Ping, an Echo specialist, added: "There are some problems that straightaway you can see with an Echo, but on the ECG it might just be a suspicion."

ECGs, through electrodes on the skin, track the rate and rhythm of heartbeats. They pick up symptoms such as irregular heartbeats or palpitations. Dr Goh believes that with the use of both tests, the accuracy in detecting pre-existing heart conditions will improve from 70 per cent to 95 per cent.

But other cardiologists argue that there was no real evidence to support the need for Echo tests.

"Most sudden cardiac death causes for those below 35-years-old are due to heart rhythm disorders which, more often than not, produces a perfectly normal echocardiogram," said Dr David Foo, head of the department of cardiology at Tan Tock Seng Hospital.

Dr Ong Hean Yee, who heads Khoo Teck Puat Hospital's cardiology department, pointed out that, based on the coroner's report, Specialist Cadet Ee's cardiomyopathy was complicated with small vessel coronary artery disease. Both tests, he said, would not have detected the condition.

In the case of Specialist Cadet Ee, who never regained consciousness after he was found unconscious on the second day of a navigation exercise on Aug 2, 2011, the disease might also have developed after screening, he added.

"If truly an Echo-all approach will pick up more cases, I'm sure the nation will find money to fund it," said Dr Ong, who co-authored a study on heart screening of pre-enlistees in February last year. "It's just that we don't think so, based on the data we already have."

Instead, he and several SAF doctors are looking into increasing the sensitivity of ECGs by tweaking the thresholds of what is considered abnormal.

Mindef also said it regularly reviews its screening methods, and that the SAF has, since last year, been working with the National Heart Centre Singapore.

It added: "The health and well-being of our servicemen is of paramount importance."

Electrocardiogram v Echocardiogram

ECG: An electrocardiogram measures the electrical activity of the heart. It can detect irregular heartbeat or palpitations.
- Price of machine: $7,000
- Cost: About $12
- Time for test: 10 minutes
Echo: An echocardiogram uses ultrasound to create an image of the heart. It helps detect structural abnormalities such as thickening of the heart muscle, valve restrictions and holes in the heart.
- Price of machine: $250,000
- Cost: About $400
- Time for test: 20 minutes


Last August, Army Specialist Cadet Ee Chun Sheng died after being found unconscious during an exercise. The coroner, who ruled late last month that the 21-year-old had a heart muscle disease, suggested an Echo test may have detected the condition.


Make Echo a must:
Dr Leslie Lam believes Singapore should take the lead among countries in making Echo tests compulsoryDr Goh Ping Ping says using both tests will improve the accuracy in detecting pre-existing heart conditions from 70 per cent to 95 per cent
No need for Echo:
Dr David Foo says the main cause of sudden cardiac death in young adults is heart rhythm disorders, which ECGs can detectDr Ong Hean Yee, who has done a study on heart screening of pre-enlistees, says the current process already errs on the side of caution and instead advocates tweaking the current ECG abnormalities checklist to better suit Asians


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