Cardiovascular Screening In Athletes Research Articles

Pre-participation cardiovascular screening in athletes with a focus on Asia

Pre-participation screening (PPS) in young competitive athletes aims to identify conditions associated with sudden cardiac death (SCD) in this population, with a view to appropriate management and potential mitigation of risk. A medical history questionnaire and physical examination are standard components of a PPS programme, whereas controversy still exists regarding mandatory utilisation of resting 12-lead electrocardiogram as a screening tool. Apart from a landmark study from Italy attributing the reduction of SCD rates in athletes to the implementation of a mandatory PPS programme, there remains no additional compelling evidence for similar outcomes to date. Nonetheless, comprehensive PPS programmes when carried out systematically, are efficacious in detection of cardiac pathology and cost-effective. While the incidence rate of SCD in athletes from Western countries is estimated to be around 1:50,000, comparable data in Asian athletes remain lacking. Prospective registries are much needed to accurately determine the magnitude of this issue in Asia and recent recommendations on PPS in young Asian athletes have been published to increase awareness and encourage collaboration. To further reduce SCD events, prompt recognition of sudden cardiac arrests and early defibrillation are vital components in the spectrum of SCD prevention. This review aims to outline the rationale, current status and efficacy of PPS in athletes, with a focus on Asia.

Symptoms Preceding Sports-Related Sudden Cardiac Death in Persons Aged 1-49Years.

Sports-related sudden cardiac death (Sr-SCD) is a leading natural cause of death in young athletes. To prevent Sr-SCD in athletes, it is important to identify individuals at risk. This review sought to summarize the current knowledge of symptoms prior to Sr-SCD in athletes aged 1-49years. Cardiovascular screening of athletes is a subject of interest. However, the cost of ECG screening in a young population is relatively high compared to potential benefits, and systematic screening of athletes is heavily debated. In the background population, both cardiac and non-specific symptoms are often present prior to SCD. Both cardiac and non-specific symptoms are present in up to 74% prior to Sr-SCD. The main symptoms are syncope, chest pain, palpitations and dizziness. Knowledge of symptoms could potentially be used in combination with non-invasive prediction models to prevent Sr-SCD and treat athletes at risk.

Performance of the American Heart Association ( AHA ) 14-Point Evaluation Versus Electrocardiography for the Cardiovascular Screening of High School Athletes: A Prospective Study.

BackgroundPreparticipation cardiovascular screening in athletes is fully endorsed by major medical societies, yet the most effective screening protocol remains debated. We prospectively compared the performance of the American Heart Association (AHA) 14‐point screening evaluation and a resting ECG for cardiovascular screening of high school athletes.Methods and ResultsCompetitive athletes participating in organized high school or premier/select level sports underwent cardiovascular screening using the AHA 14‐point history and physical examination, and an ECG interpreted with the Seattle Criteria. A limited echocardiogram was performed for all screening abnormalities. The primary outcome measure was identification of a cardiovascular disorder associated with sudden cardiac death. From October 2014 to June 2017, 3620 high school athletes (median age, 16 years; range 13–19; 46.2% female; 78.6% white, 8.0% black) were screened. One or more positive responses to the AHA 14‐point questionnaire were present in 814 (22.5%) athletes. The most common history responses included chest pain (8.1%), family history of inheritable conditions (7.3%), and shortness of breath (6.4%). Abnormal physical examination was present in 356 (9.8%) athletes, and 103 (2.8%) athletes had an abnormal ECG. Sixteen (0.4%) athletes had conditions associated with sudden cardiac death. The sensitivity (18.8%), specificity (68.0%), and positive predictive value (0.3%) of the AHA 14‐point evaluation was substantially lower than the sensitivity (87.5%), specificity (97.5%), and positive predictive value (13.6%) of ECG.ConclusionsThe AHA 14‐point evaluation performs poorly compared with ECG for cardiovascular screening of high school athletes. The use of consensus‐derived history questionnaires as the primary tool for cardiovascular screening in athletes should be reevaluated.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations, and Future Directions: Erratum.

Cardiovascular (CV) screening in young athletes is widely recommended and routinely performed before participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for CV screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation CV screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal CV screening strategy for all athletes including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate CV screening strategy unique to their athlete population, community needs, and resources. The decision to implement a CV screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. American Medical Society for Sports Medicine is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

Pre-participation screening of asymptomatic athletes : "Don't do stupid stuff".

Catastrophic events, be it traffic accidents, natural disasters or homicides, always lead to scrutiny. Could we have seen the event coming and could it have been prevented? In the case of a sudden cardiac arrest of a seemingly healthy athlete the public outcry is not any different. Despite an intrinsic appeal for screening to prevent similar events, there is no evidence that justifies routine cardiovascular pre-participation screening of athletes. On balance, cardiovascular screening in athletes will most likely do more harm than good. Fatal exercise-related cardiac arrests do not occur very often. The true diagnostic yield of the pre-participation evaluation is not known and once a cardiac condition has been identified, the most appropriate intervention is often unclear. It follows that pre-participation screening of large groups of athletes without known cardiac disease will inevitably result in many false positive findings, while at the same time providing a false sense of security to those screened negative. Except for compelling reasons (e. g. cascade screening, research settings, professional athletes), physicians should not engage in routine examination of asymptomatic athletes to prevent cardiac events.

Optimal Screening Methods to Detect Cardiac Disorders in Athletes: An Evidence-Based Review.

Which screening method should be considered best practice to detect potentially lethal cardiac disorders during the preparticipation physical examination (PE) of athletes? The authors completed a comprehensive literature search of MEDLINE, CINAHL, Cochrane Library, Embase, Physiotherapy Evidence Database (PEDro), and SPORTDiscus from January 1996 to November 2014. The following key words were used individually and in combination: ECG, athlete, screening, pre-participation, history, and physical. A manual review of reference lists and key journals was performed to identify additional studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this review. Studies selected for this analysis involved (1) outcomes of cardiovascular screening in athletes using the history, PE, and electrocardiogram (ECG); (2) history questions and PE based on the American Heart Association recommendations and guidelines; and (3) ECGs interpreted following modern standards. The exclusion criteria were (1) articles not in English, (2) conference abstracts, and (3) clinical commentary articles. Study quality was assessed on a 7-point scale for risk of bias; a score of 7 indicated the highest quality. Articles with potential bias were excluded. Data included number and sex of participants, number of true- and false-positives and negatives, type of ECG criteria used, number of cardiac abnormalities, and specific cardiac conditions. The sensitivity, specificity, false-positive rate, and positive predictive value of each screening tool were calculated and summarized using a bivariate random-effects meta-analysis model. Fifteen articles reporting on 47 137 athletes were fully reviewed. The overall quality of the 15 articles ranged from 5 to 7 on the 7-item assessment scale (ie, participant selection criteria, representative sample, prospective data with at least 1 positive finding, modern ECG criteria used for screening, cardiovascular screening history and PE per American Heart Association guidelines, individual test outcomes reported, and abnormal screening findings evaluated by appropriate diagnostic testing). The athletes (66% males and 34% females) were ethnically and racially diverse, were from several countries, and ranged in age from 5 to 39 years. The sensitivity and specificity of the screening methods were, respectively, ECG, 94% and 93%; history, 20% and 94%; and PE, 9% and 97%. The overall false-positive rate for ECG (6%) was less than that for history (8%) or PE (10%). The positive likelihood ratios of each screening method were 14.8 for ECG, 3.22 for history, and 2.93 for PE. The negative likelihood ratios were 0.055 for ECG, 0.85 for history, and 0.93 for PE. A total of 160 potentially lethal cardiovascular conditions were detected, for a rate of 0.3%, or 1 in 294 patients. The most common conditions were Wolff-Parkinson-White syndrome (n = 67, 42%), long QT syndrome (n = 18, 11%), hypertrophic cardiomyopathy (n = 18, 11%), dilated cardiomyopathy (n = 11, 7%), coronary artery disease or myocardial ischemia (n = 9, 6%), and arrhythmogenic right ventricular cardiomyopathy (n = 4, 3%). The most effective strategy to screen athletes for cardiovascular disease was ECG. This test was 5 times more sensitive than history and 10 times more sensitive than PE, and it had a higher positive likelihood ratio, lower negative likelihood ratio, and lower false-positive rate than history or PE. The 12-lead ECG interpreted using modern criteria should be considered the best practice in screening athletes for cardiovascular disease, and the use of history and PE alone as screening tools should be reevaluated.

How the New International recommendation for Electrocardiographic interpretation in Athletes would change our practice

Recent evidences in the prevention of sudden cardiac death (SCD) confirmed the importance of pre-participation cardiovascular screening in athletes to early identify, and further disqualify from the competition, all the athletes

Cardiovascular screening practices in US National Governing Bodies and National Paralympic Committees

Cardiovascular screening in athletes has been a source of controversy within the sports medicine community. Annual screening inclusive of ECG is currently required by all major professional sports leagues in...

The differences in electrocardiogram interpretation in top-level athletes.

The Ministry of Health in Poland recommends electrocardiogram (ECG)-based cardiovascular screening in athletes, but so far there has been a lack of guidelines on preparticipation assessment. We compared different criteria of ECG screening assessment in a group of top-level athletes. The aims were to evaluate the prevalence of ECG changes in athletes that necessitate further cardiological work-up according to three criteria in various age groups as well as to identify factors determining the occurrence of changes related and unrelated to the training. 262 high-dynamic, high-static Polish athletes (rowers, cyclists, canoeists) were divided into two age categories: young (≤ 18 years of age; n = 177, mean age 16.9 ± 0.8; 15-18 years) and elite (> 18 years of age; n = 85, mean age 22.9 ± 3.4; 19-34 years). All sports persons had a 12-lead ECG performed and evaluated according to 2010 European Society of Cardiology (ESC) recommendations, 2012 Seattle criteria, and 2014 Refined criteria. The Refined criteria reduced (p < 0.001) the number of training-unrelated ECG findings to 8.0% vs. 12.6% (Seattle criteria) and 30.5% (ESC recommendations). All three criteria revealed more training-related changes in the group of older athletes (76.5% vs. 55.9%, p = 0.001). Predictors that significantly (p < 0.005) affected the occurrence of adaptive changes were the age of the athlete, training duration (in years), and male gender. 1. The ESC criteria identified a group of athletes that was unacceptably large, as for the screening test, requiring verification with other methods (every fourth athlete). 2. The use of the Refined criteria helps to significantly reduce the frequency and necessity for additional tests. 3. The dependence of adaptive changes on training duration and athletes' age confirms the benign nature of those ECG findings.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current evidence, knowledge gaps, recommendations and future directions

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk...

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations and Future Directions.

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for cardiovascular screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation cardiovascular screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal cardiovascular screening strategy for all athletes, including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate cardiovascular screening strategy unique to their athlete population, community needs, and resources. The decision to implement a cardiovascular screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence-base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. AMSSM is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

History and application of the AHA 12 points for assessing cardiovascular risk in athletes.

The cardiovascular (CV) evaluation, one important part of the preparticipation physical examination (PPE), is the focus of this special communication. Cardiac events during sporting events, albeit rare, can be fatal, and these events are often very public (5,7,10). In the United States, most athlete PPE for ages 6 to 24 years are performed by family physicians and pediatricians (8), some with subspecialty training in sports medicine. Often, the PPE is the first encounter with the health care system for adolescents and serves as the sole opportunity for general screening, risk factor evaluation, and health education. This may be especially true for adolescents in lower income strata. The PPE is intended to reduce the risk of adverse outcomes without unduly restricting athlete participation. A thorough history examination can uncover a large portion of the athlete’s risk for injury or illness, and the physical examination unveils other abnormalities. There are very few proven screening methods that assure an athlete’s health, but the PPE provides a framework to assess and stratify sport participation risk. The intent of these evaluations is to deliver to health care providers pertinent information to educate athletes and parents and enable them to make an informed participation decision. The first PPE monograph was published in 1992 by five organizations (American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine). The American College of Sports Medicine joined for the third edition in 2005, and the fourth edition was published in 2010 (1). The American Heart Association (AHA) developed CV preparticipation screening recommendations for young athletes in 1996 and updated the statement in 2007 (8). The AHA and the American College of Cardiology have reaffirmed their position regarding the CV PPE and electrocardiography (ECG) screening in healthy 12- to 25-year-old young people with a comprehensive review that endorses the 12-element history and physical examination in the 2014 Scientific Statement (9). This recent document added two elements regarding palpitations and previous evaluations similar to those in the fourth PPE. The question sets from the two examination recommendations are similar, and the fourth PPE monograph uses the same general questions, with some differences in syntax and depth of question content. The question wording of the third PPE monograph was based on input from parent and high school athlete focus group sessions to enhance the “understandability” of the questions for the end users. Of note, the question sets are based on expert opinion and have not been subjected to scientific study. In the late 1990s, after surveys showed poor compliance with both the use of consensus-based forms and the AHA question set, some high schools and colleges across the country incorporated the elements of the PPE and the AHA questions (3,9) in their athlete evaluations. Despite progress, however, a 2013 Washington state survey showed that only 47% of physicians understood the AHA guidelines (4). This is unfortunate, given the evidence that supports the efficacy of adopting a standardized PPE form (10).The 12-Step Questionnaire Recommendations for Health Care Providers for Preparticipation Cardiovascular Screening in Athletes (8)Understanding and utilizing the AHA 12-point CV examination and its constellation of responses is essential to make logical, cost-effective decisions regarding additional evaluations, consultations, and sport participation recommendations (1,9). This document is intended to direct the use of diagnostic testing, including ECG, and reduce reflex use of consults and diagnostics along the lines of the American Medical Association “Choosing Wisely” campaign (6) and encourage the implementation of either the AHA 12-point or the PPE-4 CV screening tools as the minimal standard for athlete screening, not to endorse one questionnaire over the other. The AHA 12-point question/examination set and the fourth-edition PPE monograph 13 history questions and five physical examination points are outlined as follows. Both emphasize the importance of personal and family history. This Special Communication will provide the reader, and particularly primary care providers conducting the PPE, a framework to address positive responses to questions and findings reveled during the examination. This will help reduce the risk of adverse outcomes and allow athletes to participate in activities that best fit their risk profile. Positive responses to the CV questions require additional history and sometimes diagnostic investigations to rule out CV problems that put athletes at undo risk. Individual questions will be highlighted in a case presentation to illustrate the significance of each question. Informed analysis of the questions and judicious use of diagnostics will be the key to risk reduction, cost control, and unnecessary athlete restriction. The burden of these decisions rests on the shoulders of the physicians performing the PPE.

SCREENING FOR SUDDEN CARDIAC DEATH IN ATHLETES: THE PSYCHOLOGICAL IMPACT OF BEING DIAGNOSED WITH POTENTIALLY LETHAL DISEASE

BackgroundThe purpose of cardiovascular screening in athletes is the identification of disorders at risk for sudden cardiac death. No study has assessed the experiences of athletes diagnosed with a serious...

Standardised pre-competitive screening of athletes in some European and African countries: the SMILE study

Most of the available data on the cardiovascular screening of athletes come from Italy, with fewer records being available outside of Italy and for non-Caucasian populations. The goals of the SMILE project (Sport Medicine Intervention to save Lives through ECG) are to evaluate the usefulness of 12-lead ECGs for the detection of cardiac diseases in athletes from three European countries and one African country and to estimate how many second-level examinations are needed subsequent to the initial screening in order to classify athletes with abnormal characteristics. A digital network consisting of Sport Centres and second and third opinion centres was set up in Greece, Germany, France and Algeria. Standard digital data input was carried out through the application of 12-lead ECGs, Bethesda questionnaires and physical examinations. Two hundred ninety-three of the 6,634 consecutive athletes required further evaluation, mostly (88.4%) as a consequence of abnormal ECGs. After careful evaluation, 237 were determined to be healthy or apparently healthy, while 56 athletes were found to have cardiac disorders and were thus disqualified from active participation in sports. There was a large difference in the prevalence of diseases detected in Europe as compared with Algeria (0.23 and 4.01%, respectively). Our data confirmed the noteworthy value of 12-lead resting ECGs as compared with other first-level evaluations, especially in athletes with asymptomatic cardiac diseases. Its value seems to have been even higher in Algeria than in the European countries. The establishment of a digital network of Sport Centres for second/third opinions in conjunction with the use of standard digital data input seems to be a valuable means for increasing the effectiveness of screening.

Reframing the debate: Screening athletes to prevent sudden cardiac death

In a recent issue of HeartRhythm, Maron1 and Sharma2 shared their opinions regarding a mandatory, national cardiovascular screening program for athletes in the United States. The point/counterpoint centered on the inclusion (or not) of a resting 12-lead electrocardiogram (ECG) in addition to a history and physical examination during preparticipation screening of athletes. In response to these articles, we were invited to write a position paper on cardiovascular screening in athletes and to “agree with one position or the other, or with neither, or conclude that more information is needed before an opinion can be offered.” Rather than restate the arguments for and against ECG screening and the many points on which these experts disagree, we hope to reframe this debate in an attempt to help the medical community refocus on ways to improve cardiovascular screening in young athletes.

Preparticipation cardiovascular screening among National Collegiate Athletic Association Division I Institutions

BackgroundSudden cardiac arrest is the leading cause of death in competitive athletes during sport, and screening strategies for the prevention of sudden cardiac death are debated. The purpose of this...

Pre-participation cardiovascular screening in athletes: when and how?

Summary Sudden cardiac death (SCD) in athletes is a rare but highly tragic event. The majority of SCDs in young athletes are attributable to inherited or congenital cardiac disorders. Athletes harbouring such potentially fatal conditions may remain asymptomatic and sudden death is frequently the first presentation. Most implicated disorders are identifiable during life, and a variety of therapeutic options are available to minimise the risk of SCD. Whereas most health professionals advocate pre-participation cardiovascular screening (PPS) on humanitarian and medical grounds, there is controversy about the most cost-effective method of screening. The American screening model encompasses a cardiovascular health questionnaire and physical examination, while in Italy a mandatory national screening programme is in existence that also incorporates 12-lead ECG. The American model is cheap and pragmatic but has poor sensitivity for the identification of sinister cardiac disorders. In contrast, the Italian model has been shown to exhibit a high sensitivity and specificity for the detection of cardiomyopathies, and has been associated with a dramatic reduction in the incidence of SCD since its inception. However, there are concerns regarding the cost-effectiveness of large-scale ECG screening programmes driven by false positive results and costs of unnecessary additive investigations to confirm or refute the presence of a serious disorder. Nevertheless, major sporting and cardiac organisations have endorsed and advocated the ECGbased screening protocol, which currently remains the most feasible and cost-effective method of pre-participation screening. More efforts are required to address some pertinent issues regarding the universal implementation of PPS programmes.

Abnormal electrocardiographic patterns in trained athletes screened by European Society of Cardiology recommendations

IntroductionYoung, trained athletes may have abnormal 12-lead ECGs without evidence of structural cardiac disease. In 2005, the European Society of Cardiology (ESC) published recommendations for cardiovascular screening in athletes. This...

Is There Evidence for Recommending Electrocardiogram as Part of the Pre-Participation Examination?

Sudden cardiac death (SCD) is the leading cause of death in young athletes on the playing field and typically the result of undiagnosed structural or electrical cardiovascular disease. Cardiovascular screening in athletes is routinely practiced and endorsed by most major sporting and medical associations, but universal agreement on a single screening strategy to identify athletes at risk for SCD remains a topic of tremendous debate. The pool of scientific evidence supporting the efficacy and cost-effectiveness of electrocardiogram (ECG) screening for athletes is growing. However, feasibility and practical concerns regarding false-positive results, cost-effectiveness, physician infrastructure, and health care resources for large-scale implementation of ECG screening still exist. This article examines the evidence related to ECG screening in athletes and presents a contemporary model for primary prevention of SCD in sport.

Cardiovascular Screening in College Athletes With and Without Electrocardiography

Although cardiovascular screening is recommended for athletes before participating in sports, the role of 12-lead electrocardiography (ECG) remains uncertain. To date, no prospective data that compare screening with and without ECG have been available. To compare the performance of preparticipation screening limited to medical history and physical examination with a strategy that integrates these with ECG. Cross-sectional comparison of screening strategies. University Health Services, Harvard University, Cambridge, Massachusetts. 510 collegiate athletes who received cardiovascular screening before athletic participation. Each participant had routine history and examination-limited screening and ECG. They received transthoracic echocardiography (TTE) to detect or exclude cardiac findings with relevance to sports participation. The performance of screening with history and examination only was compared with that of screening that integrated history, examination, and ECG. Cardiac abnormalities with relevance to sports participation risk were observed on TTE in 11 of 510 participants (prevalence, 2.2%). Screening with history and examination alone detected abnormalities in 5 of these 11 athletes (sensitivity, 45.5% [95% CI, 16.8% to 76.2%]; specificity, 94.4% [CI, 92.0% to 96.2%]). Electrocardiography detected 5 additional participants with cardiac abnormalities (for a total of 10 of 11 participants), thereby improving the overall sensitivity of screening to 90.9% (CI, 58.7% to 99.8%). However, including ECG reduced the specificity of screening to 82.7% (CI, 79.1% to 86.0%) and was associated with a false-positive rate of 16.9% (vs. 5.5% for screening with history and examination only). Definitive conclusions regarding the effect of ECG inclusion on sudden death rates cannot be made. Adding ECG to medical history and physical examination improves the overall sensitivity of preparticipation cardiovascular screening in athletes. However, this strategy is associated with an increased rate of false-positive results when current ECG interpretation criteria are used. None.