Cardiovascular Screening In Young Athletes Research Articles

Abstract P134: Cardiac Screening in Adolescent and Young Athletes: A 3 year Cross Sectional Study Assessing the Diagnostic Accuracy of the History Questionnaire, Physical Examination, and Electrocardiogram

Background & Aim: The accuracy of each cardiac screening tool for young athletes needs further investigation. The aim of this study is to evaluate the Preparticipation Physical Evaluation Monograph 4 th Edition (PPE-4), which is the current recommendation for cardiovascular screening in young athletes, and the 12-lead electrocardiogram (ECG). Methods: During October 2010 to June 2013 student athletes from high schools around the greater Seattle area received a one-time cardiac screen including history and physical examination as recommended in the PPE-4, and a resting 12-lead ECG. Those with abnormal findings received a focused echocardiogram. Student athletes were defined as participating in at least one high school level sport or higher per year. A true positive was defined as the identification of a cardiac disorder associated with sudden cardiac death. Sensitivity (Sn), specificity (Sp), false positive rate (FP), and positive and negative likelihood ratios (+LR, -LR), were calculated for each screening tool. Results: Screening events were held at 23 high schools; 4,743 student athletes ranged in age from 13-19 (mean 15.8), 54% male, 65% Caucasian, 13% mixed race, 10% Asian/Pacific Islander, 6% African-American. A total of 1065 (23%) students had at least one positive history response after physician review, 408 (9%) had an abnormal finding on physical exam, and 185 (4%) had an abnormal ECG. Echocardiography was performed on 1417 students who presented a positive finding on history, physical, or ECG or were a male basketball player. There were 21 cardiac disorders identified that could potentially lead to SCD (0.4%). Wolff-Parkinson-White (9) was most common, followed by 4 cases of coronary artery abnormalities, 3 cases of Long QT Syndrome, 3 dilated aortic roots or aneurysm, and 1 case each of hypertrophic cardiomyopathy and Short QT Syndrome. ECG identified 14 cases of those 21, Echo identified 9 cases of those 21. The history questionnaire had a Sn of 52%, Sp 78%, +LR 2.4, and FP 22%. Physical Exam had a Sn 19%, Sp 91%, +LR 2.2, and FP 9%. ECG had a Sn 67%, Sp 96%, +LR 18.4, and FP 4%. Conclusion: ECG had the highest Sn, Sp, and +LR of the screening tools evaluated. History and physical exam had lower Sn and +LRs and higher false positive rates. A limitation to this study is that there is no gold standard for this screening protocol. ECG may miss structural abnormalities and Echo may miss conduction disorders. A combination of the two tests was considered the gold standard, meaning sensitivity of all tests may be overestimated. More research is needed to improve the performance of cardiovascular screening methods especially through the history questionnaire and physical exam. Out of the three tools evaluated the best tool to detect underlying cardiovascular conditions associated with SCD is ECG.

Cardiovascular screening of young athletes with electrocardiography in the UK: at what cost?

The promotion of exercise as a positive and powerful health intervention has never been more important, when consideration is given to the global epidemic of disease states related to a sedentary lifestyle. However, intensive exercise may be a trigger for sudden cardiac death in individuals harbouring quiescent cardiovascular diseases. Indeed, hereditary and congenital abnormalities of the heart are the most common cause of non-traumatic death during sport in young athletes.

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.

Why cardiovascular screening in young athletes can save lives: a critical review

Cardiovascular (CV) screening in young athletes remains challenging and a topic of considerable debate. Recent criticisms of ECG screening have perpetuated arguments that ECG screening is neither indicated nor effective...

Cardiovascular Screening in Young Athletes: Evidence for the Electrocardiogram.

: The objective of this study is to review the evidence for cardiovascular screening inclusive of an electrocardiogram (ECG) in young athletes. Sudden cardiac death (SCD) in athletes is the leading cause of death during exercise and occurs at a rate that is substantially higher than initially recognized. There is widespread agreement that cardiovascular screening should be performed prior to athletic competition. The primary purpose of preparticipation cardiovascular screening is to identify athletes with conditions that predispose them to SCD. Unfortunately, the traditional model in the United States of a medical history and a physical examination has limited sensitivity to detect cardiovascular disease and provides false reassurance to athletes, parents, and team officials. The addition of an ECG enhances the ability to identify disease, and modern athlete-specific ECG interpretation standards used by experienced physicians provide low false-positive rates, improving the cost-effectiveness while preserving sensitivity. The evidence is clear that if athletes are screened, ECG-inclusive strategies are most likely to meet the primary aim of preparticipation cardiovascular screening. These advanced protocols have the potential to improve health and safety during sport events and should be considered the best practice in high-risk athletes when the sports cardiology infrastructure and oversight are readily available.

The Psychological Impact of Cardiovascular Screening in Young Athletes: Perspectives Across Age, Race, and Gender.

To determine the psychological impact of electrocardiogram (ECG) screening in young competitive athletes based on age, race, and gender. Prospective multisite cross-sectional investigation. Young competitive athletes. One thousand five hundred six high school athletes (59.3% male with a mean age of 15.5 years, 56.2% white, 24.5% African American). Athletes underwent screening with a standardized American Heart Association-based history, physical examination, and ECG. Prescreen and postscreen validated assessments for health attitudes, anxiety, and impact of screening on sport. Of the athletes participated, 76.3% had normal screens, 22.7% false-positive (FP) results (12.9% history, 4.2% examination, 3.1% ECG), and 0.9% were diagnosed with serious cardiac disorders. There were no differences in anxiety levels among athletes screening normal versus FP (P = 0.69). There was no difference in anxiety based on the reason for a FP result (history, physical examination, or ECG) both during (P = 0.95) and after (P = 0.40) screening. Analysis by age, race, and gender demonstrated that before screening, females were more likely to prefer knowing about underlying cardiac conditions compared with males (P < 0.001), and males were less concerned about having cardiac disease (P < 0.001) compared with females. African Americans were less concerned about underlying disease (P < 0.001) and less interested (P < 0.001) in cardiac screening compared with whites. Athletes diagnosed with a cardiac disease described anxiety after screening, but still believe that all athletes should receive an ECG before competition. Electrocardiogram screening does not cause excessive anxiety in US high school athletes across spectrums of age, race, and gender. Recognition of age, race, and gender-specific perspectives could improve physician-patient dialogue and support mechanisms for those diagnosed with potentially lethal cardiac disorders. This article provides evidence that undue anxiety should not be used as an argument against the implementation of ECG screening during the preparticipation examinaton for young athletes. Although males and African Americans seem to be at highest risk for sudden cardiac death during exercise, they actually report being the least concerned and least worried about potentially harboring an underlying condition that might predispose them to such an event. Emotional support should readily be available for athletes who are diagnosed with cardiovascular conditions as these individuals report emotional distress after their diagnosis.

Costs and yield of a 15-month preparticipation cardiovascular examination with ECG in 1070 young athletes in Switzerland: implications for routine ECG screening

BackgroundThe usefulness and modalities of cardiovascular screening in young athletes remain controversial, particularly concerning the role of 12-lead ECG. One of the reasons refers to the presumed false-positive ECGs requiring...

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.

Cardiovascular screening in young athletes: controversies and feasibility

Summary Sport plays an important role among young people because of its positive physical, psychological and social impact. Nevertheless, for a small minority of subjects affected by cardiovascular abnormalities, sport can be harmful and lead to sudden cardiac death. Although not accepted by all, solid data indicate that a cardiovascular screening with electrocardiogram (ECG) can prevent a substantial part of these tragic events. Based on the Italian experience, the European Society of Cardiology and major sports associations recommend such a screening programme. There are however important controversies about this issue, particularly about the role of ECG in the screening programme. In fact, ECG has been considered to have inherent limitations with a relative amount of false positive results requiring subsequent examinations, which generate increased costs for a programme that should be implemented on a large scale. It is therefore essential that criteria used for the ECG interpretation provide the optimal balance between sensitivity and specificity. With increasing knowledge about the ECG of athletes, recommendations for the interpretation of ECG have been edited. Based among others on our recent experience in a large prospective series, it seems that with specific clinical experience and applying modern and rigorous criteria for ECG interpretation, the screening of young athletes can be realised at a relatively low cost potentially allowing the implementation of this policy on a large scale.

Abstract 9479: Comparison of European Society of Cardiology and Circulation Criteria for Interpretation of the electrocardiogram in Young Athletes

Background: adding ECG to cardiovascular screening of young athletes remains controversial. One of the reasons refers to the false positive rate of ECG requiring subsequent examinations and raising costs. In an attempt to increase specificity, the European Society of Cardiology (ESC) in 2010 and a group of experts in 2011 (Circulation - CIRC) have proposed recommendations for interpretation of ECG in athletes. The purpose of this study is to compare the ESC and the CIRC criteria for interpreting ECG in young athletes. Methods: ECG was analysed as part of a prospective study about the impact of cardiovascular screening with ECG in young (14-35 years) competitive athletes. ECG was interpreted applying strictly the ESC criteria and the CIRC criteria. The rate of pathologic ECG following both criteria were compared. Results: ECG of 1070 athletes (75 % males, age 19.7 ± 6.3 years) was analysed. ECG was considered pathologic in 211 (19.7 %) athletes following the ESC criteria and in 42 (3.9 %) athletes following the CIRC criteria (p &lt; 0.001). In table 1 are reported the ECG changes in whom there were differences in pathologic ECG applying ESC and CIRC criteria. Conclusions: strictly applying ESC criteria for interpretation of ECG in young athletes, in respect to CIRC criteria, results in a considerably higher proportion of pathologic ECG thus requiring more subsequent examinations. It appears that ESC criteria should be improved toward the best balance between false positive and negative findings.

Cardiovascular Screening in Young Athletes in Sarajevo Canton

Potential risk of sudden death during sports participation makes screening of competitive athletes of vital importance. Congenital cardiac anomalies and non-atherosclerotic, acquired myocardial conditions are primary causes underlying exercise-induced cardiac death in young patients. Since cardiovascular conditions are the leading causes of non-traumatic, exercise-induced cardiac events, cardiovascular screening preceding sports participation in mandatory. The objectives of this study were to determine prevalence of cardiac conditions through cardiovascular screening of young athletes and to establish preventive strategy. The study was conducted at the Sports Medicine Center of Sarajevo Canton and at the Pediatric Clinic of University of Sarajevo Clinics Centre in the period 2007-2009. The study was supported by Canton Sarajevo Ministry of Health and Ministry of sports, science and culture. The study targeted a group of 214 athletes, 8-18 years of age with average age being 15.26. The group was subdivided into five groups according to the age. After taking the anamnesis (family, personal and cardiological) patients were subjected to the measuring of body mass and height, blood pressure and heart rate and oxygen saturation, recording of 12-lead ECG, specialist examination (pediatrician, sports medicine specialist and cardiologist) and complete heart echocardiography. No examined athletes expressed subjective discomfort. Congenital cardiac anomalies were not diagnosed in any athlete. Also, cardiovascular abnormalities requiring additional evaluation, positive cardiac anamnesis, abnormal auscultatory findings, hypertension or abnormal ECG findings were not recognized in any patient. Moderate correlation was found among the left ventricle mass and heart rate (p<0.05). In order to minimalize or even possibly prevent the risk of sudden cardiac death it is necessary to establish an adequate strategy of cardiovascular screening of young athletes.

Potential benefits of ECG screening in young athletes

Performing 12-lead electrocardiography (ECG) in addition to US standard cardiovascular screening in young athletes improves detection of cardiac abnormalities; furthermore, ECG use may be a cost-effective strategy to prevent sudden cardiac death among this population, according to two studies published in the Annals of Internal Medicine.

Preparticipation Cardiovascular Screening in Young Athletes

How to best screen athletes for conditions predisposing to sudden cardiac death is a topic of debate. The European Society of Cardiology and International Olympic Committee recently endorsed a standardized screening evaluation modeled after the successful Italian system, which utilizes a 12-lead electrocardiogram (ECG) along with a detailed history and physical exam. The ECG increases the power of the history and physical exam to detect underlying causes of sudden cardiac death. In 2007, the American Heart Association (AHA) panel recommended against implementation of such a system in the United States because of a lack of current infrastructure, providers, and expertise. The lack of standardization of the current cardiovascular screening system in the United States hinders its effectiveness and prevents systematic evaluation. The AHA strongly recommends establishing a national standard for cardiovascular screening as well as a certification process for non-physicians who perform screening exams. Well designed studies are needed in the U.S. to demonstrate the effectiveness of the ECG for identifying underlying cardiovascular abnormalities in young athletes.

Cardiovascular Screening in Young Athletes: Missed Opportunities

As controversy continues about use of noninvasive diagnostic tests (e.g., electrocardiography) for preparticipation cardiovascular screening in young athletes (JW Pediatr Adolesc Med Dec 19 2007 and JW Pediatr Adolesc Med Nov 4 2009), many experts advocate that a careful history and physical examination is the most practical screening approach. The Preparticipation Physical Evaluation …

Sudden cardiac death due to hypertrophic cardiomyopathy can be reduced by pre-participation cardiovascular screening in young athletes

Sudden death of a young well-trained athlete has a high impact on everyone involved and raises concern in the medical community. It is hardly acceptable that a ‘healthy’ individual dies suddenly during athletic activity. And the question that always arises is whether this athlete could have been identified by pre-participation cardiovascular screening and this sudden cardiac death could have been prevented. The first documented ‘marathon runner’ dying suddenly within an hour after physical exertion while announcing the Greek victory (‘Nike’) over the Persians was Pheidippides in 490 BC. More recently, the death of well-trained athletes has focused interest on pre-participation cardiovascular screening. The European Association for Cardiovascular Prevention and Rehabilitation (EACPR) Section Sports Cardiology of the European Society of Cardiology proposed an ‘European protocol’ for pre-participation cardiovascular screening to prevent sudden cardiac death in young athletes, which is supported by the International Olympic Committee (IOC).1,2 In this common ‘European protocol’, pre-participation cardiovascular screening is performed every year or every other year according to the Italian strategy consisting of personal and family history, physical examination, and 12-lead resting ECG. The EACPR Section Sports Cardiology has started to implement this protocol in European countries. Also the FIFA (Federation Internationale de Football Association) performed pre-participation cardiovascular screening in all soccer players participating at the world championship in Germany 2006.3 Sudden cardiac death … **Corresponding author. Tel: +31 26 48 34 440; fax: +31 26 36 37 649. E-mail address : nicole.panhuyzen{at}planet.nl