Preparticipation Sports Research Articles

Left-Dominant Arrhythmogenic Cardiomyopathy

A 50-year-old recreational futsal player was referred to our sports cardiology outpatient clinic for palpitations and detection of frequent (>5000) ventricular premature beats with bigeminy and runs of nonsustained ventricular tachycardia at 24-hour Holter monitoring. Rest ECG showed normal QRS morphology with negative T waves in precordial lateral (V4 to V6) and inferior leads (Figure 1A). Less-prominent negative T waves in lateral but not inferior leads also were present in previous ECGs obtained during routine sports preparticipation evaluation at age 26 years (Figure 1B) but in the absence of symptoms and arrhythmias at Holter monitoring; no other diagnostic test was performed at that time. Figure 1. Rest ECGs. A , Rest ECG obtained in 1984 showing negative T waves in lateral precordial leads (V4 to V6). B , Rest ECG obtained in 2010 showing more-prominent negative T waves in lateral precordial leads. A stress ECG failed to reveal ST-segment changes diagnostic for myocardial ischemia, whereas frequent polymorphic ventricular premature beats with right bundle branch block morphology and a short run of nonsustained ventricular tachycardia were observed during the recovery phase. Two-dimensional echocardiography showed a mild reduction of ejection fraction with a diffuse apical a-dyskinesia of the left ventricle (LV), whereas the right ventricle (RV) presented normal dimensions and global function but hypokinesia of the apex and …

Can we prevent sudden cardiac death in young athletes: the debate about preparticipation sports screening

All high school athletes in the United States require a preparticipation screening examination. The American Heart Association recommends a focused history and physical examination. The European Society of Cardiology recommends that all examinations include an electrocardiogram (ECG). We review the risks and costs of screening, discuss legal ramifications and analyse the ethical implications of these considerations. There are too many unknown about ECG screening to require it as routine testing for all high school athletes. Doctors must inform young athletes and their parents about the option of ECG screening and about the debate over its efficacy. Patients and parents may then choose to have an ECG or not. Mandatory universal screening is not warranted at this time.

Vital Signs and Demographics in the Preparticipation Sports Exam

Much attention recently has been paid to the detection of those young athletes who may be at risk for sudden cardiac death (SCD) in sports participation. In this article, we attempt to summarize the remarkably few studies that examine the question of whether vital signs and basic demographics are associated with athletes at risk for SCD. Historical items such as chest pain, dyspnea, and palpitations are not reviewed. The only demographics mentioned in the literature as associated with SCD are being of the male gender, which is associated highly with SCD, and being African-American. Most notably, we were unable to find even prospective data asking the question of whether resting pulse, blood pressure, height, weight, and age are potential risk factors. Therefore, we also have included recent data from our own research to make this summary more complete.

Sudden Cardiac Death of the Young in Michigan: Development and Implementation of a Novel Mortality Review System

Advances in screening, detection and treatment make Sudden Cardiac Death of the Young (SCDY) a potentially preventable condition. Since hereditary causes account for many deaths, identification of an affected individual has implications for immediate relatives; who should receive targeted screening with the aim of preventing SCDY. To develop a mortality review process for SCDY and to identify potential unmet needs for family-based, medical system and public health interventions. The Michigan Department of Community Health and Michigan State University developed a system for investigating SCDY. Review of medical records and next-of-kin (NOK) interviews were conducted. A de-identified summary of each case was presented to an expert panel. The panel identified factors that contributed to the death and possible actions to prevent future deaths. If the case was deemed to have a likely heritable cause, NOK were notified of a possible increased risk and need for evaluation of immediate family members. Twenty-three deaths aged 1-39 years between 2006 and 2008, were selected for review. Sixteen NOK were interviewed. Several primary and secondary prevention measures were identified, including enhanced pre-participation sports screening; provider education; public awareness of risk factors, symptoms, emergency response training for coaches and the general public; and creation and dissemination of emergency response and medical examiner protocols. Seventeen NOK were notified of the potential heritable cause. Investigation of these deaths has led to identification of individual, family, public and provider needs and motivated policy makers to initiate changes to prevent future SCDY.

Sports Preparticipation Examination to Screen College Athletes for Chlamydia trachomatis

This study assessed the prevalence of Chlamydia trachomatis in the college athlete and the benefit of using the sports preparticipation examination (PPE) as a screening opportunity. Chlamydia teaching and screening was part of the sports PPE. The 439 athletes (220 men and 219 women) answered a questionnaire and provided urine specimens. Using positive test results as an indication of prevalence, the chlamydia prevalence rate was calculated by sex and race. Using the questionnaire responses, we determined the students' accessibility to health care and the percentage of sexually active students who were ever offered chlamydial screening. Thirteen of 439 athletes tested positive. One test was a false positive. The test positivity was 2.7%: 3.2% men and 2.2% women. In sexually active athletes, the test positivity rose to 3.8%: 4.0% men and 3.7% women. African American athletes had a higher prevalence of 9.1%: 8.9% in men and 9.5% in women, making them six times more likely to have chlamydia than Caucasian athletes (odds ratio = 6.43, 95% confidence interval = 1.58-30.55). Number of partners, contraceptive type, symptoms, and prior history of chlamydia were not statistically different between groups. Over 75% of students saw their private physicians, yet of the sexually active students, only 31% of women and 6.8% of men were ever offered chlamydial screening. The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force guidelines recommending annual chlamydial screening for all sexually active women younger than 26 yr are not being met in the community. Taking advantage of opportunities, including the mandated sports PPE, where sexually active men and women 25 yr and younger interface with the health care system to screen for C. trachomatis, is crucial to decreasing the continued rise of chlamydial infection.

Preparticipation Sports Evaluation: Issues for Healthy Children and Athletes With Disabilities

Athletic participation in youth sports is occurring on an ever-increasing level each year. All states require an examination before young athletes are allowed to participate in interscholastic sports to identify conditions that may increase the risk of injury. The aims of a preparticipation sports evaluation are to detect conditions that might be life-threatening, disabling, or that may predispose to injury; to indicate which sports are safe for the individual; to serve as a limited general health screening and to meet legal requirements. Preparticipation sports evaluation therefore plays a crucial in ensuring the health and safety of the disabled and healthy young athlete.

Health Literacy Instrument in Family Medicine: The "Newest Vital Sign" Ease of Use and Correlates

Health literacy has been defined as the ability to obtain, process, and understand the basic information needed to make appropriate health decisions. Half of adults lack the health literacy skills needed for our complex health care environment. In 2005, Weiss et al introduced the Newest Vital Sign (NVS), an instrument that can be used to quickly assess health literacy. The purpose of this study was to determine the acceptability and timeliness of using the NVS to measure the level of health literacy in various suburban, urban, and rural primary care settings. A secondary purpose was to determine the influence of taking a health class on one's level of health literacy. In this cross-sectional design, adults were recruited from 4 primary care settings and student athletes were recruited during preparticipation sports physicals. The NVS was administered and health literacy rates were compared with known trends. A subset of 50 patients was timed during test administration, and refusals were logged throughout. The adults and the athletes were analyzed separately. One thousand fourteen patients (including athletes) agreed to participate (response rate, 97.5%). Average time needed to complete the NVS was 2.63 minutes. Of the adults tested, 48.1% demonstrated adequate health literacy. In logistic regression analysis, younger age, more formal education, health class participation, and body mass index were positive predictors of adequate health literacy among adults. An interaction term was used for gender/race, with white women used as the comparator. The gender/race odds ratio negatively affected literacy, with white men at 0.497 (95% CI, 0.328-0.753), non-white women at 0.177 (95% CI, 0.111-0.282), and non-white men at 0.210 (95% CI, 0.110-0.398). Among the participating middle- and high-school athletes, 59.7% had adequate health literacy. In logistic regression of this population, body mass index was a positive predictor whereas gender/race was a negative predictor. The NVS revealed health literacy status in less than 3 minutes, was widely accepted, and provided results comparable to more extensive literacy tests. Particularly, taking a health education class was associated with higher levels of health literacy among adults.

Preparticipation Sports Physical for All

Preparticipation Sports Physical for All

Adherence to Guidelines for Cardiovascular Screening in Current High School Preparticipation Evaluation Forms

We compared the content of the cardiac screening questions on US state high school athletic association preparticipation evaluation forms with current consensus recommendations. We reviewed the high school athletic association's approved, recommended, or required sports preparticipation form from each of the 50 US states and the District of Columbia, and compared the content of the personal and family history components with current recommendations for cardiac screening questions. We found that 85% of the preparticipation forms in current use contain all elements of the formerly recommended guidelines, but only 17% contain all elements of the new consensus guidelines. We conclude that although there appears to be some improvement in the content of the preparticipation forms in current use compared with previous studies, the vast majority of these forms are incomplete compared with current consensus guidelines.

Sports preparticipation examination and chronic illness: Let the games begin!

Article Sports preparticipation examination and chronic illness: Let the games begin! was published on July 1, 2008 in the journal International Journal on Disability and Human Development (volume 7, issue 3).

Commentary: The Value of the ECG in the Preparticipation Sports Physical Examination: The Italian Experience: Table.

1. Renato Vitiello, MD 1. Unita Operativa Complessa di Pediatria e Neonatologia Ospedal Civile Torre Annunziata Torre Annunziata, Italy Editor’s note: This commentary by Dr Vitiello addresses cardiovascular preparticipation sports screening by describing the extensive Italian protocol aimed at preventing cardiovascular deaths in athletes. Presented data indicate the value of the protocol, and extending the practice across Europe has been proposed. Readers not only will find this information to be educational but also will appreciate the value of viewpoints and experiences from other countries. We hope to present more of these contributions from outside of North America in the near future.—LFN In 1982, the Italian Ministry of Health mandated required screening for everyone who participates in competitive sports. (1) The law states that every 1 to 2 years, all competitive athletes must be certified for participation. The definition of …

Commentary: The Value of the ECG in the Preparticipation Sports Physical Examination: The Italian Experience

Editor’s note: This commentary by Dr Vitiello addresses cardiovascular preparticipation sports screening by describing the extensive Italian protocol aimed at preventing cardiovascular deaths in athletes. Presented data indicate the value of the protocol, and extending the practice across Europe has been proposed. Readers not only will find this information to be educational but also will appreciate the value of viewpoints and experiences from other countries. We hope to present more of these contributions from outside of North America in the near future.—LFNIn 1982, the Italian Ministry of Health mandated required screening for everyone who participates in competitive sports. (1) The law states that every 1 to 2 years, all competitive athletes must be certified for participation. The definition of a competitive athlete includes students in secondary schools, members of sports clubs, and professional athletes. By law, the screenings are performed at designated “Centers for Sport Medicine” and are conducted by sports medicine specialists. The evaluation includes a comprehensive family and personal history, a physical examination, a 12-lead electrocardiogram (ECG), and a urinalysis. Furthermore, athletes participating in certain high-intensity sports also must undergo exercise testing and pulmonary function testing (TableT1). Those in whom abnormalities are found on the initial screening studies are referred for additional tests, including echocardiography, 24-hour Holter monitoring, and others as necessary. (1)In Italy, there has been considerable interest in preventing sudden death in young athletes by preparticipation screenings because there is a high incidence of catastrophic deaths caused by cardiomyopathy in young athletes. (2)(3)(4)(5)The Italian preparticipation screening program, by requiring ECG studies, might reduce mortality. The thinking is that the ECG is an excellent screening test for hypertrophic cardiomyopathy (HCM), (6) the leading cause of sports-related cardiac death. (7)(8)(9)(10) Burke and associates (8) found that 24% of sudden deaths during competitive sporting events were caused by HCM. After the institution of the Italian law, Corrado and colleagues (11) prospectively studied 269 consecutive cases of sudden death in young people and observed a significant reduction of HCM-caused sudden death from the expected 24% to 2% (one case). Furthermore, recognition of the relatively more rare disease, arrhythmogenic right ventricular (RV) cardiomyopathy, as a cause of death increased. Thus, it appears that the ECG has been an extremely valuable addition to the Italian program.Besides HCM, other causes of cardiac arrest in athletes may manifest ECG abnormalities at the preparticipation cardiovascular screening. These disorders include arrhythmogenic RV cardiomyopathy, long QT syndrome, dilated cardiomyopathy, and Brugada syndrome. With this knowledge inmind, it is critical to characterize the ECG findings in these diseases fully and to disseminate this information concisely to those administering the preparticipation screenings.We believe that the Italian screening system, which by national law requires examinations and also routinely employs the ECG, results in a significant reduction in sport-related cardiac deaths. Accordingly, there has been great interest in the Italian model from the greater European medical community. Recently, the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology presented a consensus document, in which the key role of the 12-lead ECG for identification of cardiac diseases leading to sudden death was emphasized. (12) This same study group is working on updated European guidelines to be published soon, although there may be problems for the different health organizations in the European countries.

Consultation with the Specialist: Cardiovascular Preparticipation Sports Screening

1. Anoop Singh, MD* 2. Michael Silberbach, MD† 1. *Fellow, Pediatric Cardiology, Department of Pediatrics, Oregon Health & Science University, Portland, Ore 2. †Editorial Board After reading this article, readers should be able to: 1. Describe the key cardiac elements of the preparticipation examination. 2. Identify red flags in a patient’s cardiac history and physical examination that warrant consultation with a cardiologist. 3. Characterize the cardiovascular findings of the well-trained athlete. 4. Recognize the common causes of sudden cardiac death on the playing field. 5. Discuss the absolute and relative contraindications to athletic participation. In the United States, the preparticipation examination (PPE) has become a standard for athletic clearance of high school students in nearly every state. This screening serves many purposes, but a primary goal is to restrict athletic participation of those who may be predisposed to dying on the playing field. The death of a high school athlete devastates the child’s family, significantly affects the local community, and often generates extensive media coverage. Fortunately, sudden death remains a rare phenomenon; best estimates predict an incidence of 1 per 200,000 high school athlete-years. In 75% of such cases, cardiovascular disease is the cause. Accordingly, medical professionals must have a keen sense for detecting silent cardiac disease in young athletes. The medical history is the most important part of the cardiovascular PPE. It is best to ask open-ended questions of the patient. A volunteered complaint warrants greater attention than a “yes/no” response. A checklist of questions that probes for potential cardiac disease is also helpful (see the form available in the online version of this article only). Family concerns or observations complement the picture of the adolescent’s health. Indeed, the American Heart Association recommends that a parent verify all elements of the history. The personal history focuses on symptoms such as chest pain, chest tightness, dyspnea, near-syncope, syncope, dizziness, exercise intolerance, and fatigue. The setting in which symptoms occur is very important. Symptoms in the context of athletic activity may …

Consultation with the Specialist: Cardiovascular Preparticipation Sports Screening

Consultation with the Specialist: Cardiovascular Preparticipation Sports Screening

Resource on Sports Preparticipation Exam Updated

Resource on Sports Preparticipation Exam Updated

Determinants for Clinical Diagnosis of Hypertrophic Cardiomyopathy

Although hypertrophic cardiomyopathy (HC) occurs in 1 of 500 adults, most cardiology practices treat relatively few patients with HC, suggesting that many affected patients evade clinical recognition. Determining the clinical circumstances under which HC is identified will provide clues to its under-recognition. Clinical triggers leading to diagnostic echocardiograms were analyzed in 711 consecutive patients with HC. In most (384 [54%]), HC was initially suspected only after the onset of cardiac symptoms or acute cardiac events. In a substantial minority (327 [46%]), HC was recognized while patients were asymptomatic, including 225 (32%) by routine medical evaluations, in 27 of whom (4%) HC was recognized during preparticipation examinations for competitive sports or other activities. Women, older patients (age > or =50 years), and those with outflow obstruction at rest (gradient > or =30 mm Hg) were more likely suspected to have HC by virtue of cardiac symptoms or events (p <0.0001). Conversely, patients with extreme hypertrophy (wall thickness > or =30 mm) and those at high risk for sudden death were more often asymptomatic and identified by routine or family screenings (p <0.0001 and p = 0.004, respectively). Patients who subsequently died of heart failure or experienced embolic stroke were more often identified by virtue of symptoms or acute events (p = 0.03). In conclusion, although most patients with HC were recognized clinically only after overt disease manifestations, a substantial minority were diagnosed by routine examinations while asymptomatic, including an important subset of patients with HC recognized solely because of findings on sports preparticipation screening. These data underscore the need for heightened awareness and clinical suspicion of HC to increase the number of diagnosed patients, including many who may be at high risk for sudden death.

Helping Depressed Adolescents

Depression among adolescents has received recognition as a significant psychiatric problem that requires prompt intervention. This article will help primary care providers to understand the significance of adolescent depression, recognize its prevalence in primary care, cite the evidence supporting cognitive-behavioral therapy (CBT) as a treatment for depressed adolescents, recognize the challenges of using CBT in primary care, and use 7 different CBT approaches with their patients. Psychiatric diagnoses may be present in 38% of adolescents who see a primary care physician, and among that number, depression is the most common diagnosis. Cognitive-behavioral therapy provides a scientifically proven tool for those physicians who want to provide their young depressed patients an effective counseling approach. Cognitive-behavioral therapy enhances self-control, perceptions of personal efficacy, rational problem-solving skills, social skills, and participation in activities and physical exercise that bring the adolescent a sense of pleasure or mastery. CBT has been proven to be effective when delivered by physicians who have received significant instructions. Unfortunately, CBT techniques can at first seem overly abstract, overwhelming in number, and difficult to teach in the 15-minute visit. However, CBT techniques can be made clear and accessible for a busy physician. The case of a depressed 14-year-old male high school student who comes to his physician for a pre-participation sports physical is presented to illustrate the application of CBT in primary care.

Sun-protective Behavior Among High-School and Collegiate Athletes in Los Angeles, CA

To evaluate the use, knowledge, and perceptions of sun-protective behavior (SPB), among young athletes in Southern California. Cross-sectional survey, assessing various measures of SPB, sun exposure, attitudes, and knowledge. A total of 1006 students from 2 public high schools and 1 public university in the Los Angeles area volunteered. Athlete volunteers were recruited during sports preparticipation examinations. Nonathlete controls were recruited from physical education classes (high school) and from an introductory lecture class (university). Use of SPB during sports and nonsports activities, sun exposure, sun-protection knowledge, and attitudes. Results from athletes were compared with those from controls at each site. Overall rates of SPB were low. During nonsports activities, university athletes had higher rates of sunscreen (37.7% vs. 32.3%, P = 0.03) and hat use (34.7% vs. 17%, P < 0.001) than did controls. However, university athletes had lower rates of use of long shirts (27.9% vs. 39.8%, P < 0.001), long pants (38.8% vs. 63%, P < 0.002), and had higher total sun exposure (16.1 vs. 10.1 h/wk, P < 0.001). Similar results were seen among the high-school subjects. Despite having good knowledge of the potential dangers of ultraviolet radiation exposure, approximately 1 in 5 subjects overall had experienced a blistering sunburn within the past year. Young athletes in the Los Angeles area reported low rates of SPB, high levels of ultraviolet radiation exposure, and high rates of sunburns, despite knowing the risks of sun exposure. Specific educational and behavioral interventions should be directed toward improving SPB in this high-risk group.

Abnormal Blood Pressures in Adolescents on the Preparticipation Sports Examination: What Is the Prevalence and How Often Is It Missed?

Abnormal Blood Pressures in Adolescents on the Preparticipation Sports Examination: What Is the Prevalence and How Often Is It Missed?

Screening for sexually transmitted diseases during preparticipation sports examination of high school adolescents

In an urban school district, 636 students in grades 9–12 were tested for Chlamydia trachomatis and Neisseria gonorrhoeae by ligase chain reaction assays using specimens collected for routine urinalyses during sports physical examinations. Chlamydia and gonorrhea prevalences were 2.8% and 0.7% among males, and 6.5% and 2.0% among females, respectively. Among athletes infected with either sexually transmitted disease (STD), 93.1% reported no symptoms, and treatment was documented for 75.9%. Sports physicals offered a unique opportunity to screen and treat adolescents for STDs and to provide STD-prevention counseling.