Preparticipation Evaluation Research Articles

Value of preparticipation cardiovascular evaluation of master athletes by self-reported symptoms and cardiovascular risk-score

Purpose The risk of sudden cardiac death (SCD) is increased during endurance competitive sports. Coronary artery disease (CAD) is the most common cause of SCD in master athletes ≥ 35 years old (MAs). To reduce the risk of SCD self-assessment of symptoms by questionnaire, and evaluation of cardiovascular risk-score, are recommended as pre-participation cardiovascular evaluation (PCVE). We aimed to examine whether PCVE predicts CVD in MAs with or without increased risk as measured by validated score instruments. Methods We performed a single-site observational cohort study of healthy MAs based on findings at PCVE. They were allocated in two different groups: those MAs with reported symptoms on the questionnaire and/or with elevated cardiovascular risk score were allocated to a symptom group (SG), while MAs with no symptoms, nor raised risk score were defined as control group (CG). Thereafter, all were examined with extended examinations: resting-ECG, cardiorespiratory exercise testing and echocardiography. Results Total, 81 (18 women) MAs participated in the study. There were no differences at baseline between SG (n = 39) and CG (n = 42); sex (p = 0.11), age (55.0 ± 9.8 vs. 51.9 ± 11.1 years; p = 0.18), maximal oxygen uptake (49.8 ± 7.6 vs. 51.6 ± 7.0 ml/kg/min; p = 0.26), resting heart rate (61.4 ± 12.8 vs. 60.2 ± 11.0/min; p = 0.66), training hours/week (7.0 ± 3.2 vs. 7.1 ± 3.1; p = 0.88). After further examination, sixteen (20%) MAs were found with CVD: 12 in SG, 4 in CG (p = 0.024). The negative predictive value and specificity of the PCVE were 90% and 58%, respectively. Conclusion Negative findings on PCVE by questionnaire and cardiovascular risk-score may be a strategy to exclude subjects from preparticipation screening, thus saving resources.

Cardiac Adaptation in Power Athletes: Differential Impact of Judo and Weightlifting.

Background: According to the ESC guidelines, sport disciplines are classified in relation to the predominant component (skill, power, mixed and endurance), including a wide range of disciplines with different isometric/isotonic exercises and exercise-induced heart remodeling. The aim of our study was to evaluate differences in morpho-functional cardiac adaptations in power athletes, comparing judokas with weightlifters. Methods: We enrolled 55 Olympic athletes (38 judokas, 17 weightlifters), aged 24.5 ± 3.8 years, 25 (45.4%) of whom were males, and they underwent a pre-participation evaluation, including a physical examination, ECG, transthoracic echocardiogram, and exercise stress test. Results: The judokas presented significant differences in cardiac adaptations, with larger left ventricle (LV) end-diastolic and end-systolic volumes indexed (LVEDVi, p = 0.002 and LVESVi, p = 0.004) and higher LVMass values indexed (p = 0.033), but similar LV wall thicknesses (p = 0.093) and LV ejection fractions (p = 0.981). Also, the left atrium (LA) dimension (p = 0.0002) and volume indexed (p < 0.0001) were higher in the judokas, as were the larger right ventricle (RV) areas. Finally, the judokas showed higher VO2max (p = 0.012), O2 pulse (p = 0.007), VE/O2 LT1 (p = 0.041) and VE/O2 LT2 (p = 0.036) values, with a lower resting heart rate (p = 0.031) and higher exercise capacity (p = 0.011). Conclusions: The judokas showed substantial differences in cardiac morpho-functional adaptations from the weightlifters, and, accordingly, judo should be more properly considered not a pure strength sport but more similar to mixed disciplines of the ESC classification.

Recommendations for competitive sports eligibility: what's new in the 2023 COCIS protocols

The benefit of physical exercise is well established, but, at the same time, it is now well known that an intense sports activity can trigger adverse cardiac events and increase sport-related death. Since 1982, Italy has a State law which obliges athletes to undergo a pre-participation evaluation, based on history, physical examination, ECG and stress test. From its introduction, a significant reduction in cardiac sport-related adverse events has been shown. During the pre-participation screening, some cardiological issues or suspects can arise and the sports medicine doctor should deal with them before releasing the certification for participation in competitive sport. In order to give precious advices to these colleagues and help athletes to securely practice sport, the Italian Society of Sports Cardiology, the Italian Federation of Sports Medicine and the other cardiological scientific societies gathered in the COCIS Committee, periodically produce and publish a booklet named "Cardiological Protocols for Competitive Sports Eligibility". The object of this review is to underline the recent 2023 version innovations when compared to previous editions.

Coronary atherosclerotic burden in veteran athletes: The relationship between cardiovascular risk and volume of exercise

Introduction and objectivesThe association between exercise and coronary atherosclerosis still remains unclarified. We aimed to analyze the prevalence of high coronary atherosclerotic burden in veteran athletes, considering cardiovascular (CV) risk and volume of exercise. MethodsA total of 105 asymptomatic male veteran athletes (48±5.6 years old) were studied. A high coronary atherosclerotic burden was defined as one of the following characteristics in coronary computed tomography angiography: calcium score >100, >75th percentile, obstructive plaques, involving left main, three-vessels or two-vessels including proximal anterior descending artery, segment involvement score >5 or CT-adapted Leaman score ≥5. CV risk was stratified by SCORE2 and volume of exercise by metabolic equivalent task score. ResultsMost athletes (n=88) were engaged in endurance sports for 17.1±9.8 years, with a median exercise volume of 66 [IQR 44–103] metabolic equivalent of tasks/hour/week. The mean Systematic Coronary Risk Evaluation 2 was 2.8±1.5%; 76.9% of athletes had a low-moderate risk and none a very high risk. High coronary atherosclerotic burden was present in 25.7% athletes. Athletes with high cardiovascular risk and high exercise volume (above the median) showed significantly high coronary atherosclerotic burden compared to those with low-moderate risk and high volume (50.0% vs. 15.6%; p=0.017). Among athletes with low to moderate risk, a high volume of exercise tended to be protective, while in those with low volume, there was similar rate of high coronary atherosclerotic burden, regardless of CV risk. ConclusionsA combination of higher volume of exercise and high cardiovascular risk revealed the worst association with coronary atherosclerosis in veteran athletes. The relationship between these variables is controversial, but integrating exercise characteristics and risk assessment into preparticipation evaluation is essential.

Correlation between handgrip strength and lower extremity strength amongst Malaysian professional football players

ABSTRACT Background: We investigated the pattern of handgrip strength (HGS) and lower extremity strength in professional football players and how they were correlated. Methods: Secondary data were gathered during pre-participation evaluation sessions from a sample of 87 Selangor state-based Malaysian professional football players. The statistical analysis of the pattern of lower limb strength and HGS was based on the player’s position on the field. The correlation between HGS and lower extremity strength was looked at using Pearson’s correlation coefficient. The factors that affect HGS were analysed using a multivariate regression model. Results: In both dominant (P = 0.026) and non-dominant hands (P = 0.016), goalkeepers had significantly higher HGS than strikers. Dominant HGS had a moderate correlation with knee extensor strength (r = 0.38, P &lt; 0.05). The moderate correlation between HGS and knee extensor strength remains consistent despite being controlled for weight (r = 0.33, P &lt;0.05) and skeletal muscle mass (SMM) (r = 0.31, P &lt; 0.05). Significant correlations were observed despite the lower correlation value between dominant HGS and hip flexor strength (r = 0.31, P &lt; 0.05), hip extensor strength (r = 0.30, P &lt; 0.05) and knee flexor strength (r = 0.29, P &lt; 0.05). Dominant knee extensor strength and SMM were identified as statistically significant predictors for dominant HGS (F [2,84] = 11.60, P &lt; 0.01) with R2 = 0.22. Conclusions: The unique anthropometric traits of professional footballers, especially goalkeepers, improve HGS. Handgrip and knee extensor strength were moderately correlated, supporting previous study findings on the existence of a non-local effect between upper limb and lower limb strength.

Utility of the Counseling Center Assessment of Psychological Symptoms Screen in a Collegiate Athlete Population.

Mental health screening as a part of collegiate athletic preparticipation evaluations is becoming increasingly common, but effective and efficient screening depends on a screening tool that can accurately identify mental health symptoms and the need for mental health intervention. Case-control study. Archival clinical records review. Two cohorts of incoming National Collegiate Athletics Association Division I collegiate athletes (N = 353). Athletes completed the Counseling Center Assessment of Psychological Symptoms (CCAPS) Screen as a part of their preparticipation evaluation. These data were then matched with basic demographic data and mental health treatment history from clinical records, and the utility of the CCAPS Screen in determining a future or ongoing need for mental health services was analyzed. Score differences for each of the 8 CCAPS Screen scales (Depression, Generalized Anxiety, Social Anxiety, Academic Distress, Eating Concerns, Frustration, Family Distress, and Alcohol Use) were found based on several demographic variables. Logistic regression analysis demonstrated that female sex, team sport participation, and the Generalized Anxiety scale score predicted future participation in mental health treatment. Decision tree testing of the CCAPS scales showed low utility in classifying those who received mental health treatment versus those who did not. The CCAPS Screen did not appear to differentiate well between those who eventually received mental health services and those who did not. This should not be taken to mean that mental health screening is not useful but rather that a 1-time, state-based screening is not sufficient for athletes who experience intermittent but recurring stressors in a dynamic environment. A proposed model for improving the current standard of practice for mental health screening is provided as a focus of future research.

English

English

The cardiac preparticipation sports evaluation.

Sudden cardiac death (SCD) is the leading cause of death in young athletes during sports participation. Preparticipation cardiovascular screening aims to identify those at an increased risk of SCD. This review aims to provide a background of SCD in young athletes, to discuss the various screening recommendations of major medical societies, and to review recent evidence and current practice. Numerous studies have evaluated various preparticipation screening practices, particularly regarding the inclusion of ECG as part of an initial evaluation to identify conditions with an increased risk of SCD. Some analyses have shown ECG inclusion to provide increased screening sensitivity and specificity, though others have shown no benefit when compared with evaluation with history and physical examination alone. Furthermore, in countries for which more extensive screening protocols have been employed, postimplementation statistics have not shown a significant decrease in SCD. SCD in young athletes primarily results from underlying cardiac disease. Various preparticipation screening recommendations exist globally, with the common goal of decreasing the rates of SCD by identifying youth at risk during sports participation. Current guidelines in the United States support universal preparticipation evaluation using history and physical examination, with cardiology referral if abnormalities are identified.

Sport activities for children and adolescents: the Position of the European Academy of Paediatrics and the European Confederation of Primary Care Paediatricians 2023-Part 1. Pre-participation physical evaluation in young athletes.

The European Academy of Paediatrics (EAP) and the European Confederation of Primary Care Paediatricians (ECPCP) emphasize the importance of promoting healthy lifestyles within the pediatric population. Many health professionals have questions concerning adequate levels of physical activity for both the healthy pediatric population and for those who may have specific complications. Unfortunately, the academic literature that provides recommendations for participation in sport activities within the pediatric population that have been published during the last decade in Europe is limited and is mainly dedicated to specific illnesses or advanced athletes and not toward the general population. The aim of part 1 of the EAP and ECPCP position statement is to assist healthcare professionals in implementing the best management strategies for a pre-participation evaluation (PPE) for participation in sports for individual children and adolescents. In the absence of a uniform protocol, it is necessary to respect physician autonomy for choosing and implementing the most appropriate and familiar PPE screening strategy and to discuss the decisions made with young athletes and their families. This first part of the Position Statement concerning Sport Activities for Children and Adolescents is dedicated to healthy young athletes.

Diagnostic yield in national team football players

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Malta Football Association. Introduction Sudden cardiac death (SCD) is an important cause of morbidity in competitive athletes. Pre-participation evaluation (PPE) is mandatory for most sporting organisations. The ECG plays a very important diagnostic role and is included in most screening algorithms. PPE for athletes ≥14 years registered with the National Football Association is now mandatory. Study objectives: The objective of this study was to assess the diagnostic yield of PPE in a group of elite Maltese football players competing at national level. Methodology Players selected at national level (years 2020-2022) underwent PPE (history, physical examination, and resting ECG). Senior team players also underwent echocardiography (biannually) as per regulations. Data was tabulated and analyzed in Microsoft Excel. Results 300 athletes (69% male) were selected in this timeframe. 10.6% (n=32) required referral for secondary evaluation, equating to 1 in 11 athletes screened. Referrals were more frequent in male vs female athletes (22.1% vs 10.2%, p=0.005). Most referrals were from the men’s senior’s squad (22.5%), followed by the men’s U17 squad (21.7%) and 20% of the men’s U15 team. The ECG was the commonest reason for referral to a sports cardiologist (n=23, 71.8%). The commonest abnormal ECG patterns included anterior TWI (n=9, 3.0%), inferior/lateral TWI (n=6, 2.0%) and WPW (n=2, 0.7%). 108 (36.0%) had echocardiography as a first line screening modality. This was abnormal in a fifth of those referred (n=7, 21.9%), 4 of these had a normal ECG. 3 (1.0%) athletes were diagnosed with a condition linked to SCD (n=2 WPW, n=1 HCM). Another 5 (1.7%) athletes were diagnosed with a cardiac disorder (n=1 left ventricular outflow tract ectopy, n=1 dilated aortic root, n=1 aortic regurgitation, n=1 atrial septal defect, n=1 mitral regurgitation). Echocardiography doubled the diagnostic yield (1.3% vs 2.7%), with 3 athletes having otherwise a normal history, physical examination and ECG. 1 in 38 athletes (2.7%) were given a cardiac diagnosis, 1 in 100 athletes (1.0%) were labelled with a condition linked to SCD. Conclusion The referral rate is comparable to that reported in international screening programs, higher in males. The ECG was the commonest reason for referral. The overall diagnostic yield equates to 2.7%, while 1.0% were given a diagnosis linked to SCD. The higher diagnostic yield in this population highlights the importance of raising awareness about heart disease and PPE in young athletes.

Differences in Ankle Dorsiflexion Deficit Performance between Male and Female Athletes with a History of Lateral Ankle Sprain: The Functional Pre-Participation Evaluation

The objective of this study was to determine the effects of deficit of ankle dorsiflexion in athletes who sustained a chronic lateral ankle sprain to the hopping performance. A comparative study was designed to compare the deficit and non-deficit condition of ankle dorsiflexion as a result of the weight bearing lunges test to distance hopping ability with single leg hop, which was normalized with leg length. There were no statistically significant differences in hopping performance, deficit vs non-deficit ankle dorsiflexion within-group comparisons in males (P = 0.932) or females (P = 0.999). Between group comparisons showed that ankle dorsiflexion deficit among female resulted lower hopping performance compared to male with / without ankle dorsiflexion deficit (P = 0.041 and P = 0.039). Surprisingly, hopping performance among male with ankle dorsiflexion deficit was further than female without ankle dorsiflexion deficit (P = 0.044). Meanwhile, hopping performance between male versus female without ankle dorsiflexion deficit were not significant (P = 0.054). The deficit of ankle dorsiflexion had no influence on hopping performance in athlete with a history of LAS, both male and female. Sex influenced hopping performance in athletes with ankle dorsiflexion deficits, with female athletes performing worse than male. During recovery, there might be differences in biomechanical adaptation between ankle dorsiflexion deficit conditions in female athletes compared to male. Keywords: Ankle-dorsiflexion deficit, Sex, Ankle sprain, Hopping distance, Adaptaion

A proposal for pre-participation evaluation and follow-up in the prescription of exercise and sports for resistance training

A proposal for pre-participation evaluation and follow-up in the prescription of exercise and sports for resistance training

The eSports Medicine: Pre-Participation Screening and Injuries Management-An Update.

Recently, electronic sports (eSports) became one of the growing forms of new media due to the wide diffusion of games and online technologies. Even if there is still a debate about the definition and characterization of eSports, eAthletes train heavily, compete in tournaments, must abide by competition, association, and governing body rules, just like all other athletes. Furthermore, as in any other competitive discipline, there can be injuries. Aberrant sitting posture, repetitive movements, screen vision, prolonged playing hours, and a sedentary lifestyle can lead to several medical hazards in musculoskeletal, ophthalmology, neurological, and metabolic systems. Moreover, several cardiovascular changes occur in eAthletes. This paper aims to explore the different injuries that can occur in a professional eAthlete, suggesting how every high-level gamer could benefit from a pre-participation evaluation and a correct injury prevention strategy.

Italian return to play protocol after COVID-19 in young competitive and professional athletes: diagnostic yield and cost-benefit analysis.

Return to play (RTP) protocols have been proposed to early detect cardiovascular involvement due to COVID-19 and reduce the risk of sports-related sudden cardiac death. However, uncertainties remain about the true prevalence of COVID-19 myopericarditis, the arrhythmic risk and the cost of this protocol. We collected data from 217 competitive and professional athletes of both genders who underwent RTP protocol (clinical history, resting and exercise ECG, and echocardiography). Holter monitoring and/or cardiac magnetic resonance (CMR) were performed in case of abnormalities. In 107 athletes, the RTP data were compared with those of preparticipation evaluation (PPE) performed prior to COVID-19 infection. Out of 217 consecutive athletes evaluated with the RTP protocol, 7 underwent CMR: among these we found alterations compatible with myopericarditis in 3 (1.4%), with a cost per person of € 223.93 and a cost per diagnosis of € 16,197.53. Of the 107 athletes previously evaluated with PPE, 4 underwent RMC: we made a final diagnosis of myocarditis in 1 athlete (0.9%), whereas another athlete (0.9%) showed moderate pericardial effusion. The clinical presentation of both these athletes was characterized by the presence of ventricular arrhythmias newly detected during RTP. Compared to PPE, during RTP higher values were observed for shortness of breath, weight, heart rate and corrected QT interval, whereas lower values for sinus bradycardia and the E/A ratio of mitral flow. The prevalence of myopericarditis was similar to that reported in previous cross-sectional and case-control studies. The availability of data recorded before COVID-19 was important in the evaluation of athletes with arrhythmias. The RTP protocol has proven to be less cost effective than normal PPE.

Early repolarization in adolescent athletes: A gender comparison of ECG and echocardiographic characteristics.

The early repolarization pattern (ERp) is an electrocardiographic finding previously associated with arrhythmic risk in adults. The purpose of this study is to evaluate the prevalence and characteristics of ERp in a group of adolescent athletes according to gender. Furthermore, potential associations with clinical, electrocardiographic, and echocardiographic parameters are explored. In this cross-sectional study young athletes (age < 18 years) were consecutively enrolled during the annual pre-participation evaluation, undergoing also transthoracic echocardiography assessment from January 2015 to March 2020. The prevalence of ERp was 27% in the whole population. Athletes with ERp were more frequently men practicing endurance sports. Women with ERp showed lower heart rate at rest, greater posterior, and relative ventricular wall thickness than those without ERp. Men with ERp presented higher systolic blood pressure at peak exercise, greater septal wall thickness, and indexed left ventricular mass than those without ERp. Both genders with ERp showed increased QRS voltage and narrower QRS duration. The ERp phenotype in men was more frequently notched with higher amplitude and ascending ST segment. Women's ERp presented more frequently a slurred morphology, especially in the inferior leads, and horizontal ST slope. No differences emerged in the occurrence of arrhythmias at rest and during maximal exercise test between groups, even considering higher risk phenotypes. ERp is an ECG finding compatible with normal cardiac adaptations to training in young athletes. ERp demonstrated gender differences regarding phenotypes previously associated with increased cardiovascular risk, not showing any differences in arrhythmias during maximal exercise test.

A Morte Súbita Cardíaca em Atletas e a Avaliação Médico-Desportiva Cardiovascular em Portugal

Introduction: Sudden cardiac death in athletes is an event that everyone wants to prevent, and it is necessary to know what principal causes are and the best way to diagnose them. Methods: Research on Pubmed using articles published between 2011 and 2021 and the creation of a questionnaire answered by Portuguese clubs. Results: The data acquired was accordant to the recommendations in Portugal. The echocardiogram is not regularly used. Conclusion: The use of the echocardiogram in athletes should be studied. There should also be a note on the necessity of better supervision of federated athletes to make sure they carry-out the pre-participation evaluation required by law.

Systematic Cardiovascular Screening in Olympic Athletes before and after SARS-CoV-2 Infection.

Conflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in athletes. The aim of this study was to evaluate the prevalence of cardiac involvement after COVID-19 in Olympic athletes, who had previously been screened in our pre-participation program. Since November 2020, all consecutive Olympic athletes presented to our Institute after COVID-19 prior to RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-h ECG monitoring, and spirometry. Cardiovascular Magnetic Resonance (CMR) was also performed. All Athletes were previously screened in our Institute as part of their periodical pre-participation evaluation. Forty-seven Italian Olympic athletes were enrolled: 83% asymptomatic, 13% mildly asymptomatic, and 4% had pneumonia. Uncommon premature ventricular contractions (PVCs) were found in 13% athletes; however, only 6% (n = 3) were newly detected. All newly diagnosed uncommon PVCs were detected by CPET. One of these three athletes had evidence for acute myocarditis by CMR, along with Troponin raise; another had pericardial effusion. No one of the remaining athletes had abnormalities detected by CMR. Cardiac abnormalities in Olympic athletes screened after COVID-19 resolution were detected in a minority, and were associated with new ventricular arrhythmias. Only one had evidence for acute myocarditis (in the presence of symptoms and elevated biomarkers). Our data support the efficacy of the clinical assessment including exercise-ECG to raise suspicion for cardiovascular abnormalities after COVID-19. Instead, the routine use of CMR as a screening tool appears unjustified.

Cardiovascular screening in olympic athletes before and after SARS-CoV-2 infection

Funding AcknowledgementsType of funding sources: None.BackgroundConflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in the athletic population. However, these data are mainly based on Troponin and imaging findings.PurposeAim of the study was to evaluate the prevalence of cardiac involvement after COVID-19 in Olympic athletes, who had previously been screened in our pre-participation program.MethodsSince November 2020, all consecutive Olympic athletes presented to our Institute after COVID-19 prior RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-hours ECG monitoring, spirometry. Cardiovascular Magnetic Resonance (CMR) was also performed. All Athletes were previously screened in our Institute as part of their periodical pre-participation evaluation.ResultsForty-seven Italian Olympic athletes were enrolled: 83% asymptomatic, 13% mildly asymptomatic, 4% had pneumonia. The evaluation was performed after a median of 9 days from negative SARS-CoV-2 swab. Uncommon premature ventricular contractions (PVCs) were found in 13% athletes, however, only 6% (n=3) were newly detected. All newly diagnosed uncommon PVCs were detected by CPET. One of these three athletes had evidence for acute myocarditis by CMR, along with Troponin raise; another had mild pericardial effusion. No one of the remaining athletes had abnormalities detected by CMR (Figure).ConclusionsCardiac abnormalities in Olympic athletes screened after COVID-19 resolution were detected in a minority and were associated with new ventricular arrhythmias. Only one had evidence for acute myocarditis (in presence of symptoms and elevated biomarkers). No one of the remaining athletes had abnormalities by imaging or laboratory test. Our data support the efficacy of the clinical assessment including exercise-ECG to raise suspicion for cardiovascular abnormalities after COVID-19. Instead, the routine use of CMR as a screening tool appears not justified.

Acceptability and Practicality of a Quick Musculoskeletal Examination into Sports Medicine Pre-Participation Evaluation.

Background: Child musculoskeletal (MSK) diseases are common and, even if often benign, sometimes can lead to significant impairment in the future health of children. Italian pre-participation evaluation (PPE), performed by a sports medicine physician, allows for the screening of a wide range of children every year. Therefore, this study aims to evaluate the feasibility and the acceptability of pGALS (pediatric Gait, Arms, Legs and Spine) screening, a simple pediatric MSK screening examination, when performed as part of a routine PPE. Methods: Consecutive school-aged children attending a sports medicine screening program were assessed with the addition of pGALS to the routine clinical examination. Practicability (time taken) and patient acceptability (discomfort caused) were recorded. Results: 654 children (326 male, mean age 8.9 years) were evaluated through pGALS. The average time taken was 4.26 min (range 1.9–7.3 min). Acceptability of pGALS was deemed high: time taken was “adequate” (97% of parents) and caused little or no discomfort (94% of children). Abnormal MSK findings were common. Conclusions: pGALS is a practical and acceptable tool to perform in sports medicine PPE, even if performed by a non-expert in MSK medicine. Although common, abnormal MSK findings need to be interpreted in the global clinical context and assessment.

Paediatric and adolescent athletes in Switzerland: age-adapted proposals for pre-participation cardiovascular evaluation.

High-level sports competition is popular among Swiss youth. Even though preparticipation evaluation for competitive athletes is widespread, screening strategies for diseases responsible for sudden death during sport are highly variable. Hence, we sought to develop age-specific preparticipation cardiovascular evaluation (PPCE) proposals for Swiss paediatric and adolescent athletes (under 18 years of age). We recommend that all athletes practising in a squad with a training load of at least 6 hours per week should undergo PPCE based on medical history and physical examination from the age of 12 years on. Prior to 12 years, individual judgement of athletic performance is required. We suggest the inclusion of a standard 12-lead electrocardiogram (ECG) evaluation for all post-pubertal athletes (or older than 15 years) with analysis in accordance with the International Criteria for ECG Interpretation in Athletes. Echocardiography should not be a first-line screening tool but rather serve for the investigation of abnormalities detected by the above strategies. We recommend regular follow-up examinations, even for those having normal history, physical examination and ECG findings. Athletes with an abnormal history (including family history), physical examination and/or ECG should be further investigated and pathological findings discussed with a paediatric cardiologist. Importantly, the recommendations provided in this document are not intended for use among patients with congenital heart disease who require individualised care according to current guidelines.