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

Prevention of Sudden Death in Sports: A Global and Multidisciplinary Observatory for Scientific Research and Knowledge Transfer (PREMUBID)

Background

The health benefits of sports and exercise training are well known. However, an acute bout of exercise transiently increases the risk of sudden cardiac death (SCD). To minimize the cardiovascular risks of exercise, more insight into the prevention and causes of SCD is needed.

Methods

The observatory for the prevention of sudden death in sports, PREMUBID, was created with the aim of fostering research to assess the benefits and risks of exercise at different volumes and intensities and to get insight into the underlying mechanisms of potentially cardiac (mal) adaptations.

Results

The observatory gathers researchers from a wide range of disciplines working at institutions in Europe and North America. The guiding principles of PREMUBID are to broaden the understanding of SCD in sports, strengthening collaborative research across the globe, and to develop, implement and evaluate robust pre-participation screening and emergency care strategies to further reduce the number of fatal cardiac events in sport events. During the inaugural meeting of the observatory, members and affiliated researchers discussed possibilities to initiate collaborative research projects and to exchange staff and students to share information and practices to prevent SCD. The final goal is to translate the obtained knowledge to understandable messages for the general population and healthcare workers to ensure that the population at large benefits from it.

Conclusions

The PREMUBID consortium aims to produce novel knowledge and insights in SCD prevention, in order to maximize the health benefits associated with acute and long-term exercise training.

Limited diagnostic value of questionnaire-based pre-participation screening algorithms: a "risk-exposed" approach to sports activity

BACKGROUND

Several pre-participation screening algorithms (PPSAs) have been proposed to assess sports eligibility in different populations. They are usually based on self-administered questionnaires, without further medical assessment if no risk factors are documented. The Med-Ex "Formula Benessere" worksite program includes a complete cardiovascular (CV) screening for all participants. The purpose of this study was to assess PPSAs accuracy in detecting medical and/or CV abnormalities in the general population, comparing the results with the date derived from Med-Ex program.

METHODS

The Med-Ex medical evaluation, consisting of medical history, physical examination (including body composition), resting electrocardiogram (ECG) and exercise stress test in 464 male subjects (38.4 aged) was analyzed and matched to several PPSAs - Physical Activity Readiness Questionnaire (PAR-Q) (2002-2020), American Heart Association (AHA)/American College of Sport Medicine (ACSM) (1998-2009-2014-2015), European Association of Cardiovascular Prevention and Rehabilitation (EACPR) (2011) - retrospectively simulated.

RESULTS

Five-hundred and 67 abnormalities were detected though Med-Ex medical evaluation, and one-fourth (24%) would have been undetected applying PPSA alone. In particular 28% of high blood pressure, 21% of impaired fasting glycaemia, 21% of high Body Mass Index (BMI) values and 19% of ECG abnormalities would have been missed, on average, by all PPSAs.

CONCLUSIONS

The simulation analysis model performed in this study allowed to highlight the limits of PPSAs in granting sport eligibility, compared to a medical-guided CV screening. These findings emphasize the importance of a more balanced approach to pre-participation screening that includes a thorough evaluation of the cost/benefit ratio.

Sudden cardiac death in sports: could we save Pheidippides?

Hereditary diseases under the age of 35 are the most common underlying heart disease, leading to sudden cardiac death (SCD) in competitive sports, while in older people, atherosclerotic coronary artery disease (CAD) is the main cause. The following preventive measures are recommended: (a) The pre-participation cardiovascular screening, (b) the genetic testing, (c) the use of implantable cardioverter-defibrillator (ICD), (d) the prohibition of doping in sports, (e) the prevention of 'exercise-induced' cardiac complications, (f) the reduction of high-risk factors for CAD, and (g) the use of cardiopulmonary resuscitation. The cost-effectiveness of the electrocardiograms in the pre-participation screening programs remains questionable. Genetic testing is recommended in borderline cases and positive family history. Athletes with ICD can, under certain conditions, participate in competitive sports. Excessive endurance exercise appears to harm the endothelium, promotes inflammatory processes and leads to fibrosis in the myocardium, and calcium deposition in the coronary vessels. Cardiac arrest may be reversed if cardiopulmonary resuscitation is performed and a defibrillator is immediately used. Thus, equipping all fields with automatic external defibrillators are recommended.

Pre-Participation Screening of Athletes: Primary Health Care Physicians' Knowledge, Experience, and Approach in Turkey

Pre-participation screening (PPS) is crucial for assessing the competitive athletes since their risk of sudden death is higher than non-athletes. In Turkey, PPS is performed at the primary health care setting by primary care physicians (PCPs) who are family medicine specialists (FMSs) or general practitioners (GPs). Although there are national guidelines, there is no legal regulation for this process. This study aims to evaluate PCPs' knowledge, experience, and approach about PPS. We prepared an online survey for PCPs and used non-probabilistic sampling. PPS attitudes and practices were analyzed and compared according to factors such as experience, education, and being GP or FMS. Of the 214 PCPs included in the study, 39.3% were female. The mean age was 44.9 years (SD:8.88). The average work experience was 7.9 years. Most participants were aware of their authorization to perform PPS (89.7%) and had previously prepared it (90.2%). However, 6.5% of them felt confident in performing PPS. Only 13.1% were aware of the guidelines. Almost 25% of the participants stated being informed about the subject at some part of their career, but this did not affect the confidence or referral decisions. In addition to medical history and physical examination, further testing was considered necessary by 96.3% of the participants. Significantly more tests were ordered by GPs than FMSs (p=0.026 and p=0.011, respectively). The accurate referral decision ratio was 59.3%, without difference between FMSs and GPs (p=0.216). We found that awareness of the guidelines was low among PCPs who lack confidence in PPS. These factors collectively increased the tendency for unnecessary further testing and referral. Therefore, the PPS implementation into medical school and residency curriculums and national legal regulation for the process is a necessity in Turkey.

Professional footballers have a limited understanding of the precompetition medical assessment and the possible outcomes including disqualification: a cross-sectional survey

Objectives

To determine professional footballers’ level of understanding of the purpose of the precompetition medical assessment (PCMA) and to evaluate their knowledge of potential outcomes following a PCMA, including disqualification.

Methods

Professional footballers from the Australasian A-League and Westfield W-League were asked to complete a 25-question survey. The relationship between dichotomised outcomes and explanatory variables was analysed with multivariate logistic regression; p<0.05 was considered statistically significant.

Results

A total of 212 players participated (response rate=48.8%). Most respondents selected ‘To detect medical conditions that may affect performance’ and ‘To detect current injuries’ (n=137, 64.6%; n=130, 61.3%) as the purpose of a PCMA. Approximately one-third (n=74, 38.1%) were neutral or believed that a normal PCMA prevented cardiac arrest. Receiving more PCMAs (p<0.0003) and receiving an explanation during their PCMA (p=0.0175) led to greater awareness of the assessment’s limitations. Most participants did not know the definitions of syncope (n=181, 93.3%) or Marfan syndrome (n=183, 94.3%). Fifty players (28.1%) did not know that disqualification was a possible outcome of a PCMA, and younger players were less aware of this possible outcome (p=0.0216).

Conclusion

Professional footballers appear to have a limited understanding of the purpose of a PCMA, emphasising the musculoskeletal system and performance. They also appear unfamiliar with the components of the PCMA and medical terms. Finally, many are unaware that disqualification can result from an abnormal PCMA. Player health knowledge must be improved; the informed consent process appears an ideal time to provide this education.

Impact of exercise addiction on attitude to preparticipation evaluation and adherence to medical prescription

AIMS

Identification of silent cardiovascular diseases by preparticipation evaluation (PPE) and disqualification from competitive sports have the potential to prevent sudden death but may induce adverse psychological consequences, particularly for exercise addicted athletes. We investigated the relationship between exercise addiction, attitude towards PPE and reaction to cardiovascular disease diagnosis.

METHODS

We invited Italian competitive athletes to participate in an online questionnaire investigating exercise addiction, opinion about mandatory PPE and potential reaction to both sports disqualification and hypothetical diagnosis of different cardiovascular diseases.

RESULTS

The survey was completed by 1011 athletes (75% men, median age 30 years) encompassing a wide range of sports disciplines and competition levels. According to the 'Exercise Dependence Scale-21', 6% were classified as exercise addicted. The vast majority of both exercise addicted and nonexercise addicted athletes agreed that PPE should be mandatory (92 and 96%, P = 0.17) and that the eligibility decision should be left to the sports medicine physician (82 and 89%, P = 0.08). In case a cardiovascular disease is identified, a higher proportion of exercise addicted athletes would undergo 'open-heart' surgery if this would allow resuming high-intensity sport (54 versus 31%, P < 0.001) and would continue exercising in case of diagnosis of a disease at risk of sudden death (57 versus 32%, P < 0.001).

CONCLUSION

Exercise addiction does not interfere with a general positive opinion about PPE, but is likely to impact on the adherence to medical prescription should a cardiovascular diagnosis be made. Exercise addiction should be taken into account when counselling athletes with newly diagnosed heart diseases.

Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks Into Perspective-An Update: A Scientific Statement From the American Heart Association

Epidemiological and biological plausibility studies support a cause-and-effect relationship between increased levels of physical activity or cardiorespiratory fitness and reduced coronary heart disease events. These data, plus the well-documented anti-aging effects of exercise, have likely contributed to the escalating numbers of adults who have embraced the notion that "more exercise is better." As a result, worldwide participation in endurance training, competitive long distance endurance events, and high-intensity interval training has increased markedly since the previous American Heart Association statement on exercise risk. On the other hand, vigorous physical activity, particularly when performed by unfit individuals, can acutely increase the risk of sudden cardiac death and acute myocardial infarction in susceptible people. Recent studies have also shown that large exercise volumes and vigorous intensities are both associated with potential cardiac maladaptations, including accelerated coronary artery calcification, exercise-induced cardiac biomarker release, myocardial fibrosis, and atrial fibrillation. The relationship between these maladaptive responses and physical activity often forms a U- or reverse J-shaped dose-response curve. This scientific statement discusses the cardiovascular and health implications for moderate to vigorous physical activity, as well as high-volume, high-intensity exercise regimens, based on current understanding of the associated risks and benefits. The goal is to provide healthcare professionals with updated information to advise patients on appropriate preparticipation screening and the benefits and risks of physical activity or physical exertion in varied environments and during competitive events.

[ECG in sportsmen: Distinguishing the normal from the pathological]

An ECG is recommended by the French Society of Cardiology in the screening of a competitive athlete. An intense and prolonged physical activity (>4 hours of intense sport/week) can lead to a physiological electric remodeling. In addition to physical activity (type, intensity, duration), the ECG should be interpreted according to the athlete's ethnicity and age. It is necessary to know the physiological modifications related to sport practice to avoid either false reassurances or the realization of unjustified additional examinations because of a wrong interpretation. The latest athlete ECG classification published in 2017 can be used to identify in which athlete additional tests are recommended (figure 1).

Prevention of Sudden Death Related to Sport: The Science of Basic Life Support-from Theory to Practice

The sudden cardiac arrest (CA) and death of athletes are dramatic and emotionally impacting events for health professionals, family, and society. Although the practice of sport participation improves general health, physical fitness, and quality of life, intense physical exercise can be a trigger for CA and sudden death occasionally in the presence of known or unknown cardiac disorders (mainly hypertrophic cardiomyopathy) and risk factors (environment, health style, family, and genetic). The present review found that sudden death associated with CA was not such a common event in competitive athletes, but it might be an underestimated event in recreational athletes. Thus, considering the exponential increase in sport participation, both in a recreational or competitive way, and the rate of sudden CA, knowledge of implementing prevention and treatment strategies is crucial. This includes preparation of health professionals and lay people in basic life support (BLS); screening and pre-participation assessment in sport programs and health education; and promotion for the recognition of CA and early completion of BLS and rapid access to automatic external defibrillator to improve the victim survival/prognosis. Thus, the purpose of this review is to provide for health professionals and lay people the most updated information, based on current guidelines, of how to proceed in an emergency situation associated with sudden CA of young adult athletes.