Evolution in the process of screening United States high school student-athletes for cardiovascular disease

Preparticipation State Cardiac Screening Forms for Athletes

BACKGROUND AND OBJECTIVES

Annual preparticipation physical evaluation (PPE) is used in the United States to screen adolescents for potential causes of sudden cardiac death. The American Heart Association recommends 14 screening elements of history and physical examination. This study sought to define the utilization of these screening elements by each of the 50 states before high school athletics.

METHODS

PPE forms were obtained from the public website of the high school athletics governing body in every state. Form content was analyzed to identify which of the 14 screening elements were explicitly fulfilled. Additional PPE forms provided by private/parochial schools, other professional societies, or independent groups were excluded from this study.

RESULTS

A total of 48 states (96%) had PPE forms posted online. The remaining 2 states (4%) deferred the specific method of PPE documentation to individual school districts and provided no standardized form. Of the 48 states providing PPE forms, 13 (27%) included all 14 American Heart Association screening elements. The median criteria included by each state was 11 (range 3-14). The 3 criteria most commonly absent were (1) the examination of femoral pulses to exclude coarctation (58%), (2) a family history of specific inherited cardiac disease (31%), and (3) personal history of hypertension (27%).

CONCLUSIONS

Annual preparticipation forms are important screening tools. Only a minority of states include all 14 cardiac screening elements recommended by the American Heart Association.

The pre-participation screening in young athletes: which protocol do we need exactly?

The aim was to assess the utility and feasibility of a comprehensive cardiac screening protocol in young athletes before participation in sports. A total of 380 athletes referring before participation in sports, between April, 2014 and April, 2015, were included in this study. The mean age was 12.4 years. A screening protocol has been applied to all, including personal and family history, physical examination, 12-lead electrocardiography, transthoracic echocardiography, 24-hour rhythm Holter analysis, and treadmill exercise test. The most frequent complaints were chest pain in 19 (5%), dyspnoea in 13 (3.4%), and dizziness and fainting in five patients (1.3%) on exercise. There was sudden death and arrhythmia in 41 patients (10.7%) owing to family history. Heart murmur was present in 20 (5.2%) and hypertension in 10 patients (2.6%) on physical examination. The 12-lead electrocardiography was abnormal in 9 patients (2.4%). The findings of transthoracic echocardiography were insignificant in 47 patients (12.3%) and in five patients (1.3%) a haemodynamically important condition was detected. The 24-hour rhythm Holter analysis was abnormal in six patients (1.5%). There were significant ST changes in two patients (0.5%) on treadmill exercise test with normal findings on myocardial perfusion scans. No significant relation was present between findings of screening protocol and transthoracic echocardiography, 24-hour rhythm Holter analysis, or treadmill exercise test results. Pre-participation screening in young athletes should consist of a targeted personal history, family history, physical examination, and 12-lead electrocardiography. Other tests should be applied only if the screening indicates the presence of a cardiovascular disease.

Preparticipation Evaluation of the Young Athlete: What an Orthopaedic Surgeon Needs to Know

The preparticipation evaluation (PPE) is a widely used tool for detecting health conditions that may delay or disqualify athletic participation. The medical interview is the most valuable tool for identifying athletes who may be at increased risk for injury. Physical examination is tailored to identifying cardiac abnormalities or factors that may place an athlete at increased risk for injury. Although practiced in Europe, universal cardiac screening with electrocardiography is not currently recommended in the United States largely due to the high rate of false-positive results. Neuropsychological testing for management of concussion and laboratory testing for sickle cell trait may be indicated in select groups of athletes. Health care providers should view the PPE as a chance for anticipatory guidance and athlete-directed health counseling. Despite widespread acceptance of the PPE, the quality of such examinations varies significantly, which is an area for possible improvement and further research.

Pre-participation screening for athletes and the role of advanced practice providers

Pre-participation screening of athletes for underlying cardiovascular disease is recommended by the AHA/ACC. However, vigorous debate continues as to whether the ECG should be used as part of a broad-based screening program. The AHA/ACC "do not support national mandatory screening ECGs of athletes, because the logistics, manpower, financial and resource considerations make such a program inapplicable to US". In an effort to address these impediments and to increase access for communities, we explore the use of advanced practice providers (Nurse Practitioners and Physician Assistants) in providing pre-participation screening to athletes with ECG interpretation. In the current healthcare environment with limited primary care resources, advanced practice providers are an important new element in improving access to care. Pre-participation screening with ECG interpretation is currently within an advanced practice provider's scope of practice. Emerging data shows that advanced practice providers perform care that is within acceptable patient care standards, safely, and cost effectively, compared to physician counterparts. To further improve pre-participation screening, a national education and certification program on 12-lead ECG interpretation is needed. Standardized screening tools and mass screening protocols that include screening ECGs for targeted athlete populations who are at high risk for SCD are needed. These recommendations are aimed at addressing some of the barriers raised by the AHA/ACC group to pre-participation screening with ECG.

State-specific differences in school sports preparticipation physical evaluation policies

OBJECTIVE

This study evaluated the current preparticipation physical evaluation (PPE) administrative policies and cardiovascular screening content of all 50 states and Washington, DC.

METHODS

PPE policies, documents, and forms from all 50 states and Washington, DC, were compared with the preparticipation physical evaluation-fourth edition (PPE-4) consensus recommendations. All electronic documents were publicly available and obtained from state interscholastic athletic associations.

RESULTS

Fifty (98%) states required a PPE before participation. Most states (53%, n = 27) required a specific PPE form, whereas 24% (n = 12) of states recommended a specific form. Twenty-three states (45%) required or recommended use of the PPE-4 form or a modified version of it, and 27 states (53%) required or recommended use of outdated or unidentifiable forms. Ten states (20%) had not revised their PPE forms in >5 years. States permitted 9 different health care providers to administer PPEs. Only 22 states (43%) addressed all 12 of the PPE-4 personal and family history cardiovascular screening items, and 2 states (4%) addressed between 8 and 11 items. For the remaining 26 states, most (29%) addressed ≤3 screening items.

CONCLUSIONS

Our results show that inconsistencies in PPE policies exist nationwide. Most states have been slow to adopt PPE-4 recommendations and do not adequately address the personal and family cardiovascular history questions. Findings suggest a need for PPE standardization nationwide and adoption of an electronic PPE process. This approach would enable creation of a national database and benefit the public by facilitating a more evidenced PPE.

The preparticipation physical evaluation: an analysis of clinical practice

OBJECTIVE

To evaluate current preparticipation physical evaluation (PPE) clinical practice behaviors.

DESIGN

Telephone and Web-based survey study with attention to utilization of the Fourth Edition PPE Monograph.

SETTING

We contacted the Washington State American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP) chapters, all Washington State high school athletic directors (ADs), and every state high school athletic association.

INTERVENTIONS

Data collection and analysis regarding clinical practice.

MAIN OUTCOME MEASURES

Awareness and utilization of the Fourth Edition PPE Monograph.

RESULTS

The response rate was 72% (559/776) from the AAP, 56% (554/990) from the AAFP, 75% (317/424) from the ADs, and 100% (50/50) from the state athletic associations. Few physicians (37%) and ADs (6%) reported an awareness of the PPE Monograph. Knowledge of the Monograph did not vary by physician type, practice/school location, or experience (P > 0.05). Reported obstacles to the delivery of the PPE included time with patient (56%) and the lack of a standard form (52%). Physician awareness of the Monograph reduced the perception of obstacles (P < 0.01). Athletic directors reported financial limitations of the family as the primary obstacle (62%). Adoption of a single statewide PPE form was well supported (96% of physicians and 67% of ADs). Nationally, only 46% of state athletic associations mandate a single form, and only 16% use a form consistent with the Fourth Edition PPE Monograph.

CONCLUSIONS

The medical community is largely unaware of national screening guidelines. New directions for education and policy are necessary to improve this implementation gap.

Sudden cardiac death and preparticipation screening: the debate continues-in support of electrocardiogram-inclusive preparticipation screening

Sudden cardiac death (SCD) is the leading cause of death in young athletes during exercise, and there is international agreement among major medical and sporting bodies that young athletes should undergo preparticipation cardiovascular screening. However, there is currently no universally accepted screening protocol, and substantial debate exists about what constitutes the ideal approach to preparticipation screening. The primary objective of preparticipation screening is the detection of intrinsic structural or electrical cardiovascular disorders that predispose an athlete to SCD. Considerable evidence exists suggesting that screening athletes with only a history and physical examination leaves most athletes with a serious underlying cardiovascular disease undetected and, thus, cannot adequately achieve the primary objective of screening. Preparticipating cardiovascular screening inclusive of an electrocardiogram (ECG) greatly enhances the ability to identify athletes at risk and is the only model shown to be cost-effective and may reduce the rate of SCD. The major obstacle to ECG screening in the United States is the lack of a physician workforce skilled in interpretation of an athlete's ECG. However, recent studies have demonstrated a capacity to distinguish physiologic ECG alterations in athletes from findings suggestive of underlying pathology that is both feasible and has a low false-positive rate. Efforts are underway to increase physician education in ECG interpretation. After 2 decades debating the proper screening strategy to identify athletes at risk, the weight of scientific evidence suggests that a screening program inclusive of ECG is the only strategy that merits promotion.

The pre-sports cardiovascular evaluation: should it depend on the level of competition, the sport, or the state?

Sudden cardiac death (SCD) in an athlete is a rare but tragic event, and significant controversy exists regarding the most effective method to define those at highest risk. Recommendations of the American Heart Association require that a history and physical examination be used for preparticipation screening with an abnormal cardiac finding expected to prompt further evaluation. Given the lack of data documenting that electrocardiogram (ECG) screening in all competitive athletes is either feasible or appropriate, these same guidelines state that such screening is optional but not mandatory. The extremely low incidence of SCD events, in conjunction with the low sensitivity and specificity of ECG as a screening tool in athletes, contributes to this recommendation. Although these guidelines target all competitive athletes, however, there may be subgroups of athletes, based on age, level of competition, individual sport, or state of residence, for which mandatory ECG screening may be both appropriate and sensible. Given the lack of resolution of the ongoing ECG debate, it is perhaps reasonable to consider screening specific high-risk subgroups of athletes rather than continuing to dispute whether to screen all competitive athletes or none at all. Recent data suggest that such a program may be feasible and may provide a rationale basis for subsequent expansion of cardiovascular screening programs.

Is there evidence for recommending electrocardiogram as part of the pre-participation examination?

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

Expert opinion and controversies in musculoskeletal and sports medicine: preventing sudden cardiac death in young athletes

Sudden cardiac death in young athletes has become a highly visible public health concern. Over the past 2 decades, unexplained or premature deaths of numerous athletes at the youth, collegiate, and professional levels have garnered extensive media coverage and stimulated a discussion centered on prevention of such tragic events. A number of issues related to the prevention and management of sudden cardiac arrest on the playing field are currently debated in the medical literature, including the true incidence of sudden death in the young athletic population, the adequacy of the preparticipation physical evaluation, and the emergency response and effectiveness of secondary prevention strategies such as use of automated external defibrillators in the athletic setting. Clinicians who care for competitive athletes and/or cover youth sporting events must be aware of the benefits and limitations of different preparticipation screening programs to identify at-risk athletes, and they must be prepared to respond to life-threatening emergencies during athletic participation.

Electrocardiogram testing during athletic preparticipation physical examinations

CONTEXT

Sudden cardiac death (SCD) is a relatively rare yet unfortunate risk of athletic participation. To reduce the incidence of SCD, electrocardiogram (ECG) use during athletic preparticipation examinations (PPEs) has been proposed to detect underlying cardiac abnormalities.

OBJECTIVE

To estimate the effectiveness of ECG use during athletic PPEs.

DESIGN

Epidemiologic modeling.

POPULATIONS

Public high school athletes.

DATA COLLECTION AND ANALYSIS

Estimates of ECG sensitivity (70%) and specificity (84%) were drawn from the literature, as was the estimate of overall prevalence of cardiac conditions relevant to SCD (0.3%). Participation rate by sex was determined from National Federation of State High School Associations data. Participation by ethnicity was assumed to be proportionate to the public high school attendance rates for grades 9 through 12 (18.4% African American). Population-specific ECG effectiveness (positive predictive value), estimated total costs, cost per year of life saved, and cost to identify 1 additional case were computed. Total annual PPE screening costs reflected a cardiologist's office visit, including echocardiogram for those athletes with a positive ECG screen.

RESULTS

The model predicted that 16% of all athletes would be expected to have a positive ECG, but only 1.3% of athletes with a positive ECG would have a cardiac abnormality capable of causing SCD, including hypertrophic cardiomyopathy, structural defects, and various conduction abnormalities. Total annual cost estimates for ECG screening and follow-up exceeded $126 million. Average cost per year of life saved across groups was $2693, and the cost to identify 1 additional case averaged $100 827. Compared with females, males had both lower cost per year of life saved and lower cost to identify 1 true case. Similarly, black males exhibited lower costs than white males. Across groups, false-positive ECG screening exams accounted for 98.8% of follow-up costs.

CONCLUSIONS

Large-scale, mass ECG testing would be a costly method to identify athletes with cardiac abnormalities. Targeting high-risk populations can increase the effectiveness of the ECG for athletic PPE screening.

Athletes at Risk for Sudden Cardiac Death

High school athletes represent the largest group of individuals affected by sudden cardiac death, with an estimated incidence of once or twice per week. Structural cardiovascular abnormalities are the most frequent cause of sudden cardiac death. Athletes participating in basketball, football, track, soccer, baseball, and swimming were found to have the highest incidence of sudden cardiac death. Screening of athletes prior to participation in competitive sports usually falls short of recommended guidelines. Poorly defined legislation and the absence of a national standard for sports physicals have contributed to inadequate health screenings of athletes. This article will describe the incidence and causes of sudden cardiovascular death in young athletes as well as guidelines intended to prevent this unfortunate problem.

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.

Commotio cordis and the epidemiology of sudden death in competitive lacrosse

OBJECTIVE

Athletic field risks associated with blunt, nonpenetrating chest blows (commotio cordis) are receiving increasing attention, but the epidemiology of these events is incomplete.

METHODS

We assessed our Sudden Death in Young Athletes Registry, 1980-2008, to formulate a clinical profile of those sudden deaths attributed to commotio cordis (and other causes) occurring in competitive lacrosse, the most rapidly growing youth sport in the United States.

RESULTS

Twenty-three sudden deaths or cardiac arrests were identified in high school and college lacrosse participants. Ages were 18 +/- 2 years; each athlete was male. Ten died after blunt precordial blows, including 4 goalies wearing commercially available chest protectors. Twelve others collapsed because of presumed or documented cardiovascular disease, including hypertrophic cardiomyopathy, long QT syndrome, mitral valve prolapse, or ruptured cerebral aneurysm. The mortality rate associated with lacrosse was 1.46 deaths per 100,000 person-years and was similar to that of other sports including baseball, basketball, football, and hockey. However, deaths attributed to commotio cordis were more frequent in lacrosse (0.63 deaths per 100,000 person-years) than in other sports (P < .02), with the exception of hockey.

CONCLUSIONS

Sudden deaths in competitive lacrosse participants are rare and no more common than in most other sports. These catastrophic events were caused disproportionately by commotio cordis and included athletes wearing chest barriers, thereby underscoring the importance of developing effective chest protection to create a safer athletic environment for our youth.

Comparison of U.S. and Italian experiences with sudden cardiac deaths in young competitive athletes and implications for preparticipation screening strategies

Controversy has evolved over the most practical and effective strategy for preparticipation cardiovascular screening of competitive athletes to detect unsuspected cardiovascular disease and prevent sudden death on the athletic field. Athlete screening in the Veneto region of Italy is part of a national program (with 12-lead electrocardiography) that has reported the detection of previously undiagnosed hypertrophic cardiomyopathy and a decrease in the cardiovascular death rate in young athletes. In this study, over time periods of similar length, cardiovascular-related mortality rates in Veneto athletes were compared with those of a demographically similar region of the United States (Minnesota) in which screening is limited to history and physical examination. There were 55 sudden cardiovascular deaths reported in Veneto over 26 years (2.1/year), compared with 22 deaths in 23 years (0.96/year) in Minnesota. Over the recent and comparable 11-year period, 1993 to 2004, 12 deaths were reported in Veneto and 11 in Minnesota. When analyzed as deaths per 100,000 person-years, Veneto exceeded Minnesota for all years combined (1.87 for 1979 to 2004 vs 1.06 for 1985 to 2007, respectively, p = 0.006), although the 2 regions did not differ significantly for 1993 to 2004 (0.87 vs 0.93, respectively, p = 0.88) or most recently for 2001 to 2004 (0.43 vs 0.90, respectively, p = 0.38). In conclusion, sudden cardiovascular deaths in young competitive athletes occurred at a low rate in both Veneto and Minnesota. Despite different preparticipation screening strategies, athlete sudden death rates in these demographically similar regions of the United States and Italy have not differed significantly in recent years. These data do not support a lower mortality rate associated with preparticipation screening programs involving routine electrocardiography and examinations by specially trained personnel.

Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006

BACKGROUND

Sudden deaths in young competitive athletes are highly visible events with substantial impact on the physician and lay communities. However, the magnitude of this public health issue has become a source of controversy.

METHODS AND RESULTS

To estimate the absolute number of sudden deaths in US competitive athletes, we have assembled a large registry over a 27-year period using systematic identification and tracking strategies. A total of 1866 athletes who died suddenly (or survived cardiac arrest), 19+/-6 years of age, were identified throughout the United States from 1980 to 2006 in 38 diverse sports. Reports were less common during 1980 to 1993 (576 [31%]) than during 1994 to 2006 (1290 [69%], P<0.001) and increased at a rate of 6% per year. Sudden deaths were predominantly due to cardiovascular disease (1049 [56%]), but causes also included blunt trauma that caused structural damage (416 [22%]), commotio cordis (65 [3%]), and heat stroke (46 [2%]). Among the 1049 cardiovascular deaths, the highest number of events in a single year was 76 (2005 and 2006), with an average of 66 deaths per year (range 50 to 76) over the last 6 years; 29% occurred in blacks, 54% in high school students, and 82% with physical exertion during competition/training, whereas only 11% occurred in females (although this increased with time; P=0.023). The most common cardiovascular causes were hypertrophic cardiomyopathy (36%) and congenital coronary artery anomalies (17%).

CONCLUSIONS

In this national registry, the absolute number of cardiovascular sudden deaths in young US athletes was somewhat higher than previous estimates but relatively low nevertheless, with a rate of <100 per year. These data are relevant to the current debate surrounding preparticipation screening programs with ECGs and also suggest the need for systematic and mandatory reporting of athlete sudden deaths to a national registry.

Contemporary approaches to the identification of athletes at risk for sudden cardiac death

PURPOSE OF REVIEW

The appropriate screening strategy to prevent sudden cardiac death (SCD) in athletes remains a challenging and a highly debated issue. The purpose of this review is to examine the added value and controversies of including a 12-lead electrocardiogram (ECG) in addition to a comprehensive personal and family history during preparticipation screening of cardiovascular abnormalities in athletes.

RECENT FINDINGS

Studies in support of ECG screening are evolving rapidly, utilizing more rigorous ECG criteria with a lower total positive rate- and thus reduced levels of false positives. Reported estimates on the incidence of SCD in young athletes vary widely based on the methods of data collection and have likely underrepresented the incidence of SCD with implications on screening recommendations. More accurate calculations of SCD incidence combined with lower total positive rates yield a promising cost-effectiveness analysis in favor of universal ECG screening of athletes.

SUMMARY

The devastating impact of SCD in young athletes warrants the commitment of additional resources to identify those at risk. It is time for a systematic preparticipation screening program for all competitive athletes, using at least a standardized comprehensive personal and family history questionnaire and a screening ECG at the time of matriculation to high school and college. Although additional outcomes-based research is required, improved efforts to expand the infrastructure necessary for effective cardiac screening in young athletes are recommended.