Ethics of preparticipation cardiovascular screening for athletes

Symptoms and healthcare contact preceding sudden cardiac death in persons aged 1-49 years

Sudden Cardiac Death (SCD) is a leading cause of death among persons in their youth and early middle-age. To prevent SCD it is crucial to identify persons at high-risk of SCD. Knowledge of symptoms and medical contact prior to SCD could potentially aid in the identification of high-risk persons in the general population who would benefit from further investigation. This review aims to summarize the current knowledge of symptoms and healthcare contact preceding SCD in persons aged 1-49 years, and to explore how the symptoms differ according to SCD cause and age of the deceased. There was a high frequency of both cardiac and non-specific symptoms prior to SCD. Additionally, many SCD victims contacted the healthcare system prior to death on the basis of their symptoms and only a few were diagnosed with cardiovascular disease. This information underlines that young persons reporting potential cardiac symptoms should also be thoroughly examined. Furthermore, such symptoms could be used in combination with other easily accessible information in non-invasive prediction models aiming at identifying persons at high risk of SCD that would benefit from further investigation and possibly treatment.

Performance of the American Heart Association ( AHA ) 14-Point Evaluation Versus Electrocardiography for the Cardiovascular Screening of High School Athletes: A Prospective Study

Background

Preparticipation cardiovascular screening in athletes is fully endorsed by major medical societies, yet the most effective screening protocol remains debated. We prospectively compared the performance of the American Heart Association (AHA) 14‐point screening evaluation and a resting ECG for cardiovascular screening of high school athletes.

Methods and Results

Competitive athletes participating in organized high school or premier/select level sports underwent cardiovascular screening using the AHA 14‐point history and physical examination, and an ECG interpreted with the Seattle Criteria. A limited echocardiogram was performed for all screening abnormalities. The primary outcome measure was identification of a cardiovascular disorder associated with sudden cardiac death. From October 2014 to June 2017, 3620 high school athletes (median age, 16 years; range 13–19; 46.2% female; 78.6% white, 8.0% black) were screened. One or more positive responses to the AHA 14‐point questionnaire were present in 814 (22.5%) athletes. The most common history responses included chest pain (8.1%), family history of inheritable conditions (7.3%), and shortness of breath (6.4%). Abnormal physical examination was present in 356 (9.8%) athletes, and 103 (2.8%) athletes had an abnormal ECG. Sixteen (0.4%) athletes had conditions associated with sudden cardiac death. The sensitivity (18.8%), specificity (68.0%), and positive predictive value (0.3%) of the AHA 14‐point evaluation was substantially lower than the sensitivity (87.5%), specificity (97.5%), and positive predictive value (13.6%) of ECG.

Conclusions

The AHA 14‐point evaluation performs poorly compared with ECG for cardiovascular screening of high school athletes. The use of consensus‐derived history questionnaires as the primary tool for cardiovascular screening in athletes should be reevaluated.

See Editorial Maron et al

There is No Reason to Adopt ECG s and Abandon American Heart Association/American College of Cardiology History and Physical Screening for Detection of Cardiovascular Disease in the Young

See Article Williams et al.

Prevention of sudden death in hypertrophic cardiomyopathy: bridging the gaps in knowledge

Sudden cardiac death (SCD) is the most devastating complication of hypertrophic cardiomyopathy (HCM). Although the annual rate of SCD in the general HCM population is <1% per year according to contemporary series, there is still a small subset of patients who are at increased risk of SCD. The greatest challenge in the management of HCM is identifying those at increased risk as an implantable cardioverter defibrillator is a potentially life-saving therapy. In this review, we sought to summarize the available data on SCD in HCM and provide a clinical perspective on the current differing and somewhat conflicting European and American recommendations on risk stratification, with balanced guidance with regards to rational clinical decision making. Additionally, we sought to learn more on the actual implementation of the guidelines by HCM experts worldwide.

Sudden Cardiac Arrest during Participation in Competitive Sports

BACKGROUND

The incidence of sudden cardiac arrest during participation in sports activities remains unknown. Preparticipation screening programs aimed at preventing sudden cardiac arrest during sports activities are thought to be able to identify at-risk athletes; however, the efficacy of these programs remains controversial. We sought to identify all sudden cardiac arrests that occurred during participation in sports activities within a specific region of Canada and to determine their causes.

METHODS

In this retrospective study, we used the Rescu Epistry cardiac arrest database (which contains records of every cardiac arrest attended by paramedics in the network region) to identify all out-of-hospital cardiac arrests that occurred from 2009 through 2014 in persons 12 to 45 years of age during participation in a sport. Cases were adjudicated as sudden cardiac arrest (i.e., having a cardiac cause) or as an event resulting from a noncardiac cause, on the basis of records from multiple sources, including ambulance call reports, autopsy reports, in-hospital data, and records of direct interviews with patients or family members.

RESULTS

Over the course of 18.5 million person-years of observation, 74 sudden cardiac arrests occurred during participation in a sport; of these, 16 occurred during competitive sports and 58 occurred during noncompetitive sports. The incidence of sudden cardiac arrest during competitive sports was 0.76 cases per 100,000 athlete-years, with 43.8% of the athletes surviving until they were discharged from the hospital. Among the competitive athletes, two deaths were attributed to hypertrophic cardiomyopathy and none to arrhythmogenic right ventricular cardiomyopathy. Three cases of sudden cardiac arrest that occurred during participation in competitive sports were determined to have been potentially identifiable if the athletes had undergone preparticipation screening.

CONCLUSIONS

In our study involving persons who had out-of-hospital cardiac arrest, the incidence of sudden cardiac arrest during participation in competitive sports was 0.76 cases per 100,000 athlete-years. The occurrence of sudden cardiac arrest due to structural heart disease was uncommon during participation in competitive sports. (Funded by the National Heart, Lung, and Blood Institute and others.).

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations and Future Directions

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for cardiovascular screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation cardiovascular screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal cardiovascular screening strategy for all athletes, including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate cardiovascular screening strategy unique to their athlete population, community needs, and resources. The decision to implement a cardiovascular screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence-base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. AMSSM is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current evidence, knowledge gaps, recommendations and future directions

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for cardiovascular screening in athletes remains an issue of considerable debate. At the centre of the controversy is the addition of a resting ECG to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation cardiovascular screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcome-based evidence at this time precludes AMSSM from endorsing any single or universal cardiovascular screening strategy for all athletes, including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate cardiovascular screening strategy unique to their athlete population, community needs and resources. The decision to implement a cardiovascular screening programme, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. AMSSM is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

Comparison of the Frequency of Sudden Cardiovascular Deaths in Young Competitive Athletes Versus Nonathletes: Should We Really Screen Only Athletes?

The issue of sudden death in young athletes and consideration for the most practical and optimal strategy to identify those genetic and/or congenital heart diseases responsible for these tragic events continues to be debated. However, proponents of broad-based and mandatory national preparticipation screening, including with 12-lead electrocardiograms have confined the focus to a relatively small segment of the youthful population who choose to engage in competitive athletic programs at the high school, college, and elite-professional level. Therefore, lost in this discussion of preparticipation screening of athletes is that the larger population of young people not involved in competitive sports (and, therefore, a priori are excluded from systematic screening) who nevertheless may die suddenly of the same cardiovascular diseases as athletes. To substantiate this hypothesis, we accessed the forensic Hennepin County, Minnesota registry in which cardiovascular sudden deaths were 8-fold more common in nonathletes (n = 24) than athletes (n = 3) and threefold more frequent in terms of incidence. The most common diseases responsible for sudden death were hypertrophic cardiomyopathy (n = 6) and arrhythmogenic right ventricular cardiomyopathy (n = 4). These data raise ethical considerations inherent in limiting systematic screening for unsuspected genetic and/or congenital heart disease to competitive athletes.

Historical Perspectives on Sudden Deaths in Young Athletes With Evolution over 35 Years

Sudden death in young competitive athletes has become a highly visible and substantial issue within cardiovascular medicine of interest both to the general public and to the practicing community. At this time, it is instructive to revisit the evolution of this clinical problem over the past 35 years starting with introduction into the public and medical consciousness by the unexpected sudden deaths of 2 college basketball players within 8 weeks of each other in 1976, 1 with Marfan syndrome and the other with hypertrophic cardiomyopathy. Subsequently, over the next years, a number of elite athletes died suddenly, raising public visibility and awareness of these tragic events: Len Bias, "Pistol" Pete Maravich, Hank Gathers, Reggie Lewis, Kori Stringer, Jason Collier, and Thomas Herrion. Intense interest in these and many other athlete deaths has led to a considerable understanding regarding the demographics, incidence, and causes of these deaths, which include a variety of genetic and/or congenital cardiovascular diseases (most commonly hypertrophic cardiomyopathy), blunt trauma, commotio cordis, and sickle cell trait. Ultimately, initiatives emerged creating consensus guidelines for disqualification versus eligibility decisions, and preparticipation screening to detect unsuspected cardiac abnormalities. This journey of now >3 decades has generated voluminous data and even controversy, but continues to hold great interest in clinical scientists, medical practitioners, and the general public.