The Psychological Impact of Cardiovascular Screening in Young Athletes: Perspectives Across Age, Race, and Gender

Does cardiovascular preparticipation screening cause psychological distress in athletes? A systematic review

OBJECTIVE

To evaluate the psychological implications of cardiovascular preparticipation screening (PPS) in athletes.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, PubMed, CINAHL, SPORTDiscus, APA PsycInfo, Cochrane Library and grey literature sources.

STUDY ELIGIBILITY CRITERIA

Observational and experimental studies assessing a population of athletes who participated in a cardiovascular PPS protocol, where psychological outcomes before, during and/or after PPS were reported.

METHODS

Results of included studies were synthesised by consolidating similar study-reported measures for key psychological outcomes before, during and/or after screening. Summary measures (medians, ranges) were computed across studies for each psychological outcome.

RESULTS

A total of eight studies were included in this review (median sample size: 479). Study cohorts consisted of high school, collegiate, professional and recreational athletes (medians: 59% male, 20.5 years). Most athletes reported positive reactions to screening and would recommend it to others (range 88%-100%, five studies). Increased psychological distress was mainly reported among athletes detected with pathological cardiac conditions and true-positive screening results. In comparison, athletes with false-positive screening results still reported an increased feeling of safety while participating in sport and were satisfied with PPS. A universal conclusion across all studies was that most athletes did not experience psychological distress before, during or after PPS, regardless of the screening modality used or accuracy of results.

CONCLUSION

Psychological distress associated with PPS in athletes is rare and limited to athletes with true-positive findings. To mitigate downstream consequences in athletes who experience psychological distress, appropriate interventions and resources should be accessible prior to the screening procedure.

PROSPERO REGISTRATION NUMBER

CRD42021272887.

Implementing a Standardized Cardiac Protocol for the Adolescent Preparticipation Sports Examination

INTRODUCTION

To evaluate adolescent athletes for cardiovascular (CV) abnormalities before engaging in competitive sports, the American Heart Association guidelines recommend preparticipation screening. The initiative aimed to implement a standardized protocol to increase the identification of CV abnormalities during athletic physical examinations.

METHOD

A rapid-cycle model with four Plan-Do-Study-Act cycles was implemented in two urgent care clinics. Providers used a CV-specific screening checklist; parents were engaged in a discussion about the importance of this screening, and team engagement activities were used. Outcomes were measured with chart audits and surveys.

RESULTS

Because of the intervention, 62% of athletes were screened, with 29% identified as having a CV risk. The satisfaction of the patients and the team increased by 3% and 62.5%, respectively.

DISCUSSION

Despite competing foci in the clinics, athletes were properly screened using a standardized checklist, which is easily sustainable and can be duplicated in other settings.

Psychological impact of electrocardiogram screening in National Collegiate Athletic Association athletes

PURPOSE

Determine the psychological impact of false-positive ECG screening in National Collegiate Athletic Association (NCAA) athletes.

METHODS

Athletes representing seven NCAA institutions received a standardised history, physical examination and ECG interpreted using the 2013 Seattle Criteria. Assessments of health attitudes, anxiety and impact of screening on sport were conducted using validated prescreen and postscreen measurements.

RESULTS

1192 student-athletes participated (55.4% male, median age 19 years, 80.4% Caucasian). 96.8% of athletes had a normal cardiovascular screen, 2.9% had a false-positive ECG and 0.3% were diagnosed with a serious cardiac condition. Prior to screening, 4.5% worried about potentially harbouring cardiac disease and 70.1% preferred knowing about an underlying condition, rather than play sports without this knowledge. There was no difference in anxiety described by athletes with a normal versus false-positive screen (p=0.369). Reported anxiety levels during screening also did not differ when analysed by different gender, race, division of play or sport. Athletes with normal and false-positive screens had similar levels of satisfaction (p=0.714) and would recommend ECG screening to other athletes at similar rates (p=0.322). Compared with athletes with a normal screen, athletes with false-positive results also reported feeling safer during competition (p>0.01). In contrast, athletes with false-positive screens were more concerned about the possibility of sports disqualification (p<0.001) and the potential for developing a future cardiac condition (p<0.001).

CONCLUSIONS

Athletes with a false-positive ECG do not experience more anxiety than athletes with a normal screen but do express increased concern regarding sports disqualification and the development of a cardiac disorder. These findings do not justify avoiding advanced cardiovascular screening protocols. Further understanding of athlete experiences could better prepare the practising physician to counsel athletes with an abnormal ECG.

Sudden Cardiac Death in the Young

Although the occurrence of sudden cardiac death (SCD) in a young person is a rare event, it is traumatic and often widely publicized. In recent years, SCD in this population has been increasingly seen as a public health and safety issue. This review presents current knowledge relevant to the epidemiology of SCD and to strategies for prevention, resuscitation, and identification of those at greatest risk. Areas of active research and controversy include the development of best practices in screening, risk stratification approaches and postmortem evaluation, and identification of modifiable barriers to providing better outcomes after resuscitation of young SCD patients. Institution of a national registry of SCD in the young will provide data that will help to answer these questions.

The impact of diagnosis: measuring the psychological response to being diagnosed with serious or potentially lethal cardiac disease in young competitive athletes

AIM

To determine the psychological impact of athletes diagnosed with cardiac disease.

METHODS AND DESIGN

Athletes diagnosed with cardiovascular disorders were recruited to complete the Impact of Event Scale (IES), a validated tool measuring responses to a traumatic event. IES scoring =0-88 (<12= normal, 12-32=recommend monitoring, >33=significant stress reaction). Subscales include: intrusion, avoidance and hyperarousal.

RESULTS

30 athletes (53% male, 83% Caucasian, median age 18.0, median age at diagnosis 15.7) participated. Diagnoses included: 6 hypertrophic cardiomyopathy, 9 Wolff Parkinson White, 4 Long QT syndrome, 3 atrial septal defect, 2 supraventricular tachycardia and 6 other. For the group, the mean IES-Revised (IES-R) score=16.6 (SD=12.1), subscales: intrusion 6.6 (SD=4.3), avoidance=7.4 (SD=6.5), hyperarousal=2.7 (SD=3.5). Higher risk individuals included: permanently disqualified athletes (p<0.01), athletes requiring daily medication (p<0.01), those with genetically inheritable conditions (p<0.01), and athletes undergoing medical management instead of definitive therapy (p<0.01). No differences were reported by gender (male=16.6, female=16.6). Higher IES-R scores were reported in more competitive athletes (college=17.8, high school=13.3; p=0.369) and African-American individuals (African-American=25.8, Caucasian=14.8 p=0.061), although not statistically significant. Athletes with cardiomyopathy (IES-R=24) and channelopathy (IES-R=28) reported the highest IES results. Athletes with high IES-R scores were most likely to psychologically respond through avoidance of feelings/situations/ideas.

CONCLUSIONS

Athletes diagnosed with potentially lethal cardiac disorders are at risk for significant psychological distress. These athletes tend to avoid thoughts, feelings and conversations associated with their diagnosis and should be offered consistent emotional support to mitigate psychological morbidity.

SIGNIFICANCE

Currently, there are no recommendations to guide physicians on how to support an athlete that is newly diagnosed with a potentially career altering heart condition. Proper planning and use of appropriate support mechanisms can be useful for emotionally vulnerable athletes.