This post was authored by Michelle A. Grenier, MD, FACC, member of the ACC’s Sports and Exercise Cardiology Section Leadership Council.

There is little that sparks more controversy amongst physicians caring for young athletes than the pre-participating screening physical. There are factions amongst some of the most intelligent, well-read, elite practitioners. On one end of the spectrum, there is the belief: “What use is the screening physical if the end result is the final common pathway (unstable ventricular arrhythmia)?” On the other end, there is the belief that “All young athletes, regardless of sport and level of participation require history, physical, EKG and echo… and if necessary, MRI and stress!” In reality, the majority fall somewhere in between, and vacillate somewhat in real-world practice.

What inspires such passion is the fact that sudden cardiac death in the young is estimated to occur in anywhere between 0.5 to 1/100,000 participating athletes below the age of 35 years, according to recent literature. If the lottery were played with these odds, very few tickets would be sold. And yet, the loss of a bright, shining young star always grasps the heart of the public, lay persons and medical personnel alike. Great athletes such as Reggie Lewis and Flo Hyman come to mind. But also local athletes, such as 13-year-old “Oreo,” who was trying out for track one day, and stopped dead the next, literally, in his tracks. It doesn’t seem fair that those most fit to play sports like basketball, football, track, baseball, soccer, and more, collapse doing what they love. Therein lies the controversy: how do we prevent these events if they are so rare? Do they justify use of our already thin medical resources?

We have targeted the final common pathway – unstable ventricular arrhythmia – by popularizing the automated external defibrillator and educating the general public in the techniques of basic cardiopulmonary resuscitation. We have devised the 12-point American Heart Association (AHA) screening tool to be used in concert with the guidelines (35th Bethesda, which are currently being updated – Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities) to identify individuals at risk for these events. The problem is that it is not an exact science (very little are Level A evidence). And whether the proponents of abandoning screening as a useful tool due to its inexactitude request its demise, screening is done all over the U.S. by urgent care centers, large high school screenings staffed by a wide variety of health care providers, pediatricians, family practitioners, nurse practitioners and chiropractors. The screenings can be free in large settings, as they are in Mississippi, where they are conducted in the coliseum; they can be the $35 variety provided by the corner pharmacy (“Your Neighborhood Clinic”); or they may be reimbursed by insurance in the cardiologist’s office. But they ARE being done, and in most states they ARE required before any team, school or private coach accepts liability for a child.

In Italy in 2006, Domenico Corrado, MD, PhD, and colleagues were able to show a reduction in the incidence of sudden cardiac death due to the screening intervention and appropriate restriction of athletes with arrhythmogenic right ventricular dysplasia. Proponents of screening in the U.S. believe we may achieve the same results. However, is it possible to extrapolate when our country is so large and geographically/ethnically/racially diverse? How do we achieve 100 percent capture? Would it make a difference? Perhaps it is best to focus on some achievable goals in pre-participation screening: 1) identify individuals known to be at risk and allow stratification of these risks; 2) make recommendations regarding participation.

In the current climate, pre-participation screenings are not going away, so therefore it is important they are “done right.” We have made progress since 1997 when the concept of pre-participation screening was introduced. Back then 60 percent of states had forms that did not incorporate AHA recommendations and were missing essential questions, no states offered a standard for examiners and 50 percent sanctioned non-physician examiners. Fast forward to 2005, 81 percent of states had adequate questionnaires with > 9 of 12 AHA items incorporated, and 64 percent of states allowed non-physician examiners.

The good news is we have the tools we need to make sure these screenings are “done right.” There are published forms and guidelines. There is an ACC Sports and Exercise Cardiology Section tasked with training individuals to properly screen and restrict athletes. Only through adherence to these guidelines can objective evidence and fundamental questions regarding the most effective measures to avoid harm to our athletes be obtained. Before the pre-participation screening exam can be abandoned as ineffective and costly, it will need to be trialed in a standardized format by trained practitioners. Only then can the level of evidence be available and preventative measures be implemented.

This post is part of a series of posts from the ACC’s Sports and Exercise Cardiology Section. For more information about the Section, click here. Follow the sports and exercise cardiology conversation on Twitter with the hashtag #SportsCardio.

< Back to Listings