Advertisement

Screening for Sudden Cardiac Death Before Participation in High School and Collegiate Sports

American College of Preventive Medicine Position Statement on Preventive Practice
      The American College of Preventive Medicine (ACPM) supports an evaluation prior to participating in high school and collegiate sports using a standardized history and physical (H&P) (i.e., using standardized items as developed by the American Heart Association [AHA] to ensure uniformity and consistency in risk factor assessment; Table 1).
      • Maron B.J.
      • Thompson P.D.
      • Ackerman M.J.
      • et al.
      Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
      ACPM recommends against routine screening for potential sudden cardiac death (SCD) with electrocardiogram (ECG), echocardiography, and genetic testing in individuals without personal risk factors. The recommendations by ACPM address only mass screening approaches to detecting SCD and are not targeted toward individuals who may be identified by their healthcare provider as “above average” risk who may benefit from additional testing with the modalities mentioned above. ACPM supports the adoption of the National Heart, Lung, and Blood Institute (NHLBI) Working Group research agenda to evaluate the effectiveness of any screening program in reducing SCD, its cost–benefit ratio, and its impact on health outcomes (Table 2).
      • Kaltman J.R.
      • Thompson P.D.
      • Lantos J.
      • et al.
      Screening for sudden cardiac death in the young: report from a national heart, lung, and blood institute working group.
      The full-length version of the current article can be found on the ACPM website (www.acpm.org/?page=Policy_Statement).
      Table 1The 12-element AHA recommendations for pre-participation cardiovascular screening of competitive athletes
      • Maron B.J.
      • Thompson P.D.
      • Ackerman M.J.
      • et al.
      Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
      Medical history
      Parental verification is recommended for high school and middle school athletes.
      Personal history
       1. Exertional chest pain/discomfort
       2. Unexplained syncope/near-syncope
      Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion.
       3. Excessive exertional and unexplained dyspnea/fatigue, associated with exercise
       4. Prior recognition of a heart murmur
       5. Elevated systemic blood pressure
      Family history
       6. Premature death (sudden and unexpected, or otherwise) before age 50 years due to heart disease, in ≥1 relative
       7. Disability from heart disease in a close relative aged <50 years
       8. Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias
      Physical examination
       9. Heart murmur
      Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction. AHA, American Heart Association
       10. Femoral pulses to exclude aortic coarctation
       11. Physical stigmata of Marfan syndrome
       12. Brachial artery blood pressure (sitting position)
      a Parental verification is recommended for high school and middle school athletes.
      b Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion.
      c Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.AHA, American Heart Association
      Table 2Recommendations of the NHLBI Working Group to address the identified knowledge gaps in evaluating screening for SCDY
      • Kaltman J.R.
      • Thompson P.D.
      • Lantos J.
      • et al.
      Screening for sudden cardiac death in the young: report from a national heart, lung, and blood institute working group.
      Epidemiology and etiology of SCDY
       Develop an SCDY registry to prospectively estimate the incidence of SCDY
       Perform case–control studies using registry-defined cases to identify risk factors for SCDY
      Performance of the screening methodology in the target population
       Perform pilot ECG screening studies to test the characteristics of the ECG in target populations
       Perform comparative effectiveness studies to determine the incremental value of various screening methodologies, including   history and physical examination, ECG, echocardiogram, and genetic testing
      Management of asymptomatic heart disease identified by ECG screening
       Develop evidence-based management strategies for asymptomatic patients
       Evaluate risk stratification, prevention, and therapeutic strategies
       Use novel study designs and innovative recruitment strategies when studying low-prevalence diseases
      Impact of a screening program
       Evaluate the impact of a screening program on individuals and families using quality-of-life studies and patient-preference measurements
       Use decision analysis to evaluate overall effectiveness of a screening program, as well as cost and resource utilization
      Other resources to facilitate research
       Redefine the diagnostic criteria for the long-QT syndrome in the genetic era
       Define ECG norms in the U.S. population, taking into account demographic variability
      ECG, electrocardiogram; NHLBI, National Heart, Lung, and Blood Institute; SCDY, screening for sudden cardiac death in the young
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Maron B.J.
        • Thompson P.D.
        • Ackerman M.J.
        • et al.
        Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
        Circulation. 2007; 115: 1643-1655
        • Kaltman J.R.
        • Thompson P.D.
        • Lantos J.
        • et al.
        Screening for sudden cardiac death in the young: report from a national heart, lung, and blood institute working group.
        Circulation. 2011; 123: 1911-1918
        • Maron B.J.
        • Haas T.S.
        • Ahluwalia A.
        • Rutten-Ramos S.C.
        Incidence of cardiovascular sudden deaths in Minnesota high school athletes.
        Heart Rhythm. 2013; 10: 374-377
        • Cantu R.C.
        Congenital cardiovascular disease—the major cause of athletic death in high school and college.
        Med Sci Sports Exerc. 1992; 24: 279-280
        • Maron B.J.
        • Doerer J.J.
        • Haas T.S.
        • Tierney D.M.
        • Mueller F.O.
        Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006.
        Circulation. 2009; 119: 1085-1092
        • Maron B.J.
        • Carney K.P.
        • Lever H.M.
        • et al.
        Relationship of race to sudden cardiac death in competitive athletes with hypertrophic cardiomyopathy.
        J Am Coll Cardiol. 2003; 41: 974-980
        • Myerburg R.J.
        Sudden cardiac death: exploring the limits of our knowledge.
        J Cardiovasc Electrophysiol. 2001; 12: 369-381
        • Maron B.J.
        • Shirani J.
        • Poliac L.C.
        • Mathenge R.
        • Roberts W.C.
        • Mueller F.O.
        Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles.
        JAMA. 1996; 276: 199-204
        • Corrado D.
        • Basso C.
        • Schiavon M.
        • Pelliccia A.
        • Thiene G.
        Pre-participation screening of young competitive athletes for prevention of sudden cardiac death.
        J Am Coll Cardiol. 2008; 52: 1981-1989
        • Glover D.W.
        • Maron B.J.
        Profile of preparticipation cardiovascular screening for high school athletes.
        JAMA. 1998; 279: 1817-1819
        • Fuller C.M.
        • McNulty C.M.
        • Spring D.A.
        • et al.
        Prospective screening of 5,615 high school athletes for risk of sudden cardiac death.
        Med Sci Sports Exerc. 1997; 29: 1131-1138
        • Wilson M.G.
        • Basavarajaiah S.
        • Whyte G.P.
        • Cox S.
        • Loosemore M.
        • Sharma S.
        Efficacy of personal symptom and family history questionnaires when screening for inherited cardiac pathologies: the role of electrocardiography.
        Br J Sports Med. 2008; 42: 207-211
        • Baggish A.L.
        • Hutter Jr, A.M.
        • Wang F.
        • et al.
        Cardiovascular screening in college athletes with and without electrocardiography: a cross-sectional study.
        Ann Intern Med. 2010; 152: 269-275
        • Corrado D.
        • Basso C.
        • Schiavon M.
        • Thiene G.
        Screening for hypertrophic cardiomyopathy in young athletes.
        N Engl J Med. 1998; 339: 364-369
        • Pelliccia A.
        • Maron B.J.
        • Culasso F.
        • et al.
        Clinical significance of abnormal electrocardiographic patterns in trained athletes.
        Circulation. 2000; 102: 278-284
        • Steinvil A.
        • Chundadze T.
        • Zeltser D.
        • et al.
        Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death proven fact or wishful thinking?.
        J Am Coll Cardiol. 2011; 57: 1291-1296
      1. Corrado D, Basso C, Schiavon M, et al. Cost-effectiveness analysis of preparticipation screening strategies for the prevention of sudden death in young competitive athletes. American Heart Association Scientific Sessions; 7–10 Nov 2004, New Orleans, LA, USA [abstract 321].

      2. Chaitman BR. An electrocardiogram should not be included in routine preparticipation screening of young athletes. Circulation 2007;116(22):2610–4; discussion 2615.

        • Hamilton B.
        • Jaques R.
        • Budgett R.
        Observations on the "Lausanne Recommendations" on sudden cardiovascular death in sport.
        Br J Sports Med. 2007; 41: e1
        • Shephard R.J.
        • Mass E.C.G.
        screening of young athletes.
        Br J Sports Med. 2008; 42: 707-708
        • Bille K.
        • Figueiras D.
        • Schamasch P.
        • et al.
        Sudden cardiac death in athletes: the Lausanne Recommendations.
        Eur J Cardiovasc Prev Rehabil. 2006; 13: 859-875
        • Corrado D.
        • Basso C.
        • Pavei A.
        • Michieli P.
        • Schiavon M.
        • Thiene G.
        Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program.
        JAMA. 2006; 296: 1593-1601
        • American College of Sports Medicine
        ACSM current comment: pre-participation physical exam.
        ACSM, 2006 (www.acsm.org/docs/current-comments/pre-participationexam.pdf)