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Preparticipation ECG Screening Not Required for Competitive Athletes

  • Authors: News Author: Michael O'Riordan
    CME Author: Charles Vega, MD, FAAFP
  • CME / CE Released: 3/19/2007; Reviewed and Renewed: 3/20/2008
  • Valid for credit through: 3/20/2009
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Target Audience and Goal Statement

This article is intended for primary care clinicians, sports medicine specialists, cardiologists, and other specialists who care for athletes.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Specify the most common cause of sudden cardiac death among young athletes.
  • Describe the recommendations from the AHA regarding preparticipation cardiovascular screening of athletes.


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  • Michael O'Riordan

    Michael O'Riordan is a journalist, part of the WebMD Professional Network. Previously, he worked for WebMD Canada. Michael studied at Queen's University in Kingston and the University of Toronto and has a master's degree in journalism from the University of British Columbia, where he specialized in medical reporting. He can be contacted at [email protected]


    Disclosure: Michael O'Riordan has disclosed no relevant financial relationships.

CME Author(s)

  • Charles P Vega, MD

    Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine


    Disclosure: Charles Vega, MD, FAAFP, has disclosed that he has received grants for educational activities from Pfizer.

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Preparticipation ECG Screening Not Required for Competitive Athletes

Authors: News Author: Michael O'Riordan CME Author: Charles Vega, MD, FAAFPFaculty and Disclosures

CME / CE Released: 3/19/2007; Reviewed and Renewed: 3/20/2008

Valid for credit through: 3/20/2009


from Heartwire — a professional news service of WebMD

March 19, 2007 — The American Heart Association (AHA) has updated their recommendations for preparticipation screening for cardiovascular abnormalities in competitive athletes, with little changing from the 1996 prescreening statement. The AHA still does not believe it practical or financially feasible to support a large-scale preparticipation screening initiative, which would include standard 12-lead electrocardiogram (ECG) testing, similar to those proposed by the European Society of Cardiology (ESC) and the International Olympic Committee (IOC).

"The key issue is that at the present time, we don't think it makes a great deal of sense to do electrocardiograms," Paul Thompson, MD, from the Hartford Hospital in Hartford, Connecticut, co-chair of the panel that drafted the 2007 recommendations, told heartwire . "Part of that reason is based on skepticism of the European data, differences in groups of athletes versus other athletes, and the simple fact that we don't have the resources to do ECGs on every athlete."

Instead, the new AHA recommendations keep with those proposed in the 1996 scientific statement and include taking a personal history, family history, and physical examination. The recommendations in the updated scientific statement, with lead author and chair Barry Maron, MD, from the Minneapolis Heart Institute in Minneapolis, Minnesota, are published in the March 12 issue of Circulation, are an effective strategy to raise the suspicion of cardiovascular disease, the panel writes.

Dr. Thompson said that when a definitive diagnosis of heart disease is made, the consensus panel guidelines of the 36th Bethesda Conference should still be used to formulate a decision regarding the eligibility of these individuals for competition in competitive sports. Those guidelines address the medical-eligibility criteria for participation in sports, providing specific unbiased recommendations for more than 70 cardiovascular abnormalities, including hypertrophic cardiomyopathy, congenital and valvular heart disease, arrhythmias, systemic hypertension, and coronary artery disease.

A Potential Screening Pool of 10 Million Athletes

In the United States, it is estimated there are more than 5 million individual competitive athletes at the high school level, as well as more than 500,000 athletes competing at the collegiate level. Once youth, middle school, and masters-level athletes are included, the number of US athletes includes more than 10 million people. Overall, the risk of dying from cardiovascular abnormalities does constitute a public health concern, the panel notes, and based on one 12-year study that included 1.4 million student-athletes participating in 27 sports, the incidence of cardiovascular deaths is estimated to be in the range of 1 per 200,000 young person of high school age per year.

In 2004-2005, ESC and IOC proposals pushed for combining noninvasive testing, such as a 12-lead ECG, with the standard history and physical examination. The European recommendations are based on the 25-year Italian experience with a state-subsidized national screening program in which all individuals 12 to 35 years of age participating in organized sports are required to obtain annual medical clearance by accredited sports medicine clinicians. This clearance includes history, physical examination, and an ECG and has been successful in detecting hypertrophic cardiomyopathy and other cardiovascular abnormalities.

Dr. Thompson told heartwire there is concern that the Italian data might not apply, particularly as the US population is 5 times that of Italy, has a larger number of athletes to screen, and a wider geographic dissemination of athletes across the country. While there are legitimate concerns about the cost, it is estimated that mass screening for this many athletes, along with the follow-up required for abnormal findings, is more than $2 billion a year. Dr. Thompson said there is a lack of clinicians and other medical resources required for performing and reading the ECGs.

In addition to these concerns, Dr. Thompson, as well as the AHA panel, is concerned about false-positive test results that could exclude athletes from participating. Even detecting legitimate abnormalities raises questions, he said.

"Somebody who has an abnormality picked up on screening might be very, very different from somebody who has an abnormality picked up from symptoms," said Dr. Thompson. "I'm very concerned about this in athletes. I think because of the extent of screening we're doing now, and how sophisticated our tests are, we're finding a lot of athletes who we're disqualifying. We assume we're doing them a favor, but we really don't know for sure."

Circulation. Published online March 12, 2007.

The complete contents of Heartwire , a professional news service of WebMD, can be found at, a Web site for cardiovascular healthcare professionals.

Clinical Context

The precise prevalence of sudden deaths among young athletes is not known, but one study suggests this outcome occurs in 1 in 200,000 high school athletes. Cardiovascular disease is responsible for most of these sudden deaths, with hypertrophic cardiomyopathy accounting for approximately 36% of deaths due to cardiac disease. Less common abnormalities associated with sudden cardiac death in athletes include coronary artery anomalies, myocarditis, and mitral valve prolapse. Sudden death is far more common in boys than girls and disproportionately affects African Americans. In the United States, football and basketball are the sports more frequently associated with sudden cardiac death.

The current recommendations from the AHA examine issues of quality and practicality in screening young athletes in the United States for cardiac abnormalities.

Study Highlights

  • There are no laws in the United States requiring mandatory cardiovascular screening of athletes, and there is considerable heterogeneity regarding the approach to screening in different settings.
  • The authors suggest that adherence to the 2007 AHA preparticipation screening guidelines constitutes following the standard of care and may be used as a successful defense against alleged malpractice.
  • The AHA has developed a 12-item screening tool for cardiovascular disease among athletes. Any positive response or finding of the following 12 elements should prompt further cardiovascular testing. These elements include:
    • Personal history
      • Exertional chest pain/discomfort
      • Unexplained syncope/near-syncope
      • Excessive exertional dyspnea/fatigue or unexplained dyspnea
      • Prior recognition of a heart murmur
      • Elevated systemic blood pressure
    • Family history
      • Premature cardiovascular death before age 50 years in at least 1 relative
      • Disability due to heart disease in at least 1 relative younger than 50 years
      • Family history of hypertrophic cardiomyopathy, long-QT syndrome, or significant arrhythmia
    • Physical examination
      • Heart murmur
      • Diminished femoral pulses
      • Signs of Marfan syndrome
      • Elevated brachial blood pressure
  • The authors recommend that the medical history of minors be completed by parents, and they express a preference that licensed clinicians perform the screening examinations.
  • European agencies have advocated for the use of routine 12-lead ECG along with the history and physical examination components of cardiovascular screening in athletes. While screening with ECGs can reduce the rate of sudden cardiac death in athletes, it is also associated with low specificity due to normal physiologic changes in the heart of young athletes.
  • The current authors conclude that ECG should not be routinely used in the screening of young American athletes. They estimate that this program will cost $3.4 million for each potential life saved and also cite the potential for difficulty in follow-up of abnormal ECG results. They also express concern that medical personnel without adequate training will interpret ECG results.
  • The authors also recommend against the routine use of echocardiography in preparticipation examinations.

Pearls for Practice

  • Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death among young athletes in the United States.
  • The current guidelines suggest that routine preparticipation examination of young athletes in the United States should include the 12 elements of the AHA screening history and physical examination, but not ECG, echocardiography, or stress testing.

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