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Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine
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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.
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 www.theheart.org, a Web site for cardiovascular healthcare professionals.
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.
