Current controversies in pre-participation cardiovascular screening for young competitive athletes

ABSTRACT

Introduction

Pre-participation cardiovascular screening (PPCS) in athletes is recommended by numerous medical and sporting societies. While there is consensus that young athletes should be screened prior to participation in competitive sports, there are on-going debates regarding the true incidence of sudden cardiac death (SCD), the most frequent causes of SCD, and the optimal methods for PPCS.

Areas covered

This review focuses on the current evidence for the incidence of SCD, causes of SCD, and the pros and cons of a history and physical exam (H&P) and electrocardiogram (ECG) in PPCS of young competitive athletes.

Expert opinion

With significant controversy surrounding PPCS in athletes, a large-randomized trial powered for mortality is needed to assess the utility of PPCS and to define the optimal screening methods to detect cardiovascular diseases that may lead to SCD in competitive athletes. Until a trial of this caliber is created, controversy will remain and heterogeneity in care will exist. Future research should also define the optimal timing and frequency of PPCS given age-related penetrance of certain diseases, create evidence-based history questionnaires, continue to optimize ECG screening criteria, and create more learning modules for ECG interpretation in athletes.

KEYWORDS:

• Preparticipation screening
• athletes heart
• sports cardiology
• sudden death
• exercise

Article highlights

• The most common cause of SCD in young athletes is debated but thought to be from autopsy-negative SCD (e.g. primary channelopathy or arrhythmia) or HCM.

• A focused H&P is currently recommended for PPCS by all major cardiovascular and sporting governing societies.

• The H&P is limited by a low sensitivity, high false positive rate, heterogeneity in physical exam skills among providers, questionnaires are based on expert opinion, and the history requires honest reporting from athletes.

• ECG screening is currently recommended by European guidelines and most sporting societies, but only under certain circumstances in US guidelines.

• Significant limitations of ECG screening include: high costs of testing, significant experience needed to perform adequate interpretation, higher than optimal FPR in certain populations, and potential false negatives in certain conditions (e.g. coronary anomalies).

• A large-randomized clinical trial powered for mortality is needed to assess the true impacts of PPCS.

Declaration of interest

This paper was funded by the National Institute of Health/National Heart, Lung, and Blood Institute, the National Football Players Association, and the American Heart Association and AL Baggish also receives compensation for his role as team cardiologist from the US Olympic Committee/US Olympic Training Centers, US Soccer, US Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was funded by the National Institute of Health/National Heart, Lung, and Blood Institute (1R01HL125869-01A1), the National Football Players Association, and the American Heart Association and A Baggish receives compensation for his role as team cardiologist from the US Olympic Committee/US Olympic Training Centers, US Soccer, US Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University.