Annual preparticipation physical evaluation (PPE) is used in the United States to screen adolescents for potential causes of sudden cardiac death. The American Heart Association recommends 14 screening elements of history and physical examination. This study sought to define the utilization of these screening elements by each of the 50 states before high school athletics.
PPE forms were obtained from the public website of the high school athletics governing body in every state. Form content was analyzed to identify which of the 14 screening elements were explicitly fulfilled. Additional PPE forms provided by private/parochial schools, other professional societies, or independent groups were excluded from this study.
A total of 48 states (96%) had PPE forms posted online. The remaining 2 states (4%) deferred the specific method of PPE documentation to individual school districts and provided no standardized form. Of the 48 states providing PPE forms, 13 (27%) included all 14 American Heart Association screening elements. The median criteria included by each state was 11 (range 3–14). The 3 criteria most commonly absent were (1) the examination of femoral pulses to exclude coarctation (58%), (2) a family history of specific inherited cardiac disease (31%), and (3) personal history of hypertension (27%).
Annual preparticipation forms are important screening tools. Only a minority of states include all 14 cardiac screening elements recommended by the American Heart Association.
Annual sports preparticipation screening is used across the United States to optimize the safety of young athletes, including identification of known causes of sudden cardiac death. The American Heart Association guidelines recommend cardiac screening of athletes by history and physical examination.
A review of existing preparticipation screening forms across states reveals that only a minority of states include all 14 elements of cardiac screening from the American Heart Association.
Sudden cardiac death (SCD) in a young athlete is tragic and shocking, particularly because of the unexpected nature of such an event in a generally healthy population. Accordingly, strategies for the prevention of SCD in athletes have been the subject of study and debate among communities and sporting organizations, as well as within the medical profession. Although causes of SCD in athletes have been identified, screening for these in a large population remains a challenge.
Although preparticipation screening is widely supported, the debate regarding the best screening method for young athletes continues. The American Heart Association (AHA) published recommended screening elements for clinicians to include in the annual preparticipation assessment of athletes. A slate of recommendations was originally published in 1996; however, these were updated by the AHA in 2007 to include 12 total elements (8 elements of personal and family history, as well as 4 elements of the physical examination).1 Most recently, the AHA added 2 elements of “Prior restriction from participation in sports” and “Prior testing for the heart, ordered by a physician,” which now complete the 14-point screening criteria.2
Although guidelines have been in place, the adoption into practice across the United States remains uncertain.3 As such, the authors of this study sought to quantify the inclusion of the AHA 14-point screening elements on standardized preparticipation physical examination (PPE) forms for high school athletes in each of the 50 states.
Methods
PPE forms were obtained from the public website of the high school athletics governing body in every state throughout the United States, all of which were members of the National Federation of State High School Associations. These forms were analyzed to identify which of the 14-element screening checklist were explicitly fulfilled, as listed in Table 1. Certain specifications were taken to provide a standardized analysis of which forms met each criterion. For element 4, PPE forms did not fulfill AHA criteria if a question was asked about “heart problems” without specifically mentioning previous “heart murmurs.” For elements 8 and 9, PPE forms did not fulfill AHA criteria if a question was asked about premature death or heart disease in relatives “before age 35.” For element 9, forms stating heart problems when asking about known heart disease in relatives did meet AHA criteria. Regarding the physical examination sections, for element 12, PPE forms specifying examination of “femoral pulses” did not fulfill AHA criteria; however, PPE forms specifying “simultaneous brachial and femoral pulses” did meet AHA criteria. For element 13, PPE forms did not fulfill AHA criteria if a question did not explicitly state “Marfan” or the various stigmata associated with Marfan syndrome. Comparisons were made to the previously recommended 12-point screening criteria from the AHA (2007). Additional PPE forms provided by private, parochial, other professional societies, or independent groups were excluded from this study.
The 14-Element AHA Recommendations for Cardiac Screening of Adolescent Athletes
Medical historya . | Physical examination . |
---|---|
Personal history | 11. Heart murmurc |
1. Exertional chest pain/discomfort | 12. Femoral pulses to exclude aortic coarctation |
2. Unexplained syncope/near-syncopeb | 13. Physical stigmata of Marfan syndrome |
3. Excessive exertional and unexplained dyspnea/fatigue, associated with exercise | 14. Brachial artery blood pressure (sitting position)d |
4. Previous recognition of a heart murmur | |
5. Elevated systemic blood pressure | |
6. Previous restriction from participation in sports | |
7. Previous testing for the heart, ordered by a physician | |
Family history | |
8. Premature death (sudden and unexpected or otherwise) before age 50 y due to heart disease, in ≥1 relative | |
9. Disability from heart disease in a close relative <50 y of age | |
10. Specific knowledge of certain cardiac conditions in family members: hypertrophic cardiomyopathy or dilated cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias |
Medical historya . | Physical examination . |
---|---|
Personal history | 11. Heart murmurc |
1. Exertional chest pain/discomfort | 12. Femoral pulses to exclude aortic coarctation |
2. Unexplained syncope/near-syncopeb | 13. Physical stigmata of Marfan syndrome |
3. Excessive exertional and unexplained dyspnea/fatigue, associated with exercise | 14. Brachial artery blood pressure (sitting position)d |
4. Previous recognition of a heart murmur | |
5. Elevated systemic blood pressure | |
6. Previous restriction from participation in sports | |
7. Previous testing for the heart, ordered by a physician | |
Family history | |
8. Premature death (sudden and unexpected or otherwise) before age 50 y due to heart disease, in ≥1 relative | |
9. Disability from heart disease in a close relative <50 y of age | |
10. Specific knowledge of certain cardiac conditions in family members: hypertrophic cardiomyopathy or dilated cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias |
Parental verification is recommended for high school and middle school athletes.
Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion.
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.
Preferably taken in both arms.
Results
Each of the 50 United States addressed PPE on their individual websites. A total of 48 states (96%) had PPE forms posted online and publicly accessible. The remaining 2 states (4%) deferred the specific method of PPE documentation to individual school districts and provided no standardized form. Of the 48 states providing PPE forms, 13 (27%) included all 14 AHA screening elements (Fig 1), as listed in Table 1. The median number of screening elements included across all PPE forms was 11 (range 3–14). The 2 elements added by the AHA in 2014 (prior restriction from participation in sports and prior testing for the heart, ordered by a physician) were included by 42 (88%) and 36 (75%) states, respectively, with 13 states (27%) omitting at least 1 of these from the PPE form. The 3 criteria that were most commonly absent were (1) examination of femoral pulses to exclude coarctation (absent from 58%), (2) family history of “hypertrophic or dilated cardiomyopathy, long QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias, or specific knowledge of genetic cardiac conditions in family members” (absent from 31%), and (3) personal history of elevated systemic blood pressure (absent from 27%). There was no difference in the number of states fulfilling all current 14-point criteria (13, 27%) versus the previous 12-point criteria (13, 27%) (P = NS).
Map of the United States of America, with color of individual states denoting the number of AHA screening elements (out of 14 total) included in athletic preparticipation screening forms.
Map of the United States of America, with color of individual states denoting the number of AHA screening elements (out of 14 total) included in athletic preparticipation screening forms.
Discussion
Sudden cardiac death in young athletes can occur in a variety of cardiovascular diseases. The most common cause was previously believed to be hypertrophic cardiomyopathy.1 However, more recent studies have revealed autopsy-negative sudden unexplained death as the most frequent finding in SCD in athletes, suggesting channelopathies (long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, short QT syndrome, and arrhythmogenic right ventricular cardiomyopathy) as the most common underlying pathology.2 Coronary artery anomalies and hypertrophic cardiomyopathy follow in frequency.2,4 Many individuals are asymptomatic before a cardiac event. Strategies for screening a heterogenous population in the United States have been focused on consistent and standardized questions, specifically pertaining to the patient’s personal medical history, family history, and physical examination findings.
The best method of screening to identify those athletes at a high risk of SCD remains controversial. Standardized screening questionnaires have been associated with a high false positive response rate, cited up to 68% in some studies.5–7 The authors of another study of 1596 participants, including high school, collegiate, and professional athletes, reported that 380 (23.8%) had positive personal and/or family history questionnaires.6 Lastly, a large multicenter study of 5258 collegiate athletes found at least 1 positive history and/or physical examination finding in 33.3% of athletes.8 Careful and intentional review by a physician is then required for each positive response or physical examination finding, sometimes necessitating referral and/or additional diagnostic studies. For this reason, screening questionnaires continue to evolve and be refined, most recently with the publication of the fifth edition of PPE: Preparticipation Physical Evaluation, with recommendations for cardiac screening as endorsed by multiple medical societies.9
Many aspects of the PPE for high school sports will continue to be debated. Best practices regarding PPE screening, implementation, and ongoing evaluation require many stakeholders at all levels, as has been demonstrated in the medical literature with the subject of utilizing the electrocardiogram in PPE screening of athletes for cardiac disease.10–13 Recent literature suggests that the sensitivity of the 14-element screening of history and physical examination from the AHA for PPE has sensitivity and specificity of 18.8% and 68% for cardiovascular risk factors among high school athletes, respectively, whereas the sensitivity and specificity of screening ECG alone are 87.5% and 92.5%, respectively.11 Likewise, a meta-analysis revealed that the sensitivity of history, physical examination, and ECG for cardiovascular conditions in athletes was 20%, 9%, and 94%, respectively.14
Despite the issues and complexities of screening methods, the AHA has provided a 14-element checklist to guide physicians in PPE screening of athletes. After the current review herein, PPE forms in only a minority of states (27%) explicitly included all 14 elements. Previous studies have revealed similar results. In 1998, PPE screening questionnaires for high school athletes across the United States and compared with the 13 AHA recommendations listed in the 1996 AHA consensus panel guidelines on PPE screening. Of the 43 states with available questionnaires, 12 (28%) contained 4 or fewer of the 13 AHA elements, whereas 17 (40%) contained at least 9 of the 13 AHA elements.15 A follow-up study compared screening questionnaires available in 2005 with those in 1997, evaluating if cardiovascular screening for high school athletes had changed. These screening questionnaires were analyzed with respect to the 2007 12-element AHA recommended guidelines. In 2005, 48 states had approved PPE forms, with 1 (2%) containing 4 or fewer of the 12 AHA elements and 39 (81%) with at least 9 of the 12 AHA elements.16 For the medical community, this is an opportunity for ongoing education regarding PPE screening of athletes for cardiac disease, as well as continued adherence to guidelines for ECG interpretation in athletes.17
As such, there is continued momentum for the improvement of identifying pediatric and adolescent athletes who are predisposed to SCD.18 In 2012, the American Academy of Pediatrics (AAP) released a policy statement that recommended 4 questions to help identify individuals who may be at increased risk of SCD; however, unlike the AHA recommendations, the AAP screening questions were intended to be used in all children and adolescents, regardless of their intent to participate in athletics.19 In the 2021 AAP policy statement, these 4 screening questions on personal and family history were modified:
Have you ever fainted, passed out, or had an unexplained seizure suddenly and without warning, especially during exercise or in response to sudden loud noises, such as doorbells, alarm clocks, and ringing telephones?
Have you ever had exercise-related chest pain or shortness of breath?
Has anyone in your immediate family (parents, grandparents, siblings) or other, more distant relatives (aunts, uncles, cousins) died of heart problems or had an unexpected sudden death before age 50? This would include unexpected drownings, unexplained auto crashes in which the relative was driving, or SIDS.
Are you related to anyone with HCM or hypertrophic obstructive cardiomyopathy, Marfan syndrome, ACM, LQTS, short QT syndrome, Brugada syndrome, or CPVT or anyone younger than 50 years with a pacemaker or implantable defibrillator?20
The limitations of this study include that state-by-state analysis of PPE forms was only conducted by using the 14-point screening criteria from the AHA; other published recommendations were not considered. The authors of this study sought to identify if and how the most recent 14-point screening elements published by the AHA are currently used across the states. To do so, strict adherence to the wording used by the AHA was maintained. Variations in age or wording (for example, heartproblems vs heart murmurs) were not accepted to describe adherence specifically to the AHA 14-point screening elements. The current study herein analyzed only existing PPE screening forms available in the public domain. Additional screening that may have been performed and documented for individual athletes by providers was not considered. Likewise, additional forms or screening tools available to or required by various educational institutions, other professional societies, or independent groups were not considered.
Conclusions
Annual PPE forms are commonly used by medical providers to improve the health and safety of athletes; however, only a minority of states currently include all 14 cardiac screening elements recommended by the American Heart Association. Athlete wellness and prevention of sudden cardiac death should be a national priority. This study reveals that conversations between physicians and high school activities associations are needed to increase the utilization of recommended criteria in annual screening forms provided by high school athletic associations in all states.
Dr Blank collected data, conducted the initial analyses, and drafted the initial manuscript; Drs Robinson and Spicer conceptualized and designed the study and coordinated and supervised data collection; and all authors reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
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