Cardiovascular screening

Cardiovascular Screening of Student Athletes
JAMES M. LYZNICKI, M.S., M.P.H.
American Medical Association Council on Scientific Affairs, Chicago, Illinois
NANCY H. NIELSEN, M.D., PH.D
State University of New York at Buffalo, Buffalo, New York
JOHN F. SCHNEIDER, M.D., PH.D.
University of Chicago Hospitals, Chicago, Illinois

Each year, a number of children and adolescents die suddenly from cardiac problems that are associated
with a small subgroup of disorders and high-risk behaviors. While sudden cardiac death in any child or
adolescent is distressing, it can be particularly devastating when it occurs in a seemingly healthy
young athlete. Although uncommon in competitive sports, sudden death is a catastrophe that physicians
who care for athletes should attempt to prevent. To prevent the occurrence of sudden death or
cardiovascular disease progression in young athletes, the American Academy of Family Physicians,
American Academy of Pediatrics, American College of Cardiology, American College of Sports Medicine,
American Heart Association, American Medical Society for Sports Medicine, American Orthopaedic Society
for Sports Medicine and American Osteopathic Academy of Sports Medicine have developed or endorsed
recommendations for cardiovascular screening of student athletes as part of a comprehensive sports
preparticipation physical evaluation (PPE). Knowledge and understanding of these recommendations can
help physicians make informed decisions about the eligibility of an athlete to participate in a
particular sport and encourage development of a more uniform PPE screening process. (Am Fam Physician
2000;62:765-84.)

Sudden cardiac death is defined as a nontraumatic, nonviolent, unexpected event resulting from sudden
cardiac arrest within six hours of a previously witnessed state of normal health.1 Reliable estimates of
the frequency of sudden cardiac death in young athletes are lacking. Such events are believed to occur
in about 1 per 200,000 high school athletes per academic year.2,3 From 1983 to 1993, the National Center
for Catastrophic Sports Injury Research4 found that nontraumatic sports-related deaths occurred in 126
high school athletes and 34 college athletes (about 16 deaths per year); 100 of these deaths were
cardiovascular in origin. Estimated death rates in high school and college athletes were fivefold higher
in men than in women (7.5 per million per year versus 1.3 per million per year).4

Most fatalities in child and adolescent athletes are caused by underlying congenital cardiac anomalies,
primarily hypertrophic cardiomyopathy (36 percent), coronary artery abnormalities (19 percent) and
increased cardiac mass (10 percent).3 The remaining percentage is composed of a constellation of
cardiovascular and noncardiovascular causes including myocarditis, Marfan syndrome, mitral valve
prolapse, dysrhythmias, aortic stenosis, Wolff-Parkinson-White syndrome, idiopathic long QT syndrome,
arrhythmogenic right ventricular dysplasia, cocaine and anabolic steroid use, bulimia, anorexia nervosa,
bronchospasm and heat-related illness.3,5-11 Coronary artery disease in adolescent athletes, unlike in
the adult population, is an uncommon cause of sudden death. Detection of cardiovascular abnormalities
that may cause substantial morbidity or sudden death is difficult, considering that congenital cardiac
abnormalities relevant to athletic screening account for a combined prevalence of about 0.2 percent in
athletic populations.3

Most fatalities in child and adolescent athletes are caused by underlying congenital cardiac anomalies,
primarily hypertrophic cardiomyopathy (36 percent), coronary artery abnormalities (19 percent) and
increased muscle mass (10 percent).

Despite their rare occurrence, underlying cardiac anomalies in young athletes are emphasized because of
the potential they pose for causing cardiovascular collapse during competition.

TABLE 1
American Heart Association Recommendations for Cardiovascular Preparticipation Physical Evaluation

A national standard is needed for preparticipation medical evaluations, including cardiovascular
screening, because of heterogeneity in the design and content of preparticipation screening among
states. Some form of cardiovascular preparticipation screening is justifiable and compelling for all
high school and college athletes, based on ethical, legal and medical grounds.
Cardiovascular preparticipation screening, including a history and physical examination, should be
mandatory for all athletes and should be performed before participation in organized high school (grades
nine through 12) and college sports.
A complete and careful personal and family history and physical examination designed to identify (or
raise suspicion of) those cardiovascular lesions known to cause sudden death or disease progression in
young athletes is the best available and most practical approach to screening populations of competitive
sports participants, regardless of age.
The examination is to be performed by a health care worker (preferably a physician) who has the
requisite training, medical skills and background to reliably obtain a detailed cardiovascular history,
perform a physical examination and recognize heart disease.
For high school athletes, screening must occur every two years, with an interim history in intervening
years.

Reprinted with permission from Maron BJ, Thompson PD, Puffer JC, McGrew CA, Strong WB, Douglas PS, et
al. Cardiovascular preparticipation screening of competitive athletes. A statement for health
professionals from the Sudden Death Committee and Congenital Cardiac Defects Committee, American Heart
Association. Circulation 1996;94:850-6 [Addendum published in Circulation 1998;97:2294].

AHA Recommendations for Screening
Because of heightened concern about sudden death in competitive athletes, the American Heart Association
(AHA) issued consensus recommendations in 1996 (Tables 1 and 2) for the cardiovascular component of the
PPE.3 According to the AHA, the focus of cardiovascular PPE screening is "to provide medical clearance
for participation in competitive sports through routine and systematic evaluations intended to identify
clinically relevant and preexisting cardiovascular abnormalities and thereby reduce the risks associated
with organized sports."

Currently, there is no cost-effective battery of tests to identify all, or even most, dangerous
cardiovascular conditions.

A complete, careful personal and family history and physical examination are recommended to identify or
raise suspicion of cardiovascular lesions known to cause sudden cardiac death or disease progression in
young athletes. The cardiac history focuses on questions that screen for congenital heart disease and
symptoms that suggest an underlying cardiac problem. When cardiovascular abnormalities are identified or
suspected, the athlete should be referred to a specialist for further evaluation or confirmation.
Despite a lack of compelling evidence to show that cardiovascular PPE screening is effective, it is
recommended based on cost and medicolegal considerations. While this method may be imperfect, the AHA
panel considered it the most practical and best available strategy for screening large populations of
athletes.

Sudden cardiac death is defined as a nontraumatic, nonviolent, unexpected event resulting from sudden
cardiac arrest within six hours of a previously witnessed state of normal health.

Noninvasive testing (e.g., echocardiography and electrocardiography [ECG]) can enhance the diagnostic
power of the standard history and physical examination, but it is not recommended for cardiovascular PPE
screening. Comprehensive and expensive screening tests have not proved to be cost-effective, nor can
they consistently identify athletes at risk. This considers the large number of competitive athletes in
the United States, the relatively low frequency of cardiovascular lesions responsible for these deaths
and the low rate of sudden cardiac death in young athletes.

TABLE 2
American Heart Association Recommendations for Cardiovascular History and Physical Examination

Cardiovascular history
Inquire about and seek parental verification of a:
Family history of premature death (sudden or otherwise)
Family history of heart disease in surviving relatives, or significant disability from cardiovascular
disease in close relatives younger than 50 years, or specific knowledge of the occurrence of conditions
(i.e., hypertrophic cardiomyopathy, long QT syndrome, Marfan syndrome, or clinically important
arrhythmias)
Personal history of heart murmur
Personal history of systemic hypertension
Personal history of excessive fatigability
Personal history of syncope, or excessive/progressive shortness of breath (dyspnea) or chest
pain/discomfort, particularly if present with exertion
Physical examination
Perform precordial auscultation in supine and standing positions to identify, in particular, heart
murmurs consistent with dynamic left ventricular outflow obstruction.
Assess femoral artery pulses to exclude coarctation of the aorta.
Recognize physical stigmata of Marfan syndrome.
Assess brachial artery blood pressure in the sitting position.

Adapted with permission from Maron BJ, Thompson PD, Puffer JC, McGrew CA, Strong WB, Douglas PS, et al.
Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals
from the Sudden Death Committee and Congenital Cardiac Defects Committee, American Heart Association.
Circulation 1996;94:850-6 [Addendum published in Circulation 1998; 97:2294]

Consensus Guidelines of PPE Task Force
Some form of preparticipation screening of athletes is customary medical practice in many high schools,
colleges and universities in the United States.

TABLE 3
Objectives of the Preparticipation Physical Evaluation (PPE)

The PPE provides an opportunity to assess the overall health of the athlete to:
Detect medical or musculoskeletal conditions that may predispose to injury or illness during competition.
Detect potentially life-threatening or disabling medical or musculoskeletal conditions that may limit an
athlete's safe participation in sports.
Meet legal and insurance requirements.
Depending on available time and resources, the PPE is also an opportunity to:
Determine the general health of the athlete.
Counsel and educate athletes on health-related issues (e.g., use of tobacco, alcohol and other drugs,
unhealthy sexual practices and psychosocial issues).
Assess fitness levels for specific sports.

Reprinted with permission from Smith DM, American Academy of Family Physicians, Preparticipation
Physical Evaluation Task Force. Preparticipation physical evaluation. 2d ed. Minneapolis: Physician and
Sportsmedicine, 1997.

In 1997, the Preparticipation Physical Evaluation Task Force,12 composed of members of the American
Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American Medical Society for
Sports Medicine, American Orthopaedic Society for Sports Medicine and American Osteopathic Academy of
Sports Medicine released the second edition of a guide for physicians who perform PPEs. The monograph
covers the goals of the PPE, gives detailed instructions on how to obtain a preparticipation history and
perform a physical examination, and information on determining clearance for participation, and
discusses medicolegal precautions. It establishes the minimum content for PPEs and provides an outline
for primary care physicians regarding appropriate steps in the PPE. No optimal method of delivery of
PPEs is endorsed. If the athlete's history and physical examination findings raise suspicion, further
diagnostic work-up is recommended, including echocardiography, ECG or exercise stress testing. Like the
AHA panel,3 the PPE Task Force determined that routine use of such procedures in preparticipation
screening is not cost-effective.
The monograph includes a "Preparticipation Physical Evaluation" form (Figure 1) that physicians can copy
and use for each examination. Three items recommended by the AHA are not included on this form (i.e.,
family history of heart disease, a specific item for recognition of a heart murmur in the physical
examination and a specific item for recognition of the physical stigmata of Marfan syndrome).19 While
these discrepancies may be considered by the PPE Task Force in the future, use of the current PPE form
can help ensure that examining physicians consider the following components of the cardiac evaluation
recommended by the PPE Task Force.

Preparticipation Physical Evaluation

Medical History
It is unlikely that many young athletes who experience chest pain, syncope, exercise intolerance or
palpitations, or who have a clinically significant family history will reveal such information unless
specifically asked. The medical history is therefore a critical aspect of the cardiac evaluation.
Careful attention to the cardiac history is warranted because several of the conditions known to cause
sudden cardiac death (e.g., arrhythmias, premature coronary artery disease and aberrant coronary
arteries) have no auscultatory findings. If possible, the student athlete and a parent should complete
the history form together before the physical examination.
Dizziness, lightheadedness or syncope during or after exercise may indicate underlying hypertrophic
cardiomyopathy, conduction abnormalities, arrhythmias or valvular problems such as aortic stenosis and
mitral valve prolapse. Chest pains during or after exercise may indicate a coronary artery anomaly or
advanced cardiovascular disease. Dyspnea that is out of proportion to activity may indicate structural
abnormalities, valve problems or underlying lung disease.
Palpitations during or after exercise may signal arrhythmias or conduction abnormalities. A history of
high blood pressure, high cholesterol levels, recent viral illness (e.g., myocarditis, mononucleosis) or
prior restriction from participation in sports for cardiovascular reasons warrant further investigation.
A history of heart murmur merits concern, although a benign murmur may be detected on examination of
many athletes.
Relevant history should include recent legal and illegal drug use (including alcohol and tobacco),
eating disorders, history of congenital heart disease or previous cardiac surgery. A family history of
sudden death before age 50 is extremely important, as some causes of death can be familial (premature
coronary artery disease, Marfan syndrome and hypertrophic cardiomyopathy). Any history that suggests a
risk for congenital heart disease should stimulate more in-depth cardiac evaluation.
Physicial Examination
A complete physical examination is not indicated in a sports PPE. Screening is generally limited to
physical examination of the cardiovascular and musculoskeletal systems, eyes, oral cavity, ears, nose,
lungs, abdomen, genitalia (males) and skin. Anthropometric measurement includes height, weight and blood
pressure. Cardiovascular examination should include resting blood pressure, palpation of radial and
femoral pulses and auscultation of the heart.
Auscultation of the Heart. Auscultation of the heart should be performed with the patient in standing
and supine positions to detect murmurs and dysrhythmias. Murmurs in adolescents are common, and various
maneuvers can be performed to help differentiate functional from pathologic murmurs.
Detected arrhythmias also may require further cardiac evaluation.
Blood Pressure and Pulses. In children and adolescents, blood pressure should be compared to
age-adjusted tables. If the blood pressure remains elevated above the age-related criteria for
hypertension after a 10- to 15-minute rest period, the athlete should be questioned about the use of
caffeine, nicotine or even over-the-counter stimulants such as ephedrine, and referred to his or her own
personal physician for evaluation before clearance. Peripheral pulses (radial and femoral) also should
be measured for rate and rhythm and to rule out coarctation of the aorta.
Medical Clearance
When a significant cardiovascular problem is identified, management decisions must include the magnitude
of that person's risk for sudden death with continued participation in competitive sports and whether
the athlete should be disqualified from such participation. In addition to clinical judgment, physician
decisions regarding clearance for a particular sport may be based on guidelines established by the AAP
Committee on Sports Medicine and Fitness or, for cardiovascular abnormalities, on the 26th Bethesda
Conference guidelines.20 The report of the 26th Bethesda Conference (sponsored by the American College
of Cardiology [ACC] and the American College of Sports Medicine [ACSM]) reviews the nature and severity
of about 70 relevant cardiovascular abnormalities and diseases, and provides specific recommendations
for athletic eligibility. The AAP recommendations address cardiac problems in addition to other
potentially disqualifying medical conditions and divide sports into contact categories, based on risk of
injury from collision, and categories based on degree of strenuousness.21
Any restriction to activity should be fully explained to the athlete, parents, coaching staff and other
school personnel.12 If an athlete has not been cleared for a particular sport, the physician needs to
act as the athlete's advocate and advise the athlete, family and athletic staff regarding the risk of
participation. Physicians who perform PPEs should inform athletes and their parents of the limitations
of cardiovascular screening and the small risks that may remain despite normal findings in the screening
examination. Should the athlete and parents risk participation, it is generally necessary for them to
sign a legal document stating that they understand the potential risk of participation to the athlete,
although such documents are not always legally binding. If the athlete's condition is thought to be too
great a risk to the person or a danger to the health of other participants, the athlete still may be
excluded from participation.

Status of Preparticipation Screening
No uniformly accepted standards exist for conducting sports PPEs or certifying health professionals who
perform these examinations.3,22 Decisions on PPE content are often made locally by school districts and
even individual schools, resulting in great variation in the way PPEs are conducted. While all states
that designate specific examiners recommend that physicians be responsible for preparticipation
screening, 21 states allow nurses or physician assistants to conduct PPEs, and 11 states allow
chiropractors to provide athletic clearance.22
A survey of state high school athletic associations in the 50 states and Washington, D.C., revealed that
eight states did not offer an approved history and physical examination questionnaire to guide PPE
examiners, and one state (Rhode Island) had no preparticipation screening requirement.22 Of 43 states
that had approved PPE forms, only 17 (40 percent) had history and physical examination questionnaires
that incorporated most of the 1996 AHA recommendations. Despite the availability and medical endorsement
of a standard PPE form,12 a nationwide survey of 254 high schools revealed that only 17 percent used
forms that contained all the elements of the cardiac history recommended for identifying athletes at
risk for sudden death.23

A survey of 879 National Collegiate Athletic Association colleges and universities found that PPE
screening was required by 855 schools (97 percent) and was required annually by 446 schools (51
percent).24 Analysis of PPE forms from 625 of these schools revealed that 163 (26 percent) incorporated
most of the 1996 AHA recommendations for cardiovascular PPE screening.

Conclusions
Cardiovascular PPE screening poses problems because potentially fatal abnormalities are uncommon and in
some cases undetectable without sophisticated tests. Most sudden cardiac deaths in athletes are caused
by anomalies that are clinically silent, rare or difficult to detect by history and physical
examination. Many athletes may not experience symptoms consistent with heart disease or may not report
family histories of sudden cardiac death. Important clues to a cardiac abnormality include history of
syncope, chest pain and family history of sudden death. Any underlying condition suspected on the basis
of history or physical examination requires further diagnostic evaluation before the athlete can be
cleared for activity.
Because of variability and inconsistency among state requirements for PPEs, adoption of a more uniform
PPE screening process must be encouraged to close the gap between screening practices recommended by
sports medicine experts and actual practice. Training or accreditation of PPE examiners also should be
considered.
While the extent of screening continues to be debated, clinical guidelines for performing PPEs and
determining clearance have been established. For cardiovascular screening, a focused personal and family
history and physical examination are recommended by the AHA and seven other medical organizations as the
best available methods of identifying risk factors for sudden death in young athletes. Without
standardized methods for screening athletes for occult and possibly lethal heart disease, it is not
possible to assess the value of a focused history and physical examination in detecting and preventing
cardiovascular death.
Future advances in the diagnosis, treatment and understanding of cardiovascular disease will likely
provide better tools for preventing sudden death in young athletes. Physicians should be alert to the
emerging role of genetic testing for cardiovascular diseases in athletes with a family history of heart
disease or sudden cardiac death (e.g., hypertrophic cardiomyopathy, long QT syndrome) or a known genetic
disorder in which cardiac problems may be a component (Marfan syndrome). Currently, genetic screening
(i.e., for hypertrophic cardiomyopathy) is not practical or feasible in large populations.3,25 As this
technology becomes more available, the medical, ethical and legal implications of genetic testing of
athletes will require careful deliberation.
Members and staff of the Council on Scientific Affairs at the time this report was prepared include the
following: Myron Genel, M.D.; Michael A. Williams, M.D.; Roy D. Altman, M.D.; Scott D. Deitchman, M.D.,
M.P.H.; J. Chris Hawk III, M.D.; John P. Howe III, M.D.; Hillary D. Johnson; Nancy H. Nielsen, M.D.,
Ph.D., John F. Schneider, M.D., Ph.D.; Melvyn L. Sterling, M.D.; Zoltan Trizna, M.D., Ph.D.; and Donald
C. Young, M.D. Staff: Barry D. Dickinson, Ph.D.; James M. Lyznicki, M.S., M.P.H.; and Marsha Meyer.
The original version of this article was presented as Report 5 of the Council on Scientific Affairs at
the 1999 American Medical Association (AMA) Interim Meeting. Recommendations were adopted at that
meeting as AMA policy. See accompanying editorial for recommendations.

The Authors
JAMES M. LYZNICKI, M.S., M.P.H.,
is a senior scientist in the American Medical Association (AMA) Group on Science, Technology, and Public
Health, and assistant secretary to the AMA Council on Scientific Affairs. He received a master of
science degree at the University of Minnesota at Minneapolis and a master of public health degree at the
University of Illinois at Chicago School of Public Health.
NANCY H. NIELSEN, M.D., PH.D.,
serves as clinical faculty at the State University of New York at Buffalo School of Medicine and
Biomedical Sciences. She earned a medical degree from State University of New York at Buffalo School of
Medicine and Biomedical Sciences, where she served a residency in internal medicine. She earned a
doctoral degree in microbiology from Catholic University of America, Washington, D.C.
JOHN F. SCHNEIDER, M.D., PH.D.,
is in practice at the University of Chicago Hospitals and professor of clinical medicine in the Division
of Biological Sciences at the University of Chicago Pritzker School of Medicine. He earned a medical
degree and a doctoral degree in biochemistry from the University of Chicago Pritzker School of Medicine.
Address correspondence to Barry Dickinson, Ph.D., Secretary to the Council on Scientific Affairs,
American Medical Association, 515 N. State St., Chicago, IL 60610. E-mail address:
barry_dickinson@ama-assn.org. Reprints are not available from the authors.
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