Download Sudden Cardiac Death (SCD) is a prevalent topic and concern for all

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Sudden Cardiac Death (SCD) is a prevalent topic and concern for all involved in the care
of student-athletes. Associated with this issue is how to screen for SCD and potentially prevent
these deaths. Some believe the 12-lead electrocardiogram (ECG) is necessary as part of the preparticipation physical exam (PPE), whereas others see it as an ineffective screening tool for SCD
(Asif & Drezner, 2012; O’Conner & Knoblauch, 2010). Even though there are critics who are
against the implementation of ECGs in PPEs for a variety of reasons, with proper
implementation and education, the effectiveness of ECGs can be improved (Drezner, Asif, &
Owens, 2012).
Pre-Participation Physical Exams
Main components of PPEs at the NCAA Division II level include a thorough medical
history, including cardiovascular questions as outlined by the American Heart Association, and
physical evaluation. “Red flags” on the PPE and medical history include, but are not limited to,
heart murmur, diagnosed enlarged heart in a family member, unexplained chest pain, and
complaints of skipped heartbeats.
Electrocardiograms have become a routine part of PPEs at the collegiate level. The
thought behind the use of ECGs is to screen for cardiac adaptations that may lead to sudden
cardiac death. Even so, there are a number of reasons that ECGs have not become a requirement
for PPEs. False-positive results are the main cause of criticism because most athletes with a
positive ECG will have no actual cardiac abnormality.
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Sudden Cardiac Death:
How to Detect Abnormalities?
An issue to discuss is which cardiac abnormalities are training induced and which are
pathological. Endurance athletes often have abnormal ECG readings as a result of training
induced abnormalities. Physicians need to be trained and up-to-date on reading ECGs. A possible
solution to this problem would be to create guidelines on which adaptations are training induced,
and which are abnormal. Macarie et al. (2009) and Drezner et al. (2012) have outlined guidelines
of normal and abnormal ECG readings. With use of these modern ECG guidelines, false-positive
rates have dropped from 7-15% to 2-3% (Drezner, Asif, & Owens, 2012) at the NCAA Division
I collegiate level. Physicians should be required to be up-to-date on these guidelines. Also, it
might be beneficial to specify which physicians should be allowed to read the athletes’ ECGs.
For example, a cardiologist would be much better practiced at reading ECGs than an orthopedic
physician.
Costs
In many instances the student must pick up the follow-up costs to determine if there is a
cardiac risk or not. If an athlete is flagged as having a cardiac abnormality, needing further tests,
this is a pre-existing injury and in most cases, not covered by the school’s secondary insurance.
Therefore, the student will be responsible for the testing costs. These costs average $371
according to the 2009 Medicare Physician Fee Schedule. This leaves a large majority of studentathletes spending money on follow-up costs.
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Who is at Risk?
One of the main arguments against routine ECGs for all athletes is the high number of
false-positive results. According to research, data predicts that 16% of cardiac abnormalities
would be read as positive for a cardiac abnormality; however, only 1.3% of that 16% would
actually have the abnormality (O’Conner & Knoblauch, 2010). Research has also shown that
black males are at the highest risk for cardiac abnormalities (O’Conner & Knoblauch, 2010). The
American Heart Association (AHA) has developed guidelines consisting of 12 questions that will
identify those individuals that may have a cardiac abnormality. Any athlete flagged because of
one of the AHA questions or at risk because of ethic background should be screened with an
ECG at PPEs (Maron et al., 2007). This would help to reduce costs stemming from false-positive
results.
Case Study
At Tarleton State University, in Stephenville, TX, the Sports Medicine staff strives to be
proactive in preventing cardiac emergencies. The staff performs an ECG on every incoming
athlete in addition to compiling a thorough medical history and physical evaluation. The exercise
physiologists on campus read the ECGs for abnormalities, which are then referred to the team
physician. The athletic trainers review the medical history of each athlete, looking for red flags
that may warrant a closer look at the ECG as well.
Approximately 90 new Tarleton State University student-athletes were screened during
the Fall 2012 pre-participation physical exams (PPEs). All athletes were questioned about past
medical history on a medical history questionnaire, which included ten of the recommended 12
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cardiovascular questions. Athletic trainers, a clinical exercise physiologist, and medical doctors
reviewed the PPEs for red-flags.
The athletic trainer for cross-country athletes performed the study and specifically chose
to focus on just these athletes. There were 10 total incoming cross-country athletes that were
screened during the required PPEs. After reviewing the medical history, four athletes were
flagged by the athletic trainer for cardiac concerns due to distinguishing presentation features - 3
males (Cross Country) and 1 female (1 Cross Country). All of the athletes were in their first year
of eligibility and the average age of the athletes was 18. A 12-lead electrocardiogram (ECG) was
performed on each athlete. It is not uncommon for highly trained athletes, especially endurance
athletes, to have cardiac adaptations classified as normal in an athlete compared to a sedentary
individual. After reviewing the ECGs of each athlete, the clinical exercise physiologists
recognized abnormalities from training induced cardiac adaptations in all ECGs. One of the four
also showed right atrial enlargement, which would be typically classified as a non-training
induced cardiac abnormality. However, the physician found only training induced abnormalities.
The team physician cleared the athlete for competition, stating that the abnormality was training
induced.
Results
The athletic trainer compared how many athletes were flagged from their medical history
paper work and how many showed cardiac abnormalities from their ECG. In this study, 40%
(4/10) of the incoming cross-country athletes were flagged as having cardiac concerns from their
medical history paperwork. Of those 40%, one (25%) had a cardiac abnormality as determined
by the exercise physiologist, even though the clearing physician found no such abnormality. The
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results of the case study were similar to the data found in current research. Our numbers were a
bit off, but we also had a very small sample size. Continuing research should be continued with a
larger sample size to allow for more accurate results.
In the study performed on the cross-country athletes at Tarleton State University, the
abnormal ECG readings included left ventricular hypertrophy (LVH), incomplete right bundle
branch block (IRBBB), sinus arrhythmia, and right atrial enlargement (RAE). LVH, IRBBB, and
sinus arrhythmia were all found to be normal training induced adaptations, however RAE is
typically a non-training induced cardiac abnormality. There were no follow-up costs for the
athlete or the university since the team physician cleared the athlete at physicals. The athlete with
RAE competed for the complete cross-country season without any issues or complaints related to
his cardiac abnormality. In all other cases normal training induced abnormalities did not prevent
athletic participation.
Conclusion
In conclusion, , it should be the responsibility of the athletic trainer at the university or
high school level to provide the best care possible in preventing injuries. Included in this task is
educating your physicians on updated PPE screening policies. The NCAA mandates that 10 of
the 12 AHA guidelines are included on PPEs and that a qualified physician evaluates all athletes
(Morse & Funk, 2012). Steps that could be most effective in providing effective cardiac
screening are providing physicians with appropriate guidelines on the difference between
training induced and abnormal cardiac adaptations. Also, only those physicians with up-to-date
training on reading ECGs should be allowed to read the ECGs. To limit the number of falsepositive results, an option could be to only require ECGs for those athletes who are at risk for
having a cardiac abnormality based on their medical history questionnaires.
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References
Asif IM, Drezner JA. Sudden Cardiac Death and Preparticipation Screening: The Debate
Continues – In Support of Electrocardiogram-Inclusive Preparticipation Screening.
Progress in Cardiovascular Diseases. 2012; 54: 445-450. doi:
10.1016/j.pcad.2012.01.001
Drezner JA, Asif IM, Owens DS, et al. Accuracy of ECG interpretation in competitive athletes:
the impact of using standardised ECG criteria. Br J Sports Med. 2012. doi:
10.1136/bjsports-2012-090612
Macarie C, Stoian I, Dermengiu D, et al. (2009) The electrocardiographic abnormalties in highly
trained athletes compared to the genetic study related to cause of unexpected sudden
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Maron BJ, Thompson PD, Ackerman MJ, et al. (2007) Recommendations and Considerations
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