Download Tool for Cardiovascular Screening of Competitive Athletes

SportXXII,
Science
vol. 405
XXII,
No. 5-6, December 2013
Sport Science Review, vol.
no.Review,
5-6, 2013,
- 415
DOI: 10.2478/ssr-2013-0020
Pre Participation Examination:
Tool for Cardiovascular Screening
of Competitive Athletes
Kulroop KAUR BADWAL1
T
he heart of an athlete has instilled inquisitiveness in many
researchers, clinicians since a century. It is now well established
that tedious physical training results in significant changes in cardiac structure
and function. The recent increases in the number of people participating in
recreational exercises and sports competitions have led to growing number of
people exhibiting such changes. So the pre-participation screening becomes
an important tool for non invasive examination and for diagnostic purposes.
The main purpose of this consensus document is to reinforce the principle
of the need for pre-participation medical clearance of all competitive
athletes involved in organized sports programs, on the basis of (i) systematic
screening by 12-lead ECG (in addition to history and physical examination)
to identify hypertrophic cardiomyopathy - the leading cause of sportsrelated sudden death - and to prevent athletic field fatalities; (ii) transthoracic
echocardiography with the potential ability of screening ability in detecting
other lethal cardiovascular diseases.
Keywords: Cardiovascular screening, sudden death, athletes
1 Department of Sports Medicine & Physiotherapy, Guru Nanak Dev University, Amritsar, Punjab, India
ISSN: (print) 2066-8732/(online) 2069-7244
© 2013 • National Institute for Sport Research • Bucharest, Romania
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405
Tool for Cardiovascular Screening of Competitive Athletes
Introduction
Competitive athlete dying on a field is a tragedy having a great impact on the
lay and medical personnel (Maron, 1993). Sudden deaths in competitive athletes
are usually as a result of undiagnosed cardiovascular disease (Burke, 1991;
Maron, 1996; Van Camp, 1995). Such events generally assume a high media and
public profile because athletes are presumed to be healthy community. And they
are also subject to practical and ethical issues related to the sports. This article
is constituted to (1) increase the awareness of cardiovascular pre participation
screening, (2) to assess the benefits and limitations of screening process, (3)
to give effective recommendations and guidelines for practical, discreet and
effective screening strategies. It is an endeavour which is seemingly important
and relevant given the increasing number of competitive athletes taking part in
sports worldwide, recent public health initiatives taken up by government on
physical activity and exercise. Considerable interest has been raised regarding the
role of pre-participation screening for early identification of those cardiovascular
diseases which are responsible for athletic field deaths and for disqualification of
athletes at risk, with the expectation that such a strategy may eventually prevent
sudden death (Maron, 1987).
Background
The competitive athlete has been described as one who participates in an
organized team or individual sport requiring systematic training and regular
competition against others while placing a high premium on athletic excellence
and achievement (Maron, 1994). The aim of pre participation screening is
provide medical clearance or no objection certification for participation in
competitive sports through routine and systematic evaluations anticipated to
identify clinically relevant and preexisting cardiovascular abnormalities and
thereby decrease the risks linked with sports. However, detection of a cardiac
abnormality on screening examination is only the first step of recognition;
follow up and referral to a cardiologist for further diagnostic investigations
is sometimes required. From literature we can conclude that consensus panel
guidelines of the 26th Bethesda Conference (Maron, 1994) should be used
to formulate recommendations for continued participation or disqualification
from competitive sports. The current guidelines primarily focus on population
based screening of high school and collegiate, university level athlete’s rather
individual assessments of athletes to elite level players and players of all ages
and gender. These recommendations are particular important for participants
of professional career based sports. Athletic training is likely to increase the risk
for sudden cardiac death or disease progression in trained athletes is the formal
base of these recommendations. The vast majority of athletes dying suddenly
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Sport Science Review, vol. XXII, No. 5-6, December 2013
on field or during training can be to extent controlled by the pre participation
screening, by early detection of clinically significant diseases and allow timely
therapeutic interventions that can decrease the incidence of such events.
Causes of Sudden Death in Athletes
A variety of cardiovascular abnormalities represent most common causes
of sudden death in the competitive athletes (Corrado, 1990; Thiene, 1988;
Tsung, 1982). The precise abnormalities of cardiac morphology leading to
sudden death differ with age. The younger athletes show main cause of such
incidence to be congenital abnormalities and malformations. About one third of
cases show hypertrophic cardiomyopathy to be the predominant cause. The next
most common seen are the congenital coronary anomalies like anomalous origin
of left main coronary artery from the right sinus of valsalva (Cheitlin, 1974;
Roberts, 1987). Coronary abnormalities have been found to be predominant
cause of sudden death in team sports such as football and basketball which
are considered to be high impact sports. Older athletes (35 years and above)
represent an altogether different group as they usually participate in recreational
sports rather than organized team sports. Atherosclerotic coronary artery disease
has been found to be the major cause in this age group. Other causes such as
cerebral aneurysm, nonpenetrating blunt chest impact (Maron, 1995) sickle cell
trait, (Kark, 1987) and bronchial asthma are not considered here as this review
focuses on athlete population.
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Tool for Cardiovascular Screening of Competitive Athletes
Figure 1. Causes of sudden cardiac death in young competitive athletes (age 17),
based on systematic tracking of 158 athletes in the United States, primarily
from 1985 to 1995. Ao indicates aorta; LAD, left anterior descending
coronary artery; AS, aortic stenosis; C-M, cardiomyopathy; ARVD,
arrhythmogenic right ventricular dysplasia; MVP, mitral valve prolapse;
CAD, coronary artery disease; HCM, hypertrophic cardiomyopathy; as
shown in Maron et al .
The precise abnormalities of cardiac morphology leading to sudden death
differ with age. The younger athletes show main cause of such incidence to be
congenital abnormalities and malformations. About one third of cases show
hypertrophic cardiomyopathy to be the predominant cause. The next most
common seen are the congenital coronary anomalies like anomalous origin
of left main coronary artery from the right sinus of valsalva (Cheitlin, 1974;
Roberts, 1987). Coronary abnormalities have been found to be predominant
cause of sudden death in team sports such as football and basketball which
are considered to be high impact sports. Older athletes (35 years and above)
represent an altogether different group as they usually participate in recreational
sports rather than organized team sports. atherosclerotic coronary artery disease
has been found to be the major cause in this age group. Other causes such as
cerebral aneurysm, nonpenetrating blunt chest impact (Maron, 1995) sickle cell
trait, (Kark, 1987) and bronchial asthma are not considered here as this review
focuses on athlete population.
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Sport Science Review, vol. XXII, No. 5-6, December 2013
Scope of the Problem
Though sudden cardiac deaths are an infrequent event in sports tournaments
but still screening has been found to be a useful precaution for same. And diseases
like arrhythmogenic right ventricular dysplasia, long QT syndrome, or Marfan
syndrome are rarely seen in population otherwise and so the reliable estimation
techniques are lacking. The main obstacle to the screening process is the large
number of athletes taking part in all the sports tournaments. From athletes to
unspecified youth and children who take part in sports raise the number of
participants to be increased to an alarmingly high level. The prevalence of the
athletic field deaths reported are though less in number, the intense interest and
increased awareness in sudden death in athletes is often fuelled by the media
which gives a disproportionate augment to the actual numerical impact of
sudden death being a public health problem.
Legal considerations
The educational institutions and professional sport tournaments and
organizations are instructed to use reasonable care during conducting athletic
programs. But still there is no clear legal model regarding duties or conduction
of preparticipation screening of athletes to detect medical problems. And in
the absence of strict abiding of rules and regulations established by law or by
athletic governing bodies most institutions, academies rely on team physician
or other medical personnel to determine appropriate screening procedures. A
team physician who has medically cleared an athlete to participate in competitive
sports is not necessary legally liable for an injury or death caused by an
undiscovered cardiovascular condition. Failure to ascertain a latent asymptomatic
cardiovascular condition by a physician due to malpractice requires a proof
that the physician was deviated from the customary medical practice in his
or her speciality in performing the screening of athletes and that the use of
an established diagnostic criteria and methods which would have revealed the
medical abnormality. To develop reliable diagnostic procedures in lieu of cost
benefit and feasibility factors to establish the nature and scope of screening is a
collective judgement of medical personnel.
Ethical considerations
A general accord in the society is that it is a responsibility of the physician
to initiate appropriate efforts to identify the life threatening conditions in the
athletes to minimize cardiovascular risk associated with participation in sports.
There also appears an ethical obligation on behalf of educational institutions
to conduct cost effective strategies to ensure that athletes are not at risk for
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medical risks. Despite sufficient resources, it has been recognised that there
is not high motivation among coaches, athletes or institutions to implement
the screening procedures probably due to the economic pressures inherent in
the sports environment. The extent to which the screening procedures can be
supported at any level of cost efficiency considerations, awareness and practical
limitations; it is not possible to attain a zero risk circumstance in sports. In
a game or match, the athlete is prone to some kind of injury which cannot
be avoided due to type of games and training involved, for e.g. in hockey and
football, in which serious injuries can be a problem to athlete during the match.
So it makes important to acknowledge limitations associated with the screening
procedure in order to inform public which might otherwise harbor misconcepts
about screening principles and its efficacy; and to offer guidance to physicians
and medical personnel responsible for the process.
Current Position of Pre-participation Screening
There are no universally accepted and established standards for the screening
procedures in schools, colleges, sports organizations and sports tournaments.
There is also lack of certified health professionals who can perform the screening
procedures. Some form of medical clearance by a physician by history and
physical examination is necessary for the sportspersons participating regularly in
sports. Some appropriate models of the preparticipation examination have been
developed by a number of medical organizations and investigators (Dyment,
1991; Hulse, 1987; Durant, 1985).
Prospects of Pre-participation Screening
History and physical examination alone is not sufficient to guarantee
detection of critical medical and cardiovascular conditions in large populations
of competitive athletes. Heart murmur produced during aortic stenosis or
hypertrophic cardiomyopathy can be detected during routine screening (Wigle,
1985; Maron, 1987a,b). Besides athletes with hypertrophic cardiomyopathy do
not have family history of premature sudden death or syncope episode due
to the disease. The standard procedure of history conveys low specificity for
detection of cardiovascular diseases that might lead to sudden cardiac death
during vigorous training or during field match. In older athletes personal history
about coronary risk factors and family history of cardiac disease can be useful
for identifying those athletes who are at risk.
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Sport Science Review, vol. XXII, No. 5-6, December 2013
Benefits and Precincts of Noninvasive Screening Tests
The two-dimensional echocardiogram is the principal diagnostic tool for
clinical recognition of hypertrophic cardiomyopathy, demonstrating otherwise
unexplained asymmetric left ventricular wall thickening, the outcome of this
disease (Maron, 1987a,b; Louie, 1994; Wigle, 1985). Echocardiography can
also detect some other relevant abnormalities associated with sudden death in
young athletes, such as valvular heart disease, left ventricular dysfunction (with
myocarditis and dilated cardiomyopathy) and aortic root dilatation. However, even
such diagnostic testing cannot guarantee identification of all important lesions.
Another important limitation of screening with 2D echocardiography is the false
positive or false negative results. Screening for hypertrophic cardiomyopathy
with DNA testing for mutations in genes encoding proteins of the sarcomere is
not yet practical or feasible for large populations, given the substantial genetic
heterogeneity of the disease (Geisterfer, 1990; Tierfelder, 1994; Watkins, 1995).
Arrhythmogenic right ventricular dysplasia (ARVD) usually cannot be reliably
diagnosed solely with echocardiography and electrocardiography; the best
available noninvasive test for this disease is magnetic resonance imaging, which
is both expensive and not universally available (Ricci, 1992; McKenna, 1994).
Electrocardiography has been found to be a useful tool for mass screening of
cardiovascular abnormalities due to cost efficiency and non invasiveness. It is
more practical and is used as an alternative to echocardiography in population
based screening. In hypertrophic cardiomyopathy, the ECG has been found to be
abnormal in 95% of cases; also changes are observed in coronary abnormalities.
But it lacks imaging capability for recognition of cardiac morphological structural
defects. It has low specificity as a screening test in athletic groups because of
high frequency of ECG alterations in the trained competitive athletes due to
physiological adaptation of the athlete’s heart to the sports training.
Recommendations
Noninvasive testing can enhance the diagnostic power accompanied by
history and physical examination but it is unwise to recommend such tests like
electrocardiography, echocardiography as routine advice. False positive results
due to non invasive tests can cause anxiety in athletes, their peers and families.
Hence it is recommended to take history and perform physical examination to
identify cardiovascular abnormalities which are known to cause sudden cardiac
death or disease progression with exercise training. It should be done from
school and college level so as to have a longitudinal history of every athlete. It is
recommended to follow one standard procedure for screening procedures that
is officially recommended by all the governing sports organizations. A national
standard procedure should be formed and followed considering nature and
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Tool for Cardiovascular Screening of Competitive Athletes
scope of preparticipation medical evaluations. Coronary risk factors recognition
in older athletes and their family history should be taken with immense care and
without negligence to identify disease with screening. Exercise stress testing can
be performed before initiating competitive or contact sports. Preparticipation
sports examinations are performed by physicians or non-physician healthcare
workers with different training and experience which can be unethical. It is
recommended that athletic preparticipation screening should be performed by
a physician having requisite training, medical skills to reliably obtain a detailed
history, perform examination and recognize the underlying cardiac abnormalities.
Blood pressure measurement should also be included in the screening procedure.
The cardiovascular history should include questions designed to establish the (1)
prior occurrence of exertional chest pain/discomfort or syncope/near-syncope,
unexplained shortness of breath or fatigue associated with exercise; (2) past
detection of a heart murmur or increased systemic blood pressure; and (3) family
history of premature death (sudden or otherwise), or noteworthy disability from
cardiovascular disease in close relative younger than 50 years old or specific
knowledge of the occurrence of certain conditions (eg, hypertrophic or dilated
cardiomyopathy). The cardiovascular physical examination should accentuate
(1) precordial auscultation in both supine and standing positions to identify
heart murmurs consistent with dynamic left ventricular outflow obstruction;
(2) brachial blood pressure measurement in the sitting position; (3) recognition
of the physical stigmata of Marfan syndrome; and (4) assessment of the
femoral artery pulses to exclude coarctation of the aorta. As mentioned above,
when cardiovascular morphological diseases or abnormalities are suspected
or identified, the athlete has to be referred to a cardiovascular specialist for
further testing procedures done by expert for evaluation and confirmation. The
identified cardiovascular abnormalities should be judged with respect to the 26th
Bethesda Conference consensus panel guidelines for the final recommendation
of eligibility for future athletic competition (Maron, 1994).
References
Burke, A. P., Farb, A., Virmani, R., Goodin, J. & Smialek, J. E. (1991). Sportsrelated and non-sports-related sudden cardiac death in young adults. Am
Heart J., 121, 568-575.
Cheitlin, M. D., De Castro, C. M., & McAllister, H. A. (1974). Sudden death as
a complication of anomalous left coronary origin from the anterior sinus of
Valsalva: a not-so-minor congenital anomaly. Circulation, 50, 780-787.
412
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Corrado, D., Thiene, G., Nava, A., Rossi, L., & Pennelli, N. (1990). Sudden death
in young competitive athletes: clinicopathologic correlations in 22 cases. Am
J Med., 89, 588-596.
Durant R. H., Seymore, C., Linder, C. W., & Jay, S. (1985). The preparticipation
examination of athletes: comparison of single and multiple examiners. Am J
Dis Child, 139, 657-661.
Dyment P. G. (1991). Sports Medicine: Health Care for Young Athletes (2nd ed.) Elk
Grove Village, Ill: American Academy of Pediatrics.
Geisterfer-Lowrance, A. A., Kass, S., Tanigawa, G., Vosberg, H. P., McKenna, W.,
Seidman, C. E., & Seidman, J. G. (1990). A molecular basis for familial
hypertrophic cardiomyopathy: a β-cardiac myosin heavy chain gene missense
mutation. Cell., 62, 999-1006.
Hulse, E., & Strong, W. B. (1987). Preparticipation evaluation for athletes. Pediatr
Rev., 9, 173-182.
Kark, J. A., Posey, D. M., Schumacher, H. R., & Ruehle, C. J. (1987). Sickle-cell
trait as a risk factor for sudden death in physical training. N Engl J Med, 317,
781-787.
Louie, E. K., & Edwards, L. C. (1994). Hypertrophic cardiomyopathy. Prog
Cardiovasc Dis, 36, 275-308.
Maron, B. J., Bonow, R. O, Cannon, R. O. III, Leon, M. B., & Epstein, S. E. (1987).
Hypertrophic cardiomyopathy: interrelations of clinical manifestations,
pathophysiology, and therapy, 1. N Engl J Med, 316, 780-789
Maron, B. J., Bonow, R. O, Cannon, R. O. III, Leon, M. B., & Epstein, S. E. (1987).
Hypertrophic cardiomyopathy: interrelations of clinical manifestations,
pathophysiology, and therapy, 2. N Engl J Med, 316, 844-852.
Maron, B. J., & Garson, A. (1994). Arrhythmias and sudden cardiac death in elite
athletes. Cardiol Rev, 2, 26-32.
Maron, B. J., Isner, J. M., & McKenna, W. J. (1994). 26th Bethesda Conference:
recommendations for determining eligibility for competition in athletes with
cardiovascular abnormalities. Task Force 3: hypertrophic cardiomyopathy,
myocarditis and other myopericardial diseases and mitral valve prolapse. J
Am Coll Cardiol, 24, 880-885.
413
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Download Date | 6/18/17 3:05 AM
Tool for Cardiovascular Screening of Competitive Athletes
Maron, B. J., Poliac, L., Kaplan, J. A., & Mueller, F. O. (1995). Blunt impact to
the chest leading to sudden death from cardiac arrest during sports activities.
N Engl J Med, 333, 337-342.
Maron, B. J., Roberts, W. C., McAllister, H. A., Rosing, D. R., & Epstein, S. E.
(1980). Sudden death in young athletes. Circulation, 62, 218-229.
Maron, B. J., Shirani, J., Poliac, L. C., Mathenge, R., Roberts, W. C., & Mueller, F. O.
(1996). Sudden death in young competitive athletes: clinical, demographic
and pathological profiles. JAMA, 276, 199-204.
Maron, B. J. (1993). Sudden death in young athletes: lessons from the Hank
Gaithers affair. N Engl J Med, 329, 55-57.
Maron, B. J., Bodison, S. A., Wesley, Y. E., Tucker, E. & Green, K. J. (1987)
Results of screening a large group of intercollegiate competitive athletes for
cardiovascular disease. J Am Coll Cardiol, 10, 1214–1221.
McKenna, W. J., Thiene, G., Nava, A., Fontaliran, R., Blomstrom-Lundqvist, C.,
Fontaine, G., & Camerini, F. (1994). On behalf of the Task Force of the
Working Group for the Myocardial and Pericardial Disease of the European
Society of Cardiology and of the Scientific Council on Cardiomyopathies
of the International Society and Federation of Cardiology. Diagnosis of
arrhythmogenic right ventricular dysplasia/cardiomyopathy. Br Heart J, 71,
215-218.
Ricci, C., Longo, R., Pagnan, L., Dalla Palma, L., Pinamonti, B., Camerini, F.,
Bussani, R., & Silvestri, F. (1992). Magnetic resonance imaging in right
ventricular dysplasia. Am J Cardiol, 70, 1589-1595.
Roberts, W. C. (1987). Congenital coronary arterial anomalies unassociated with
major anomalies of the heart or great vessels. In: Adult Congenital Heart Disease
(p. 583). Philadelphia, Pa: FA Davis Co.
Thiene, G., Nava, A., Corrado, D., Rossi, L., & Pennelli, N. (1988). Right
ventricular cardiomyopathy and sudden death in young people. N Engl J Med,
318, 129-133.
Thierfelder, L., Watkins, H., MacRae, C., Lamas, R., McKenna, W., Vosberg, H. P.,
Seidman, J. G., & Seidman, C. E. (1994). α-Tropomyosin and cardiac troponin
T mutations cause familial hypertrophic cardiomyopathy: a disease of the
sarcomere. Cell, 77, 701-712.
414
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Van Camp, S. P., Bloor, C. M., Mueller, F. O., Cantu, R. C., & Olson, H. G. (1995).
Nontraumatic sports death in high school and college athletes. Med Sci Sports
Exerc, 27, 641-647. Watkins, H., Conner, D., Thierfelder, L., Jarcho, J. A., MacRae, C., McKenna, W. J.,
Maron, B. J., Seidman, J. G., & Seidman, C. E. (1995). Mutations in the
cardiac myosin binding protein-C gene on chromosome 11 cause familial
hypertrophic cardiomyopathy. Nat Genet, 11, 434-437.
Wigle, E. D., Sasson, Z., Henderson, M. A., Ruddy, T. D., Fulop, J., Rakowski, H.,
& Williams, W. G. (1985). Hypertrophic cardiomyopathy: the importance of
the site and extent of hypertrophy—a review. Prog Cardiovasc Dis, 28, 1-83.
Kulroop KAUR BADWAL, M.B.B.S., is working as final junior resident of M.D. Sports
Medicine in the Department of Sports Medicine and Physiotherapy at Guru Nanak
Dev University, Amritsar, Punjab, India. She received her Bachelor’s degree in M.B.B.S.
(Bachelor of Medicine & Bachelor of Surgery) from Baba Farid University of Health
and Medical Sciences, Faridkot, Punjab, India. Her area of interest is Sports Medicine,
Cardiology, Sports injury and Research Education. Currently she is working on research
project titled “Association of Body Composition and Heart Structural Changes in
Endurance, Strength and Combined Trained Athletes”. Dr. Kulroop Kaur Badwal is also
working on a variety of projects in both the sports and community health fields.
Corresponding address:
Kulroop KAUR BADWAL
Guru Nanak Dev University, Faculty Of Sports Medicine And Physiotherapy
GT Road, Amritsar, Punjab,
India - 143005
Phone: 09781500976
Email: [email protected]
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