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Profile of Preparticipation Cardiovascular Screening for High School Athletes
David W. Glover, MD;
Barry J. Maron, MD
JAMA. 1998;279:1817-1819.
ABSTRACT
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Context.— Sudden death in young competitive athletes due to unsuspected cardiovascular disease has heightened concern and interest in the preparticipation screening available to high school athletes in the United States.
Objective.— To assess the potential adequacy of the preparticipation screening process for detecting or increasing the suspicion of cardiovascular abnormalities.
Design.— Current guidelines and requirements for implementation of preparticipation screening from each of the high school jurisdictions in the 50 states and the District of Columbia were analyzed and compared with the 1996 American Heart Association (AHA) consensus panel guidelines on screening.
Outcome Measures.— Items contained on preparticipation screening questionnaires; the examiners designated to perform screening.
Results.— Eight states (16%) have no approved history and physical examination questionnaires to guide examiners, including 1 state without a formal screening requirement. Of the remaining 43 states, several items relevant to cardiac-related problems were frequently omitted from the questionnaires. Exertional dyspnea or chest pain, prior limitation from sports, family history of heart disease, or Marfan syndrome were included in 0% to 56% of the state forms. Specific cardiovascular items on physical examination were included in forms from only 5% to 37% of states, including documentation of a heart murmur, irregular heart rhythm, peripheral pulses, or stigmata of Marfan syndrome. Seventeen (40%) of 43 states had history and physical questionnaires judged to be most adequate with at least 9 of the 13 AHA recommendations, whereas 12 states (28%) were least adequate with 4 or less of these recommended items. Therefore, a total of 20 (40%) of the 51 states have no approved history and physical examination questionnaires, or formal screening requirement, or forms that were judged to be inadequate. In addition to physicians, 21 states also permit nurses or physician assistants to administer examinations, and 11 states specifically provide for practitioners with limited cardiovascular training (such as chiropractors).
Conclusions.— Preparticipation athletic screening for cardiovascular disease with standard history and physical examination, as presently employed in US high schools, is highly dependent on the state-approved questionnaires, which frequently are abbreviated and may be inadequate; is implemented by a variety of health care workers with varying levels of expertise; and may be severely limited in its power to detect potentially lethal cardiovascular abnormalities. These observations should represent an impetus for change and improvement in the preparticipation cardiovascular screening process for high school athletes.
INTRODUCTION
SUDDEN DEATHS in young competitive athletes have become highly visible events that cause great public concern.1-9 Most of these deaths occur in athletes of high school age2-4,7 and documented causes include mostly congenital cardiovascular malformations,2-9 with hypertrophic cardiomyopathy (HCM) as the most common responsible lesion.2-4,7, 9
Athletic field catastrophes have stimulated considerable interest in the role and efficacy of preparticipation screening10-16 and procedures for the identification of potentially lethal cardiovascular abnormalities with the expectation that disqualification of selected athletes from competition probably will reduce their risk for sudden death during sports activities.16 However, before the potential effectiveness of preparticipation screening can be judged, it is necessary to determine the current status of medical evaluations for athletes. In this article, we assess the preparticipation screening procedures that are currently available to US high school athletes, and estimate the adequacy of this process for detecting or raising the suspicion of cardiovascular abnormalities.
Methods
We contacted directors of high school athletic associations from the 50 states and the District of Columbia (in this report we refer to the 51 jurisdictions that constitute this analysis [the 50 states and the District of Columbia] as "states") to obtain the most recent approved history and physical examination questionnaires required or recommended for preparticipation screening of athletes in interscholastic sports in both public and private high schools for grades 9 through 12, and to obtain detailed information regarding administration of the screening process including the designated examiners. We analyzed portions of these questionnaires relevant to the cardiovascular system with respect to the clinical information requested from the athletes (or parents) and examiners. We also compared the composition of the history and physical examination forms against the 13 specific 1996 American Heart Association (AHA) consensus panel recommendations for preparticipation cardiovascular screening,10 which included the following: (1) family history of premature sudden death or heart disease in surviving relatives, (2) personal history of heart murmur, systemic hypertension, excessive fatigability, syncope, exertional dyspnea or chest pain, as well as parental verification of the history, (3) physical examination for heart murmur, femoral pulses, stigmata of Marfan syndrome or blood pressure measurement, which includes the recommendation of precordial auscultation in both the supine or sitting and standing positions to identify heart murmurs consistent with left ventricular outflow tract obstruction.
Results
Preparticipation Screening Questionnaires
Of the 51 US jurisdictions, 50 formally require an examination prior to participation in high school athletics, except for Rhode Island. Eight (16%) of 51 states do not have recommended history and physical questionnaires to serve as guidelines for examiners (ie, California, Georgia, Maine, Mississippi, New Hampshire, New Jersey, Oregon, and Rhode Island). History and physical examination forms approved for preparticipation screening were obtained from 42 states and the District of Columbia (as of June 1, 1997). Composition of the 43 state history and physical questionnaires varied widely in content, length, and comprehensiveness, ranging from abbreviated clearance forms composed of only a simple statement of acceptability (Pennsylvania, Wisconsin) to detailed documents with up to 37 items (District of Columbia); the average number of items per form was 12.
History
Assessment of the historical questions that constitute the approved questionnaires and require responses from athletes or parents demonstrated that the following potentially important cardiovascular items appear in only 0% to 56% of the 43 state forms: personal history of exertional dyspnea or chest pain or prior limitation from sports, and family history of heart disease or Marfan syndrome (Table 1). Only 26 (60%) of the 43 states require direct verification and approval of the personal and family history by a parent. Items most commonly included were history of medications or syncopal episodes in 88% and 86% of the state forms, respectively.
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Items Included in Recommended History and Physical Examination Forms for Preparticipation Cardiovascular Screening of High School Athletes
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Physical Examination
Assessment of the approved physical examination form demonstrated that only 5% to 37% of states included items specifically directed toward documenting a heart murmur, irregular heart rhythm, physical stigmata of Marfan syndrome, or peripheral pulses (ie, for detection of coarctation of the aorta) (Table 1). Physical examination items most commonly included were blood pressure and heart rate, in 86% and 70% of the state forms, respectively.
History and physical questionnaires were mostly developed by state high school athletic associations, often in collaboration with state medical associations. Of the 39 states with available information, the questionnaires had been developed or revised and updated within the previous 5 years in 23 states, whereas 16 states had not revised their forms in more than 5 years, and 6 of those states had not altered their forms in more than 10 years.
Comparison With AHA Recommendations
Comparison of the composition of the history and physical examination forms with the 13 specific AHA consensus panel recommendations10 revealed that 17 (40%) of the 43 state forms contained at least 9 of the 13 recommended items (greatest number of items in Missouri [n=12], Kansas [n = 11], and the District of Columbia [n=11]), whereas 12 state forms (28%) included only 0 to 4 recommended items. Five of these 12 states had none or 1 AHA panel item (ie, Florida, Nebraska, Pennsylvania, Wyoming, and Wisconsin)(Figure 1).
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Combined assessment of history and physical examination questionnaires used in 43 states, judged with respect to inclusion of the 13 specific 1996 American Heart Association (AHA) recommendations for preparticipation cardiovascular screening of high school athletes (28% of 43 states have 4 or fewer recommendations; 40% have 9 or more recommendations).10 The 8 other states have no formal questionnaires.
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Analysis of Implementation of Screening
Of the 50 states requiring preparticipation screening, 45 provide specific recommendations regarding examiners, and 5 states have no stated recommendations, restrictions, or requirements governing who may perform screening examinations. State high school athletic associations sanction a variety of examiners; each of the 45 states recommend that screening examinations be performed by medical or osteopathic physicians. However, nurse practitioners or physician assistants are eligible to administer the medical evaluations (without the direct involvement of a physician) in 21 states. Eleven states specifically provide for practitioners with no or limited cardiovascular training (such as chiropractors [n=10] or naturopathic clinicians [n=1]) to perform preparticipation medical evaluations. A total of 25 states sanction nonphysician examiners for athletic screening; no state offers specific qualifications and standards for examiners or describes guidelines for the setting of the screening examinations. Annual preparticipation screening is recommended in 33 states (65%).
Comment
The causes of sudden death in young competitive athletes have been well defined over the last several years.2-9 These catastrophes are usually caused by a variety of congenital and unsuspected cardiovascular disorders, with HCM17-18 the most common lesion responsible for these sudden deaths.2-4,7, 9 Preparticipation screening with noninvasive tests, such as electrocardiograms or echocardiograms,10-14,19-22 could increase the chances of detecting cardiovascular abnormalities, particularly HCM. However, such screening proposals would be impractical and costly for most schools to provide consistently, especially when considering that cardiovascular deaths occur among high school athletes at an estimated frequency of only 1:200000.23
These considerations focus increased attention on the role and potential efficacy of standard preparticipation screening (ie, personal and family history and physical examination) that has been in place in many US high schools for more than 30 years. We believe that it is timely and prudent to analyze this screening process to assess its potential for detecting or raising the suspicion of cardiovascular disease in athletes.
The history and physical examination questionnaire forms developed by state high school athletic and medical associations constitute the specific guidelines for designated examiners and, therefore, may be assumed to represent the objectives of cardiovascular screening for any particular jurisdiction. We found that these forms often demonstrated limitations that could reduce the chances of detecting or suspecting cardiovascular disease during the screening process. Fully 40% of the state high school associations do not offer approved history and physical examination questionnaires, have no screening requirement, or have screening forms that could be considered deficient compared with the 1996 AHA scientific statement on preparticipation screening recommendations.10 That AHA document includes consensus expert panel recommendations for preparticipation cardiovascular screening and was used in the present analysis as a "gold standard." Even though history and physical examination forms have been widely acknowledged (since 1992),15 these questionnaires have not been generally used and appear to be the basis of the screening forms in only 8 states.
Although no prospective data are available to permit a direct assessment of the efficacy of large-scale athletic screening, a retrospective analysis2 of 134 young athletes who died suddenly from a variety of cardiovascular diseases showed that only 3% of those exposed to standard preparticipation screening had been suspected of having cardiac disease by virtue of these examinations, and less than 1% received an accurate diagnosis. Based on these observations, and those in this study, the preparticipation screening process as currently structured and carried out in US high schools appears to lack sufficient power to consistently recognize clinically important cardiovascular abnormalities in many athletes.
Nevertheless, it should be emphasized that screening by standard history and physical examination has the potential to identify or raise the suspicion of cardiovascular disease in some at-risk athletes. For example, genetically transmitted diseases such as HCM17-18 and Marfan syndrome24 and some cases of arrhythmogenic right ventricular dysplasia,25 dilated cardiomyopathy, and premature atherosclerotic coronary artery disease may be suspected from the family history or by recent onset of symptoms such as exertional dyspnea and chest pain. Marfan syndrome and systemic hypertension are identifiable from physical examination, as are cardiac diseases associated with left ventricular outflow obstruction by virtue of a loud heart murmur (such as aortic valvular stenosis and some cases of HCM).
We also identified potential limitations in the implementation of cardiovascular screening in US high schools. Although each state that designates specific examiners recommends that physicians be responsible for preparticipation screening, approximately 50% sanction alternative clinicians, such as nurse practitioners, physician assistants, or chiropractors (and in 1 state, naturopathic clinicians) to provide clearance for sports competition. At present, no systematic training or accreditation criteria are required to provide assurance that such designated health care workers achieve a satisfactory level of expertise.
Based on our evaluation of preparticipation cardiovascular screening as presently constituted in US high schools (with standard history and physical examination), it would appear that although such efforts have the theoretic capability to detect or raise the suspicion of potentially lethal cardiovascular diseases in some athletes, screening is unlikely to achieve its full potential within the current format and methodology. In many states, crucial items are often absent from questionnaires used as guidelines by the examiners. These data also emphasize that it is not possible to assume that medical clearance for sports competition precludes the possibility of all potentially lethal cardiovascular diseases, and there should not be a false sense of security on the part of the general public in matters related to athletic screening. Nevertheless, it is reasonable to expect that improvement and optimization of the preparticipation screening process will permit more frequent detection of cardiovascular lesions associated with sudden death and morbidity in young competitive athletes. We suggest that serious consideration be given to national standardization of the history and physical examination forms for preparticipation screening of high school athletes.
AUTHOR INFORMATION
Reprints: Barry J. Maron, MD, 920 E 28th St, Suite 40, Minneapolis, MN 55407.
From the Ambulatory Care Division, St Luke's Hospital, Kansas City, Mo (Dr Glover); and the Minneapolis Heart Institute Foundation, Minneapolis, Minn (Dr Maron).
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