Limitations of Current AHA Guidelines and Proposal of New Guidelines for the Preparticipation Examination of Athletes

Abstract

In a patient population without any adverse cardiovascular events, the currently recommended AHA 12-elements have an unacceptably high rate of false positives. Newer screening guidelines are needed, with fewer false positives and evidence-based updates.

Interassociation consensus statement on cardiovascular care of college student-athletes

“…The generally broad and non-specific questions also elicit a high number of positive responses in athletes. In college athletes, at least one positive cardiovascular symptom, or family history response, was reported by 24–43% of athletes during preparticipation evaluations using either the AHA 12-point or PPE-4 questionnaires 33 34. In high school athletes, initial positive history responses were reported by 68% of athletes undergoing a heart screen using the PPE-4 history questions 35.…”

“…Nevertheless, some authorities do recommend the use of a resting 12-lead ECG during the preparticipation cardiovascular screening of athletes 33 34 36. Several studies have examined the ability of history, physical examination, and ECG to detect potentially life-threatening cardiovascular disease (which does not necessarily equate with identifying individuals who will actually experience a cardiac event).…”

“…Data suggests that screening by history and physical examination alone has a low sensitivity to detect conditions associated with SCD,33 and that the addition of ECG, when properly interpreted and with skilled cardiology resources available, improves cardiovascular screening if the measurable endpoint is considered the detection of silent or congenital cardiac conditions associated with SCD46 (see box 2 for preliminary findings from an NCAA-funded research study addressing the feasibility of ECG screening). Although the AHA does not support a mandatory, nationalised ECG screening programme for athletes, it has long supported, in principle, ECG screening programmes that are well designed, prudently implemented and include adequate cardiology resources and expertise 10 26 28.…”

Should Electrocardiograms Be Part of the Preparticipation Physical Examination?

“…False‐positive rates in the meta‐analysis were 6% for ECG, 8% for history, and 10% for physical examination [23]. Recent studies of current cardiac history questionnaires, however, have demonstrated a very high positive response rate in student athletes, ranging from 14% to 68% [25‐27]. In addition, sorting through the numerous and often‐vague responses on cardiac symptom questionnaires is challenging, with no standard response or secondary investigations instituted by the primary care or sports medicine communities.…”

“…Although the natural history of previously undetected conditions is not known, it has been shown that active management of hypertrophic cardiomyopathy (HCM) and arrythmogenic right ventricular cardiomyopathy (ARVC) improves outcomes. A prospective study compared 33,735 athletes screened with ECG with unscreened nonathletes [27]. In the screened athletes, there were 22 cases of HCM detected, none of whom died during the 8‐year follow‐up period, and 1 screened athlete who was undetected and died.…”