The present 2007 American Heart Association (AHA) recommendations for personal and family history and physical examination are promoted by the panel as a potentially effective strategy to raise the suspicion of cardiovascular disease in both large and small screening populations of high school and college student-athletes. These recommendations were initially proposed in the 1996 AHA Scientific Statement and appear here virtually unaltered. The 2007 AHA recommendations consist of 12 items (8 for personal and family history and 4 for physical examination). At the discretion of the examiner, a positive response or finding in any 1 or more of the 12 items may be judged sufficient to trigger a referral for cardiovascular evaluation. Parental verification of the responses is regarded as essential for high school (and middle school) students.
The 12-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes
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Medical history*
Personal history
- Exertional chest pain/discomfort
- Unexplained syncope/near-syncope†
- Excessive exertional and unexplained dyspnea/fatigue, associated with exercise
- Prior recognition of a heart murmur
- Elevated systemic blood pressure
Family history
- Premature death (sudden and unexpected, or otherwise) before age 50 years due to heart disease, in >1 relative
- Disability from heart disease in a close relative <50 years of age
- Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan syndrome, or clinically important arrhythmias
Physical examination
- Heart murmur‡
- Femoral pulses to exclude aortic coarctation
- Physical stigmata of Marfan syndrome
- Brachial artery blood pressure (sitting position)§
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*Parental verification is recommended for high school and middle school athletes.
†Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion.
‡Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
§Preferably taken in both arms.
Advisability
The AHA continues to support preparticipation cardiovascular screening for student-athletes and other participants in organized competitive sports as justifiable, necessary, and compelling on the basis of ethical, legal, and medical grounds. Indeed, preparticipation screening for athletes is viewed as an important public health issue. Noninvasive testing can enhance the diagnostic power of the standard history and physical examination. However, the AHA panel does not believe it to be either prudent or practical to recommend the routine use of tests such as 12-lead electrocardiogram (ECG) or echocardiography in the context of mass, universal screening. This view is based on the substantial size of the athlete cohort to be screened, the relatively low prevalence of cardiovascular conditions responsible for sports-related deaths, the limited resources presently available for allocation (and other cost-efficacy considerations), but particularly the absence of a physician-examiner cadre prepared and available to perform and interpret these examinations. Notably, the latter does not currently exist within the United States (US) healthcare system, and therefore, the addition of such a screening program to preexisting resources would impose a significant and unrealistic manpower burden. In addition, significant concern exists that the widespread application of noninvasive testing to athletic populations would undoubtedly result in false-positive results well in excess of the number of true-positives, thereby creating unnecessary anxiety among substantial numbers of athletes and their families, as well as the potential for unjustified exclusion from competition. However, this view represents a perspective on large-scale national screening programs and is not intended to actively discourage individual local efforts.
The panel concluded that complete and targeted personal and family history and physical examination (including brachial artery blood pressure measurement) designed to identify or raise the suspicion of those cardiovascular diseases known to cause sudden cardiac death or disease progression in young athletes represent the most practical screening strategy for implementation in large populations of young competitive sports participants in the United States. This medical evaluation should be performed by a qualified examiner and include the 12 key AHA-recommended elements for personal and family history-taking and physical examination, as well as parental verification of the medical history for high school and middle school student-athletes. Examinations should be conducted in a physical environment conducive to optimal auscultation of the heart. Obtaining echocardiograms and/or electrocardiograms as part of preparticipation screening remains optional.
Such an approach is an obtainable objective and should be mandatory for all competitive athletes before their initial engagement in organized sports. Comprehensive screening evaluations should be administered again after 2 years for high school athletes. College student-athletes should be evaluated with a complete history and physical examination on matriculation to the institution before they begin training and competition, and thereafter, an interim history (with blood pressure measurement) should be administered in each of the subsequent 3 years. Important changes in medical status detected during the solicitation of interim annual histories for college athletes may constitute evidence that another physical examination and possible further testing should be performed.
The panel recommends the development of a national standard for cardiovascular medical evaluations that could be used in the systematic assessment of all high school and college-aged student-athletes, although the guideline developers are cognizant that this aspiration would require the cooperation and input of many organizations and interested parties. The official recommendations and requirements of athletic governing bodies with regard to the nature and scope of preparticipation medical evaluations are now heterogeneous in design and content, lacking in standardization, and often inconsistent among the states (for high school athletes) or colleges and universities. In many cases, such recommendations cannot be viewed as medically sufficient. Adherence to uniform guidelines would result in the identification of many more athletes with cardiac disease and thereby positively impact the health of student-athletes by enhancing the safety of competitive sports.
For older competitive athletes (~35 to 40 years of age or older), knowledge of a personal history of coronary artery disease risk factors and/or familial occurrence of premature atherosclerotic heart disease is useful in screening for underlying cardiac disease. In addition, it may be useful to selectively perform medically supervised exercise stress testing in men >40 years of age (women >55 years of age) who wish to engage in habitual vigorous training and competitive sports and who have >2 coronary risk factors (other than age and gender), or possibly a single risk factor if it is markedly abnormal. Older athletes should also be specifically cautioned with regard to the potential significance of prodromal cardiac symptoms, such as exertional chest pain.
Certain insights offered here with regard to screening should not promulgate a false sense of security on the part of medical practitioners or the general public. The standard history and physical examination implicitly lack the power to reliably raise the suspicion of (or identify) certain potentially lethal cardiovascular abnormalities. Indeed, it is unrealistic to expect that standard large-scale athletic screening examinations can exclude all clinically relevant diseases.
Methodology
Preparticipation sports examinations in young athletes are presently performed by a variety of individuals, including physicians (compensated or volunteer) or nonphysician healthcare workers with varying degrees of training or experience. Examiners may be associated with or administratively independent of the concerned institutions, schools, or teams. The panel harbors particular concern about the current practice of 18 states that have legislated for chiropractors or naturopathic clinicians to perform preparticipation high school clearance examinations, despite their lack of formal professional training for such activities. Consequently, we strongly recommend that cardiovascular athletic screening with history and physical examination be performed only by physicians or other healthcare workers with requisite training, medical skills, and background to reliably recognize or raise reasonable suspicion of heart disease. Although it is preferable that such individuals be licensed physicians, this is not always feasible, and therefore, it is acceptable for nurse practitioners or physician-assistants formally trained in physical examination techniques to perform athletic screening evaluations. Nevertheless, the panel recommends the establishment of a standardized certification process for designated nonphysician examiners to ensure an acceptable level of expertise in performing screening evaluations in young athletes.
We recognize that the accuracy of some responses elicited by history-taking from young sports participants may depend on a level of personal compliance and their depth of medical knowledge, and this issue can have a significant impact on the accuracy of the screening process. Therefore, parents should be responsible for completing the history form for minors. Preparticipation screening is, however, only the first opportunity for recognition of cardiovascular disease. When abnormalities are identified (or suspected) on mass screening, athletes should be referred to a cardiovascular specialist for further evaluation and confirmation.
