Validity of cardiac screening questioned for athletes.
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March 5, 2018
By Carrie Baker, PhD, ATC
“Can you find it in one’s heart …”
Saint Valentine (Italian: San Valentino, Latin: Valentinus), is a widely recognized 3rd-century Roman saint commemorated on February 14 and since the High Middle Ages is associated with a tradition of courtly love. Thanks to him, February is associated with symbols of the heart. February is also known as National Heart Health Month and heart disease, dysfunction and general cardiac care is often brought into focus.
Before all the chocolates, roses and candy hearts flooded our social media feed and grocery stores, many of us sports fans and Athletic Trainers (ATs) watched the collapse of a South Carolina State basketball player and the quick action of the AT on the scene, Tyler Long, working with EMS to revive the athlete. When things like this happen, I can’t help but wonder:
What kind of preparticipation exam (PPE) was performed?
Was he exhibiting symptoms that he did not report?
What could have been done to prevent an emergency?
As ATs, many of us have these thoughts after an emergency and generally, that is how practice acts, position statements and best practice guidelines are formed. We take the care of our patients and athletes seriously and painstakingly plan, troubleshoot, screen, evaluate and educate to ensure emergency situations can be avoided. If an emergency does happen, we are ready with the best care available.
PPEs are regularly performed on all athletes and guidelines put forth, such as the National Athletic Trainers’ Association Position Statement: Preparticipation Physical Examinations and Disqualifying Conditions in 2014 and the Interassociation Consensus Statement on Cardiovascular Care of College Student Athletes in 2016 provide valuable information on best practices to ensure ATs are doing everything we can to avoid such emergencies.
However, a recent study conducted and reported in The New England Journal of Medicine that screening programs are unlikely to prevent sudden cardiac arrest in competitive athletes.3 Yes, you read that correctly. The Science News and HealthDay both reported on this study stating that while cardiac arrest is rare among young athletes (<45 yoa), 80% of cases will not be discovered through PPEs.1,2
This retrospective study reported that approximately 74 out-of-hospital sudden cardiac arrests occurred during competitive sports (16) or noncompetitive sports (58) in people aged 12-45 years during 2009 to the end of 2014.This number is out of an estimated 352,499 registered competitive athletes evaluated within the study (0.02%).3 In 6 of the cases, autopsies did not identify a cause of death. Either the cardiac structure was normal at autopsy or results of investigations were normal in the survivors but ultimately the events were attributed to primary arrhythmia.3
Due to the rarity of sudden cardiac arrest, caused by structural heart disease, researchers are questioning the value of PPEs for cardiac conditions.3 Among the survivors in this study, none had an identifiable condition through a normal PPE. Among the people who died, a PPE may have identified a maximum of 3 people at risk for cardiac arrest. They also go on to state that given their analysis “at least 146,000 athletes would have had to be screened to identify one person who had sudden cardiac arrest during participation in competitive sports.”3
As with all research, this study does have important limitations to consider:
- The study was a retrospective analysis, the researchers conducted essentially chart reviews and the participants were not identified and then followed as in a more powerful prospective study and there were not autopsies available for all participants.
- Some athletes may have been identified as having an increased risk and therefore did not participate in sports activities.
- It is possible that some professional athletes may have had cardiac arrest during a recreational sport, which would lower the incidence rate in the competitive group.
- This study only identified people who had sudden cardiac arrest during participation, not at rest or following participation in a sports activity (> 1 hour).
While this research is important and may lead to further studies evaluating the effectiveness of PPEs for cardiac conditions, it is also up to ATs to document screenings and report outcomes. Whether you belong to the National Collegiate Athletic Association injury database or a practice-based research network, a large set of data would help to get a good vision of the results of PPEs and reliable interpretation of the data. Regardless of access to technology, we can all ask robust, rich, history questions that are recommended during a PPE cardiovascular screen.
In 2014 the American Heart Association and the American College of Cardiology updated its screening checklist to include: personal history, family history and a physical examination component. Check it out here: The 14-Element Cardiovascular Screening Checklist for Congenital and Genetic Heart Disease
Other helpful resources when determining when and why you should screen:
Kevin M. Conley, Delmas J. Bolin, Peter J. Carek, Jeff G. Konin, Timothy L. Neal, and Danielle Violette (2014) National Athletic Trainers' Association Position Statement: Preparticipation Physical Examinations and Disqualifying Conditions. Journal of Athletic Training: Jan/Feb 2014, Vol. 49, No. 1, pp. 102-120.
Douglas J. Casa, Kevin M. Guskiewicz, Scott A. Anderson, Ronald W. Courson, Jonathan F. Heck, Carolyn C. Jimenez, Brendon P. McDermott, Michael G. Miller, Rebecca L. Stearns, Erik E. Swartz, and Katie M. Walsh (2012) National Athletic Trainers' Association Position Statement: Preventing Sudden Death in Sports. Journal of Athletic Training: Jan/Feb 2012, Vol. 47, No. 1, pp. 96-118.
Douglas J. Casa, Jon Almquist, Scott A. Anderson, Lindsay Baker, Michael F. Bergeron, Brian Biagioli, Barry Boden, Joel S. Brenner, Michael Carroll, Bob Colgate, Larry Cooper, Ron Courson, David Csillan, Julie K. DeMartini, Jonathan A. Drezner, Tim Erickson, Michael S. Ferrara, Steven J. Fleck, Rob Franks, Kevin M. Guskiewicz, William R. Holcomb, Robert A. Huggins, Rebecca M. Lopez, Thom Mayer, Patrick McHenry, Jason P. Mihalik, Francis G. O'Connor, Kelly D. Pagnotta, Riana R. Pryor, John Reynolds, Rebecca L. Stearns, and Verle Valentine (2013) The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations. Journal of Athletic Training: Jul/Aug 2013, Vol. 48, No. 4, pp. 546-553.
1. St. Michael's Hospital. (2017, November 15). Screening programs unlikely to prevent sudden cardiac arrest in competitive athletes. ScienceDaily. Retrieved February 14, 2018 from www.sciencedaily.com/releases/2017/11/171115175605.htm
2. HealthDay News (2017, November 15). Cardiac arrest rare in young athletes but tough to prevent. HealthDay. Retrieved February 14, 2018 from https://consumer.healthday.com/cardiovascular-health-information-20/misc-stroke-related-heart-news-360/cardiac-arrest-rare-in-young-athletes-but-tough-to-predict-728559.html
3. Cameron H. Landry, Katherine S. Allan, Kim A. Connelly, Kris Cunningham, Laurie J. Morrison, Paul Dorian. Sudden Cardiac Arrest during Participation in Competitive Sports. New England Journal of Medicine, 2017; 377 (20): 1943 DOI: 10.1056/NEJMoa1615710
About the Author
Carrie Baker, PhD, ATC is the Program Director for the Professional Graduate Athletic Training Program at the University of Tennessee at Chattanooga. She received degrees from Castleton State College in 2000, Old Dominion University 2002 and the University of Kentucky 2012. She has spent most of her career as a faculty member teaching athletic training courses, working in Division I athletics, as well as volunteering outreach services to high schools in a variety of locations. Baker has research interests in self-efficacy, balance and injury prevention. In her spare time, she loves spending time with her daughter and husband.