SUMMARY OF AHA MAJOR RECOMMENDATIONS:

Preparticipation Screening for Cardiovascular Abnormalities in Athletes

The following is a summary of the text of the American Heart Association (AHA) Guideline. To read the AHA Guideline in its entirety please see the link below (the text of which also is copied onto the website of The Michael H. Ludwig Memorial Foundation under the heading “Preparticipation Screening for Cardiovascular Abnormalities in Athletes: AHA Major Recommendations”):

AHA Major Recommendations

The present 2007 AHA recommendation is intended to be 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. A positive finding in any of the 12 items may be judged sufficient to trigger a referral for cardiovascular evaluation. Parental verification of the responses is essential for high school (and middle school) students.

The 12-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes
Medical history*
Personal history

1. Exertional chest pain/discomfort
2. Unexplained syncope/near-syncope†
3. Excessive exertional and unexplained dyspnea/fatigue, associated with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure

Family history

6. Premature death (sudden and unexpected, or otherwise) before age 50 years due to heart disease, in >1 relative
7. Disability from heart disease in a close relative <50 years of age
8. 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

9. Heart murmur‡
10. Femoral pulses to exclude aortic coarctation
11. Physical stigmata of Marfan syndrome
12. Brachial artery blood pressure (sitting position)§

*Parental verification is recommended for high school and middle school athletes.
†Judged not to be neurocardiogenic (vasovagal); of particular concern when relate d 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 supports preparticipation cardiovascular screening for students and other participants in competitive sports as justifiable, necessary, and compelling on the basis of ethical, legal, and medical grounds.  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 recommend the use of tests such as 12-lead electrocardiogram (ECG) or echocardiography for mass, universal screening. This view is based on the substantial number of athletes that could be screened, the relatively low prevalence of cardiovascular conditions responsible for sports-related deaths, limited resources and cost-efficacy considerations, but particularly the absence of in the US of a physician-examiner cadre to perform and interpret these examinations.  Widespread application of noninvasive testing would result in false-positive results well in excess of the number of true-positives, creating unnecessary anxiety among athletes and their families, and exclusion from competition. However, this view represents a perspective on large-scale national screening and is not intended to actively discourage individual local efforts.

The panel concluded that complete and targeted personal and family history and physical examination 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 (emphasis added). 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 echo cardiograms and/or electrocardiograms as part of pre-participation screening remains optional.

This approach 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.

Recommendations and requirements of athletic governing bodies with regard to pre-participation medical evaluations lack standardization, 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, benefiting the health of student-athletes by enhancing the safety of competitive sports.

(Disclaimer: The Michael H. Ludwig Memorial Foundation expressly disclaims any liability concerning the above recommendations and is providing this information solely in an effort to enable interested persons to obtain further information and make educated choices)