Screening for Sports Participation

Athletes are commonly screened to identify cardiovascular risks before participation in sports (1, 2, 3, 4). In the United States, athletes are evaluated every 2 years if high school age or younger or with a comprehensive initial evaluation and annual interim evaluations if college age. In Europe, screening is repeated every 2 years regardless of age. In practice, many school systems require annual evaluations, guidelines notwithstanding.

Screening recommendations in the United States—for college-age young adults as well as for children and adolescents—include (2, 3):

• History

• Physical examination

• Selected testing based on findings on history and physical examination

History should include questions about the following:

• Known hypertension or heart murmur

• Symptoms that are induced by exercise or are unexplained, including syncope (including convulsive syncope), near-syncope, chest pain, dyspnea, or palpitations

• Chest pain, particularly new onset, assessing quality (eg, pleuritic, pressing, burning), location, duration, intensity, relation to activity, associated symptoms

• Family history of sudden cardiac death at age < 50 years, arrhythmias, dilated cardiomyopathy, hypertrophic cardiomyopathy, long QT syndrome, or Marfan syndrome

• Use of performance-enhancing or illicit drugs (visit the U.S. Anti-Doping Agency) and medications that predispose to long QT syndrome

• In adults, risk factors for coronary artery disease

Physical examination should consist of a cardiovascular examination that includes blood pressure in both arms, supine and standing cardiopulmonary auscultation, and assessment for other conditions such as features of Marfan syndrome. These measures aim to identify apparently healthy people at high risk of life-threatening cardiac events (eg, people with arrhythmias, hypertrophic cardiomyopathy, or other structural heart disorders).

European guidelines differ from American guidelines in that a screening electrocardiogram (ECG) is recommended for all children, adolescents, and college-age athletes (4); in the United States, guidelines consider ECG screening reasonable but do not recommend it universally (2).

Canadian Guidelines recommend screening in 3 tiers (5):

• History/questionnaire

• Physical examination

• ECG only when indicated according to clinical findings

Testing follows if clinically warranted.

Screening for older adults (35 years or older) with risk factors may include incremental symptom-limited exercise testing, especially if athletes have been sedentary for a number of years.

Stress Test (Exercise Electrocardiogram [ECG])

Image

In this photo, a patient walks on a treadmill attached to multiple ECG electrodes; ECG monitoring and recording equipment is in the foreground.

DR P. MARAZZI/SCIENCE PHOTO LIBRARY

History and examination are neither sensitive nor specific (6); false-negative and false-positive findings are common because prevalence of cardiac disorders in an apparently healthy population is very low. Use of screening ECG or echocardiography improves disease detection but produces more false-positive diagnoses; ECG screening continues to be controversial for this reason, as well as the challenges of applying screening to a large population with a relative shortage of clinicians qualified to interpret ECGs (2).

Genetic testing for hypertrophic cardiomyopathy or long QT syndrome is not recommended or even feasible for the screening of athletes.

Athletes should also be screened for musculoskeletal and other risks before participation in sports.

Noncardiovascular risk factors are more common than cardiovascular risk factors. Patients are asked about the following:

• Previous or current musculoskeletal injuries (including easily triggered dislocations)

• Arthritic disorders, particularly those involving major weight-bearing joints (eg, hips, knees, ankles)

• Concussions

• Asthma

• Symptoms suggesting systemic infection

• Heat-related illness

• Easy bruising or bleeding

• Seizures

Two populations at risk for injuries are commonly overlooked:

• Boys who physically mature late are assumed to be at greater risk of injury in contact sports if competing against larger and stronger children, although this is not clearly supported by evidence (1, 2, 3).

• People with overweight or obesity are at increased risk of musculoskeletal problems because of excess body weight and associated forces on the joints and tissues. One risk is overuse injury with soft-tissue inflammation, particularly if people increase intensity and duration of exercise too rapidly. A long-term risk is osteoarthritis affecting weight-bearing joints. Another risk may be injury due to sudden stops and starts if they participate in activities that require jumping or high levels of agility.

Athletes, particularly adolescents and young adults, should be asked about use of illicit and performance-enhancing drugs. (Visit the U.S. Anti-Doping Agency.)

In girls and young women, screening should detect delayed onset of menarche. Girls and young women should be screened for the presence of the female athlete triad (eating disorders, amenorrhea or other menstrual dysfunction, and diminished bone mineral density). Two questions are validated screening measures for eating disorders:

• Have you ever had an eating disorder?

• Are you happy with your weight?

Other than certain cardiovascular disorders, there are almost no absolute contraindications to sports participation.

Exceptions in children are generally temporary and include:

• Acute splenic enlargement or recent infectious mononucleosis (Epstein-Barr virus infection) because splenic rupture is a risk

• Symptomatic or persistent fevers, which may decrease exercise tolerance, increase risk of heat-related disorders, and be a sign of serious illness

• Possibly significant diarrhea and/or recent significant vomiting because dehydration is a risk

In adults, relative contraindications are more common and lead to recommendations for precautions or for participation in some sports rather than others, for example:

• People with a history of frequent and easily triggered dislocations or multiple concussions should participate in noncollision sports.

• Males, particularly those with a single testis, should wear a protective cup for most contact sports.

• People, particularly those at risk of heat intolerance and dehydration (eg, those with diabetes, cystic fibrosis, sickle cell disease or trait, or previous heat-related illness), should hydrate frequently during prolonged activity.

• People with suboptimal seizure control should avoid swimming, weight lifting, and, to prevent injury to others, sports such as archery and riflery.

• People who have asthma need to monitor their symptoms closely.

• Screen younger participants (children through young adults) with history, physical examination, and depending on local practice, electrocardiography; those with abnormal findings or positive family history should have further evaluation.

• Screen older participants with risk factors (particularly if they have been sedentary for a number of years) with history, physical examination, and usually an exercise stress test.

• Use guidelines and shared decision-making to guide decisions about sports participation in those with most structural or arrhythmogenic heart disorders.

• Recommend against participation in children with acute splenic enlargement or recent infectious mononucleosis, symptomatic or persistent fever, and significant diarrhea or vomiting that predispose them to dehydration, until these conditions are resolved.

• In all patients, limit participation in specific sports based upon concurrent medical conditions.