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Youth and Athletic Screening: Rationale, Methods, and Outcome

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Hypertrophic Cardiomyopathy

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Abstract

Sudden cardiac death is a tragic event under any circumstance but is especially devastating when it occurs in youth and athletes. In the “paradox of sports,” exercise both promotes health and acutely increases the risk of sudden cardiac death (SCD) among those with underlying heart disorders such as HCM, arrhythmogenic right ventricular cardiomyopathy, or coronary artery anomalies. Developed societies agree that pre-participation screening is valuable and warranted to improve the safety of sports competition, but there remain significant differences in opinion regarding the best methods to employ. ECG screening in particular remains controversial, with European societies generally in favor of ECG and US guidelines against ECG inclusion. Athlete-specific ECG criteria decrease the false-positive rate and costs of screening, and new US guidelines state ECG screening can be considered in small cohorts of young people under the conditions of sufficient provider expertise and quality control. However, barriers to widespread use of ECG screening remain, including concerns about ethics, logistics, cost-effectiveness, and overall health outcomes.

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References

  1. Kong MH, Fonarow GC, Peterson ED, et al. Systematic review of the incidence of sudden cardiac death in the United States. J Am Coll Cardiol. 2011;57(7):794–801.

    Article  Google Scholar 

  2. Stecker EC, Reinier K, Marijon E, et al. Public health burden of sudden cardiac death in the United States. Circ Arrhythm Electrophysiol. 2014;7(2):212–7.

    Article  Google Scholar 

  3. Eckart RE, Scoville SL, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med. 2004;141(11):829–34.

    Article  Google Scholar 

  4. Eckart RE, Shry EA, Burke AP, et al. Sudden death in young adults: an autopsy-based series of a population undergoing active surveillance. J Am Coll Cardiol. 2011;58(12):1254–61.

    Article  Google Scholar 

  5. Drezner JA, Chun JS, Harmon KG, Derminer L. Survival trends in the United States following exercise-related sudden cardiac arrest in the youth: 2000-2006. Heart Rhythm. 2008;5(6):794–9.

    Article  Google Scholar 

  6. Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol. 2003;42(11):1959–63.

    Article  Google Scholar 

  7. Van Camp SP, Bloor CM, Mueller FO, Cantu RC, Olson HG. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc. 1995;27(5):641–7.

    PubMed  Google Scholar 

  8. Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of sudden cardiac death in National Collegiate Athletic Association athletes. Circulation. 2011;123(15):1594–600.

    Article  Google Scholar 

  9. Maron BJ, Haas TS, Ahluwalia A, Murphy CJ, Garberich RF. Demographics and epidemiology of sudden deaths in young competitive athletes: from the United States National Registry. Am J Med. 2016;129(11):1170–7.

    Article  Google Scholar 

  10. Galea S, Blaney S, Nandi A, et al. Explaining racial disparities in incidence of and survival from out-of-hospital cardiac arrest. Am J Epidemiol. 2007;166(5):534–43.

    Article  CAS  Google Scholar 

  11. Burke AP, Farb A, Pestaner J, et al. Traditional risk factors and the incidence of sudden coronary death with and without coronary thrombosis in blacks. Circulation. 2002;105(4):419–24.

    Article  Google Scholar 

  12. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980–2006. Circulation. 2009;119(8):1085–92.

    Article  Google Scholar 

  13. de Noronha SV, Sharma S, Papadakis M, Desai S, Whyte G, Sheppard MN. Aetiology of sudden cardiac death in athletes in the United Kingdom: a pathological study. Heart. 2009;95(17):1409–14.

    Article  Google Scholar 

  14. Harmon KG, Drezner JA, Maleszewski JJ, et al. Etiologies of sudden cardiac death in National Collegiate Athletic Association Athletes. Circ Arrhythm Electrophysiol. 2014;7:198.

    Article  Google Scholar 

  15. Siscovick DS, Weiss NS, Fletcher RH, Lasky T. The incidence of primary cardiac arrest during vigorous exercise. N Engl J Med. 1984;311(14):874–7.

    Article  CAS  Google Scholar 

  16. Maron BJ, Chaitman BR, Ackerman MJ, et al. Recommendations for physical activity and recreational sports participation for young patients with genetic cardiovascular diseases. Circulation. 2004;109(22):2807–16.

    Article  Google Scholar 

  17. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA. 1996;276(3):199–204.

    Article  CAS  Google Scholar 

  18. Basavarajaiah S, Wilson M, Whyte G, Shah A, McKenna W, Sharma S. Prevalence of hypertrophic cardiomyopathy in highly trained athletes: relevance to pre-participation screening. J Am Coll Cardiol. 2008;51(10):1033–9.

    Article  Google Scholar 

  19. Maron BJ, Ahluwalia A, Haas TS, Semsarian C, Link MS, Estes NA 3rd. Global epidemiology and demographics of commotio cordis. Heart Rhythm. 2011;8(12):1969–71.

    Article  Google Scholar 

  20. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007;115(12):1643–455.

    Article  Google Scholar 

  21. Wilson JMG, Jungner G. Principles and practice of screening for disease. WHO Chronicle. Geneva: World Health Organization; 1968;22(11):473. Public Health Papers #434.

    Google Scholar 

  22. Maron BJ, Haas TS, Duncanson ER, Garberich RF, Baker AM, Mackey-Bojack S. Comparison of the frequency of sudden cardiovascular deaths in young competitive athletes versus nonathletes: should we really screen only athletes? Am J Cardiol. 2016;117(8):1339–41.

    Article  Google Scholar 

  23. Maron BJ, Friedman RA, Caplan A. Ethics of preparticipation cardiovascular screening for athletes. Nat Rev Cardiol. 2015;12(6):375–8.

    Article  Google Scholar 

  24. Chandra N, Bastiaenen R, Papadakis M, Sharma S. Sudden cardiac death in young athletes: practical challenges and diagnostic dilemmas. J Am Coll Cardiol. 2013;61(10):1027–40.

    Article  Google Scholar 

  25. Maron BJ. Distinguishing hypertrophic cardiomyopathy from athlete’s heart physiological remodelling: clinical significance, diagnostic strategies and implications for preparticipation screening. Br J Sports Med. 2009;43(9):649–56.

    Article  CAS  Google Scholar 

  26. Morganroth J, Maron BJ, Henry WL, Epstein SE. Comparative left ventricular dimensions in trained athletes. Ann Intern Med. 1975;82(4):521–4.

    Article  CAS  Google Scholar 

  27. Naylor LH, George K, O'Driscoll G, Green DJ. The athlete’s heart: a contemporary appraisal of the ‘Morganroth hypothesis’. Sports Med. 2008;38(1):69–90.

    Article  Google Scholar 

  28. Spence AL, Naylor LH, Carter HH, et al. A prospective randomised longitudinal MRI study of left ventricular adaptation to endurance and resistance exercise training in humans. J Physiol. 2011;589(Pt 22):5443–52.

    Article  CAS  Google Scholar 

  29. Utomi V, Oxborough D, Whyte GP, et al. Systematic review and meta-analysis of training mode, imaging modality and body size influences on the morphology and function of the male athlete’s heart. Heart. 2013;99(23):1727–33.

    Article  Google Scholar 

  30. Mayet J, Shahi M, Foale RA, Poulter NR, Sever PS, Mc GTSA. Racial differences in cardiac structure and function in essential hypertension. BMJ. 1994;308(6935):1011–4.

    Article  CAS  Google Scholar 

  31. Sheikh N, Papadakis M, Carre F, et al. Cardiac adaptation to exercise in adolescent athletes of African ethnicity: an emergent elite athletic population. Br J Sports Med. 2013;47(9):585–92.

    Article  Google Scholar 

  32. Chandra N, Papadakis M, Sharma S. Cardiac adaptation in athletes of black ethnicity: differentiating pathology from physiology. Heart. 2012;98(16):1194–200.

    Article  Google Scholar 

  33. Rawlins J, Carre F, Kervio G, et al. Ethnic differences in physiological cardiac adaptation to intense physical exercise in highly trained female athletes. Circulation. 2010;121(9):1078–85.

    Article  CAS  Google Scholar 

  34. Sheikh N, Papadakis M, Ghani S, et al. Comparison of electrocardiographic criteria for the detection of cardiac abnormalities in elite black and white athletes. Circulation. 2014;129(16):1637–49.

    Article  Google Scholar 

  35. Basavarajaiah S, Boraita A, Whyte G, et al. Ethnic differences in left ventricular remodeling in highly-trained athletes relevance to differentiating physiologic left ventricular hypertrophy from hypertrophic cardiomyopathy. J Am Coll Cardiol. 2008;51(23):2256–62.

    Article  Google Scholar 

  36. Bernhardt DT, Roberts WO. Preparticipation physical evaluation. Elk Grove Village, IL: American Academy of Pediatrics; 2010.

    Google Scholar 

  37. Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12–25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology. Circulation. 2014;130(15):1303–34.

    Article  Google Scholar 

  38. Madsen NL, Drezner JA, Salerno JC. Sudden cardiac death screening in adolescent athletes: an evaluation of compliance with national guidelines. Br J Sports Med. 2013;47(3):172–7.

    Article  Google Scholar 

  39. Thiene G, Corrado D, Schiavon M, Basso C. Screening of competitive athletes to prevent sudden death: implement programmes now. Heart. 2013;99(5):304–6.

    Article  Google Scholar 

  40. Sharma S, Estes NA 3rd, Vetter VL, Corrado D. Clinical decisions. Cardiac screening before participation in sports. N Engl J Med. 2013;369(21):2049–53.

    Article  Google Scholar 

  41. Mackie A. Screening of competitive athletes to prevent sudden death: think twice. Heart. 2013;99(5):306–7.

    Article  Google Scholar 

  42. Rowin EJ, Maron BJ, Appelbaum E, et al. Significance of false negative electrocardiograms in preparticipation screening of athletes for hypertrophic cardiomyopathy. Am J Cardiol. 2012;110(7):1027–32.

    Article  Google Scholar 

  43. McLeod CJ, Ackerman MJ, Nishimura RA, Tajik AJ, Gersh BJ, Ommen SR. Outcome of patients with hypertrophic cardiomyopathy and a normal electrocardiogram. J Am Coll Cardiol. 2009;54(3):229–33.

    Article  Google Scholar 

  44. Maron BJ. National electrocardiography screening for competitive athletes: feasible in the United States? Ann Intern Med. 2010;152(5):324–6.

    Article  Google Scholar 

  45. Corrado D, Pelliccia A, Heidbuchel H, et al. Recommendations for interpretation of 12-lead electrocardiogram in the athlete. Eur Heart J. 2010;31(2):243–59.

    Article  Google Scholar 

  46. Uberoi A, Stein R, Perez MV, et al. Interpretation of the electrocardiogram of young athletes. Circulation. 2011;124(6):746–57.

    Article  Google Scholar 

  47. Drezner JA, Ackerman MJ, Anderson J, et al. Electrocardiographic interpretation in athletes: the ‘Seattle criteria’. Br J Sports Med. 2013;47(3):122–4.

    Article  Google Scholar 

  48. Drezner JA, Ackerman MJ, Cannon BC, et al. Abnormal electrocardiographic findings in athletes: recognising changes suggestive of primary electrical disease. Br J Sports Med. 2013;47(3):153–67.

    Article  Google Scholar 

  49. Drezner JA, Ashley E, Baggish AL, et al. Abnormal electrocardiographic findings in athletes: recognising changes suggestive of cardiomyopathy. Br J Sports Med. 2013;47(3):137–52.

    Article  Google Scholar 

  50. Drezner JA, Fischbach P, Froelicher V, et al. Normal electrocardiographic findings: recognising physiological adaptations in athletes. Br J Sports Med. 2013;47(3):125–36.

    Article  Google Scholar 

  51. Riding NR, Sheikh N, Adamuz C, et al. Comparison of three current sets of electrocardiographic interpretation criteria for use in screening athletes. Heart. 2015;101(5):384–90.

    Article  Google Scholar 

  52. Sharma S, Drezner JA, Baggish A, et al. International recommendations for electrocardiographic interpretation in athletes. J Am Coll Cardiol. 2017;69:1057–75.

    Google Scholar 

  53. Papadakis M, Carre F, Kervio G, et al. The prevalence, distribution, and clinical outcomes of electrocardiographic repolarization patterns in male athletes of African/Afro-Caribbean origin. Eur Heart J. 2011;32(18):2304–13.

    Article  Google Scholar 

  54. Gati S, Chandra N, Bennett RL, et al. Increased left ventricular trabeculation in highly trained athletes: do we need more stringent criteria for the diagnosis of left ventricular non-compaction in athletes? Heart. 2013;99(6):401–8.

    Article  CAS  Google Scholar 

  55. Kawel N, Nacif M, Arai AE, et al. Trabeculated (noncompacted) and compact myocardium in adults: the multi-ethnic study of atherosclerosis. Circ Cardiovasc Imaging. 2012;5(3):357–66.

    Article  Google Scholar 

  56. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006;296(13):1593–601.

    Article  CAS  Google Scholar 

  57. Steinvil A, Chundadze T, Zeltser D, et al. Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death proven fact or wishful thinking? J Am Coll Cardiol. 2011;57(11):1291–6.

    Article  Google Scholar 

  58. Landry CH, Allan KS, Connelly KA, et al. Sudden cardiac arrest during participation in competitive sports. N Engl J Med. 2017;377(20):1943–53.

    Article  Google Scholar 

  59. Harmon KG, Asif IM, Maleszewski JJ, et al. Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association Athletes: a decade in review. Circulation. 2015;132(1):10–9.

    Article  Google Scholar 

  60. Harmon KG, Asif IM, Maleszewski JJ, et al. Incidence and etiology of sudden cardiac arrest and death in high school athletes in the United States. Mayo Clin Proc. 2016;91(11):1493–502.

    Article  Google Scholar 

  61. Wheeler MT, Heidenreich PA, Froelicher VF, Hlatky MA, Ashley EA. Cost-effectiveness of preparticipation screening for prevention of sudden cardiac death in young athletes. Ann Intern Med. 2010;152(5):276–86.

    Article  Google Scholar 

  62. Halkin A, Steinvil A, Rosso R, Adler A, Rozovski U, Viskin S. Preventing sudden death of athletes with electrocardiographic screening: what is the absolute benefit and how much will it cost? J Am Coll Cardiol. 2012;60(22):2271–6.

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Cardiology, Hypertrophic Cardiomyopathy Clinic, University of Washington, Seattle, WA, USA

    David S. Owens

  2. Department of Cardiovascular Sciences, St. George’s University of London, London, UK

    Sanjay Sharma

Authors
  1. David S. Owens
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  2. Sanjay Sharma
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Corresponding author

Correspondence to David S. Owens .

Editor information

Editors and Affiliations

  1. Westchester Medical Center, Valhalla, NY, USA

    Srihari S. Naidu

Questions

Questions

  1. 1.

    The following are true about pre-participation athletic screening except:

    1. A.

      The USA recommends the 14-question AHA questionnaire.

    2. B.

      Italy recommends an ECG routinely.

    3. C.

      The USA recommends a history and physical.

    4. D.

      The UK recommends an echocardiography.

    5. E.

      It has not definitively reduced incidence of SCD.

    Answer: D. All of these are true except D. Currently, no society recommends echocardiography as a routine part of pre-participation screening, due to cost and false-positive rates.

  2. 2.

    The upper limit of hypertrophy for physiologic remodeling is:

    1. A.

      13 mm

    2. B.

      15 mm

    3. C.

      17 mm

    4. D.

      19 mm

    Answer: C. While experts generally consider 15 mm as a diagnosis of HCM, especially when asymmetric and in the absence of loading conditions that could otherwise produce this level of hypertrophy, general agreement is that up to 17 mm can be seen in the trained athlete. This represents a significant overlap area, especially for Black athletes, who typically may have higher degrees of hypertrophy.

  3. 3.

    Etiologies of SCD in athletes include the following:

    1. A.

      Hypertrophic cardiomyopathy

    2. B.

      Commotio cordis

    3. C.

      ARVC

    4. D.

      Coronary anomalies

    5. E.

      Myocarditis

    6. F.

      Channelopathies

    7. G.

      All of the above

    Answer: G. All of the above can be associated with sudden cardiac death in athletes, although the frequency differs in different societies. These differences may be explained by genetic distribution of cardiac conditions in segregated populations. In the USA, the largest contributor is HCM, whereas in Italy it is ARVC.

  4. 4.

    SCD in athletes has the following themes, except:

    1. A.

      It is more common in males than females.

    2. B.

      It is more common in Blacks than Caucasians.

    3. C.

      It is more common in burst athletics than lower intensity athletics.

    4. D.

      It is more common in weight lifting than in endurance athletics.

    Answer: D. All of these are true with the exception of weight lifting, although weight lifting is not advisable in HCM due to the increased afterload that might stimulate further LVH.

  5. 5.

    Challenges to screening include the following except:

    1. A.

      Cost-effectiveness indicates routine population-wide screening even with ECG would be cost-prohibitive.

    2. B.

      False-positive rates are high, leading to unnecessary testing and psychological and financial impact to the athlete or youth.

    3. C.

      Homegrown screening initiatives focus on wealthier demographics, leaving many communities with disparities in care delivery.

    4. D.

      There is a higher false-positive rate in Blacks than Caucasians.

    5. E.

      All of the above.

    Answer: E. All of the above are challenges to screening programs. Therefore, current guidelines recommend a focused history and physical examination and the AHA 14-point questionnaire in an attempt to screen all individuals prior to sports participation. Patients with concerning features move on to ECG and echocardiography, based on findings.

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Owens, D.S., Sharma, S. (2019). Youth and Athletic Screening: Rationale, Methods, and Outcome. In: Naidu, S. (eds) Hypertrophic Cardiomyopathy. Springer, Cham. https://doi.org/10.1007/978-3-319-92423-6_11

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  • DOI: https://doi.org/10.1007/978-3-319-92423-6_11

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