AHA Panel Outlines Sudden Death Screening Standards

In an effort to promote a consistent approach to the cardiac screening of young athletes, the American Heart Association (AHA) has published a set of recommendations (1) for identifying athletes at risk for fatal cardiovascular events. The recommendations were written by an AHA panel of experts in heart disease and sports medicine.

At present, preparticipation exam standards for screening the nation's 4 million high school athletes vary from state to state; clearance procedures are set by state legislatures, state high school athletic associations, or school districts. "Eleven states do not have a standard medical form, and five do not even require an examination," says Barry J. Maron, MD, panel chair and director of cardiovascular research at the Minneapolis Heart Institute Foundation.

In light of inconsistent or lacking state standards, physician groups have worked together to publish their own preparticipation guidelines. James C. Puffer, MD, a panel member who is chief of the Division of Family Medicine at the University of California at Los Angeles Medical School says that the AHA's cardiac screening recommendations are consistent with those stated in the latest edition of the preparticipation examination guide prepared by five major medical societies and also recently published (2). "Some of the same individuals who participated on the AHA panel provided advice to the people who wrote the preparticipation exam monograph," he says.

In the long term, Maron says he would like to see a national high school athletics organization adopt the AHA guidelines and mandate their use by state affiliates.

The AHA guidelines, released in August, provide a practical, reasonable framework that avoids the unnecessary use of expensive procedures, says Puffer, an editorial board member of The Physician and Sportsmedicine. "The recommendations were made after carefully reviewing the literature on this issue," he says. "There was universal consensus among the panel members to adopt the recommendations."

Though the prevalence of sudden death in competitive athletes is low—in the range of 1 in 100,000 to 1 in 200,000 for high school athletes—a young athlete's death raises questions about whether a preparticipation examination could have uncovered the problem. "If the standards for physical exams and medical histories were optimized, more high-risk cases would be identified and deaths prevented," says Maron.

The AHA recommendations take a two-pronged approach. Physicians or other healthcare professionals trained to recognize heart symptoms should conduct the screenings. They should:

• Check the blood pressure and heart sounds of all high school and college athletes every other year. Taking blood pressure in the arm helps detect coarctation of the aorta. Evaluating heart sounds with the patient sitting and standing identifies murmurs consistent with left ventricular outflow obstruction.
  
  
• Take an annual personal history to evaluate chest pains, fainting, shortness of breath, or fatigue associated with sports. In addition, a family history completed with a parent's help should focus on cardiovascular disease or premature death in parents, siblings, or other close relatives. When a cardiovascular abnormality is suspected, the athlete should be referred to a specialist. Once a cardiovascular diagnosis is made, the 26th Bethesda Conference guidelines (3) should be used to formulate the participation recommendation.

The AHA panel scrutinized causes of sudden cardiac death in athletes. The largest study (4), which reported on 134 competitive athletes who died, found that a third of the deaths resulted from hypertrophic cardiomyopathy, a thickening of the walls of the left ventricle. The second leading cause of death—congenital defects of the coronary arteries—took several forms. Most deaths occurred during basketball and football games. Only 4 of the 134 athletes had been suspected of having heart problems, and only 1 had been positively diagnosed.

The next step will be to design a standardized form for taking the personal and family history, Maron says. "If we had that in place, we'd be in a better position to team up with some other group to move forward on this important issue," he says.

References

1. Maron BJ, Thompson PD, Puffer JC, et al: Cardiovascular preparticipation screening of competitive athletes: a statement for health professionals from the sudden death committee (clinical cardiology) and congenital cardiac defects committee (cardiovascular disease in the young), American Heart Association. Circulation 1996;94 (4):850-856
2. American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine: Preparticipation Physical Evaluation, ed 2. Minneapolis, New York City, McGraw-Hill, Inc, 1996
3. Maron BJ, Mitchell JH: 26th Bethesda Conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities. J Am Coll Cardiol 1994;24(4):845-899
4. Maron BJ, Shirani J, Poliac LC, et al: Sudden death in young competitive athletes: clinical, demographic, and pathological profiles. JAMA 1996;276 (3):199-204

Carol Potera
Great Falls, Montana

RETURN TO OCTOBER 1996 TABLE OF CONTENTS