THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 9 - SEPTEMBER 98

Study Critiques Cardiac Screening of Athletes: Time for a National Standard?

The preparticipation examination forms used in most states have deficiencies that seriously reduce the chance of detecting potentially lethal cardiovascular conditions in high school athletes, according to a report in a recent issue of The Journal of the American Medical Association (1). The authors say they hope the report will spur efforts to establish national standards for the history and physical exam forms.

The researchers examined the preparticipation physical exam (PPE) standards used in all 50 states and the District of Columbia and compared them with the American Heart Association's (AHA) 1996 guidelines on screening for cardiac abnormalities (2). Their main findings:

• Eight states had no approved questionnaire forms to guide those who conduct PPEs.
• In many of the other 43 states, at least some questions considered important for detecting cardiovascular problems were missing from the preparticipation exam forms.
• Only 17 states had forms that included at least 9 of the 13 AHA recommendations.
• Twenty-one states allowed nurses or physician assistants to conduct PPEs, and 11 states allowed chiropractors to give the exams.

None of the states had history forms that addressed all 13 questions recommended by the AHA, says David W. Glover, MD, coauthor of the JAMA report and a family physician practicing in Warrensburg, Missouri. A national mandate is needed, Glover says, because "we have 51 different organizations, and it's very unlikely that they're all going to do well revising their PPE forms."

Critical Issues

Cardiac screening poses difficult problems because potentially fatal abnormalities are rare and in some cases undetectable without echocardiography or other sophisticated tests. Nevertheless, Glover and Maron say in their report that preparticipation screening by history and physical exam can uncover or raise the suspicion of such disease in some athletes, such as those who have hypertrophic cardiomyopathy (HCM) or Marfan syndrome.

Until recently, there have been no data showing the efficacy of cardiac screening exams. An Italian study, published in the August 6 issue of The New England Journal of Medicine (3), presents indirect evidence that screening reduces sudden death from HCM. The prospective study compared the sudden death rates of athletes and nonathletes (age 35 or younger) in the Veneto region of Italy from 1979 to 1996. (Since 1971, Italian law has required that competitive athletes undergo screening. The cardiovascular component includes history, family history, physical exam, 12-lead electrocardiography, and limited exercise testing.) HCM caused 2.0% (1 death) of sudden deaths among athletes, and 7.3% (16 deaths) among nonathletes.

Barry J. Maron, MD, coauthor of the JAMA report and director of cardiovascular research at the Minneapolis Heart Institute Foundation, says it's difficult to extrapolate the results of this study directly to the situation in the United States, "but it is very helpful in supporting the idea that screening can make a difference."

Despite the lack of studies showing the efficacy of screening, Glover and Maron contend that the screening inadequacies they identified hamper the ability of the process to achieve its full potential. "It is reasonable to expect that improvement and optimization of the preparticipation screening process will permit more frequent detection of cardiovascular lesions associated with sudden death and morbidity in young competitive athletes," their article states.

Some physicians, however, hesitate to embrace national screening using the AHA guidelines until efficacy and cost-effectiveness studies show a benefit. William L. Risser, MD, clinical professor of pediatrics at the University of Texas Houston Health Science Center, says that certain elements of preparticipation screening—parental input on the family history, for example—should not be mandated if doing so would obstruct sports participation among athletes of low socioeconomic status, "especially when the risk involved is small and the new intervention is unproven."

Raising the Legal Stakes

Maron says that the risk of legal liability may push state and national organizations to address the report's conclusions. "This paper can be and would be used to demonstrate that states and school districts have not measured up to the standard of care," Maron says. "The paper clearly draws a line in the sand—theoretically, the landscape has changed."

David L. Herbert, JD, a medicolegal expert and partner at Herbert & Benson in Canton, Ohio, says he agrees that Glover and Maron's article could have "profound potential medicolegal significance" and might be used in unnecessary- death claims and litigation. "Since these expressed opinions come from very respected professionals, they might be very easily adapted to legal claims and suits," says Herbert, an editorial board member of The Physician and Sportsmedicine.

Herbert notes that the JAMA article isn't the first to call for a national cardiac preparticipation exam standard. In 1996, the AHA's statement on cardiovascular screening (2) recommended a national standard for preparticipation medical evaluations, along with better training for healthcare workers who give the exams. (See "AHA Panel Outlines Sudden Death Screening Standards," October 1996, page 27.)

Steps Toward a Standard

Glover says the most logical group to spur the adoption of a national standard is the National Federation of State High School Associations (NFHS), based in Kansas City, Missouri. Though the NFHS has no regulatory power over the state associations, Glover says, its role is crucial because all 50 states and the District of Columbia belong to and communicate regularly with the organization.

The NFHS distributed the original joint PPE monograph sponsored by five medical societies (4) to its 51 members in 1992, and did the same with the revised version in 1996 (5), says Glover, who collaborates with the NFHS as a liaison from the Missouri State High School Activities Association and a liaison from the American Medical Society for Sports Medicine (AMSSM).

The time may be ripe for the NFHS to provide a stronger push for a national preparticipation standard; two years ago it established a sports medicine advisory committee, which includes two representatives from the AMSSM, Glover says. "Documenting the inadequacy of the forms that most states use is a stimulus," he says, and the sports medicine committee "provides a mechanism for getting something done."

Jerry L. Diehl, NFHS assistant director, says enforcement of a national PPE standard, if one were adopted, might be difficult because federation membership is voluntary, and the national organization does not have a role in state association governance.

Currently, the federation constitution and bylaws briefly address the medical, statutory, insurance, and liability rationales for the PPE, but do not designate what standard states should use for the exams, he says. "That's left to the discretion of the state associations," he says. Diehl says the NFHS's sports medicine committee will discuss the idea of a national PPE standard when it meets in mid-October. The committee may recommend bylaw changes to the NFHS board of directors, which meets in late October.

References

1. Glover DW, Maron BJ: Profile of preparticipation cardiovascular screening for high school athletes. JAMA 1998;279(22):1817-1819
2. 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
3. Corrado D, Basso C, Schiavon M, et al: Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339(6):364-369
4. Lombardo JA, Robinson JB, Smith DM, et al: Preparticipation Physical Evaluation, ed 1. 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. Kansas City, MO, 1992
5. 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

Lisa Schnirring
Minneapolis

Leptospirosis Cases Linked to Triathlons

In an effort to control a leptospirosis outbreak, the Centers for Disease Control and Prevention (CDC) in Atlanta and state health departments are contacting 1,850 athletes from 44 states who participated in two triathlons in the Midwest this summer. The events were held in Springfield, Illinois, June 21, and Madison, Wisconsin, July 5 (1).

Leptospirosis, a spirochetal zoonosis, causes a wide array of symptoms, including fever, headache, chills, myalgia, and sometimes a rash (2). It is spread to humans by contact with water contaminated with the urine of infected animals (1). Since 1970, most cases have occurred in home and recreational settings (ie, freshwater swimming, canoeing and kayaking, trail biking, hunting).

The incubation is typically 7 to 12 days but can range from 2 to 20 days. The diagnosis is based on a fourfold or greater rise in antibody titers in patients who are in the acute or convalescent stages. Treatment involves supportive measures along with penicillin, amoxicillin, ampicillin, doxycycline, or tetracycline to reduce the severity and duration of symptoms.

David Wang, MD, director of the general medicine and sports medicine clinics at Boynton Health Service and team physician at the University of Minnesota in Minneapolis, recently treated one of the affected athletes. The patient, a 24-year-old man, had participated in the Springfield, Illinois, triathlon. Wang says the athlete, without mentioning his triathlon participation, initially presented 24 days after the event with classic viremia symptoms—fever, headache, and myalgia. He was advised to rest at home and take acetaminophen, which seemed to relieve his symptoms, says Wang, who is an editorial board member of The Physician and Sportsmedicine.

The patient returned after the Minnesota Department of Health notified him about the leptospirosis outbreak, Wang reports. Wang ordered lab tests; liver enzymes were elevated and the albumin was decreased. The patient's serum specimen was positive for Leptospira grippotyphosa. Wang prescribed doxycycline 100 mg, twice a day for 10 days. The patient redeveloped a bad headache, unaccompanied by meningitis symptoms, but then slowly improved, Wang says.

References

1. CDC: Outbreak of acute febrile illness among athletes participating in triathlons—Wisconsin and Illinois, 1998. MMWR 1998;47(28):585-588
2. Farr RW: Leptospirosis. Clin Infect Dis 1995;21(1):1-6

News From the AOSSM Annual Meeting

• Custom ankle braces are more effective than taping for preventing and minimizing injuries, according to a study presented by lead author Monte Hunter, MD, an orthopedic surgeon at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina. The 8-year study involved 300 football players. At Wake Forest, players are required to wear ankle support during practice and games. Players were allowed to select the method of support; 52% selected tape and 48% chose braces. Of 158 ankle sprains, 115 occurred in players wearing tape and 43 occurred in players wearing braces. Braced players returned to play 2 days sooner than those injured while wearing tape. "One factor is that tape loosens during activity and does not maintain enough support to protect the ankle," said Hunter in an AOSSM press release.

• Bracing isn't crucial after anterior cruciate ligament (ACL) surgery, according to a study presented by Christopher C. Kaeding, MD, an orthopedic surgeon at the Ohio State University Sports Medicine Center in Columbus. Seventy-seven patients who underwent elective ACL reconstruction by the same surgeon were randomly divided into two groups before surgery. All underwent the same surgical procedure and participated in an aggressive, sports-oriented rehabilitation program after surgery. Three weeks after surgery, 47 patients received custom functional braces and 30 received neoprene knee sleeves. At 3 weeks and at 3, 6, and 12 months, no major differences were found between the two groups. "Postoperative bracing does not seem to be a major factor in regaining knee function after ACL surgery," Kaeding said in a press release from the AOSSM.

• Jump training can prevent knee injuries in female athletes, according to a study presented by Timothy E. Hewett, PhD, of the Cincinnati Sportsmedicine Research and Education Foundation. The trial involved a 6-week preseason program in which athletes learned proper jumping and landing techniques, built strength, power, and agility, and trained to achieve maximum vertical jump height. The study involved 1,263 high school athletes: 366 female athletes participated in the preseason training, 463 female athletes did not, and 434 male athletes served as controls. Fourteen serious knee injuries occurred during the season—10 in female athletes who did not participate in the program, 2 in girls who participated, and 2 in the male control group. "Although the increase in female athlete knee injuries is most likely due to a number of factors, we can see that training may be able to override one or more of these factors," said Hewett in a press release.

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