PPE for HCM Presentation

8/11/2019 PPE for HCM Presentation

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The Pre-participation Physical

Examination

Britta Anderson, D.O.

Detroit Medical CenterDepartment of Sports Medicine



Resources

Edited by:•

American Academy of FamilyPhysicians (AAFP)

•

American Academy ofPediatrics (AAP)

•

American College of SportsMedicine (ACSM)

• American Medical Society forSports Medicine (AMSSM)

• American Orthopaedic Societyfor Sports Medicine (AOSSM)

•

American Osteopathic

Academy of Sports Medicine(AOASM)



Resources

•

PPE 4 is seen as the current standard toperformance of the PPE in the US.

• 36th Bethesda Conference Guidelines – Eligibility Recommendations for Competitive Athletes

With Cardiovascular Abnormalities; 2005 – Pre-participation Screening and Diagnosis of

Cardiovascular Disease in Athletes; 2005

• American Heart Association (AHA)

–

Recommendations and Considerations Related toPre-participation Screening forCardiovascular Abnormalities in Competitive Athletes:2007 Update



Overview

• Goals and Objectives of PPE

• Timing, Setting and Structure

•

PPE Medical History•

PPE Physical Examination

• Clearance

•

Cardiac Issues



Goals and Objectivesof the PPE

• Main Goal is to improvethe health and safety ofathletes in training andcompetition

•

Screen for conditions thatmay be life-threatening ordisabling

• Screen for conditions that

may predispose to injuryor illness



Secondary Objectives

•

Determine GeneralHealth

• Serves as an entry

point to thehealthcare system forthe adolescent

• Opportunity to initiate

discussion on healthrelated topics



Timing, Setting, and Structure

• PPE should ideally be performed 6 weeksprior to preseason practice

– Allows time to follow-up if issues present

–

Various individuals that can be involved in thePPE process

• Physician

•

Ancillary Staff –

PA, Residents, Medical Students, ATC, Nurses, PhysicalTherapists



Method of Evaluation

•

Primary Care Office –

New Recommendation is forPPE to be a part of every wellchild adolescent care visit

–

Promotes medical home forpatient

–

Privacy to discuss confidentialissues ie) risk taking behaviors

•

Coordinated Medical Exams –

Cost effective –

At the final station of a stationbased exam, an experiencedphysician should be available to

review all data and determineclearance or provide appropriaterecommendations



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PHYSICAL EXAMINATION CLEARANCE FORMThis form must be on file in the school before practicing with any athletic team

Student Name: _________________________________ Birth Date: __________ Age: ____ Gender: M / F

Address: ______________________________________________________________________________________

Home Telephone: _____ - _____ - ________

School: ______________________________ Grade: ____ Sports: ___________________________________

I certify that the above student has been medically evaluated and is deemed to be physically fit to: (Check One Box)

(1) Participate in all school interscholastic activities without restrictions.

(2) Not cleared for: All Sports Specific Sports _________________________________________

Cross out specific sports below not cleared for participation.

Sport classification based on contact:Collision Contact Sports Limited Contact Sports Non-contact Sports

Basketball Ice HockeyBoys Lacrosse SoccerDiving WrestlingFootball

Baseball Alpine Skiing Track Field EventsCompetitive Cheer Girls Softball High Jump

Girls Lacrosse Pole VaultGirls Gymnastics Girls Volleyball

Bowling Track RunningCross Country Track Field EventsGolf DiscusSwimming Shot PutTennis

Sport classification based on intensity and strenuousness: High Intensity

High-to-Moderate DynamicHigh-to-Moderate Static

High Intensity

High-to-Moderate DynamicLow Static

High Intensity

Low DynamicHigh-to-Moderate Static

Low Intensity

Low DynamicLow Static

Alpine Skiing Track Events - DistanceCross Country Track Events - SprintFootball WrestlingIce Hockey

Baseball SwimmingLacrosse (Boys and Girls) TennisSoccer Girls Volleyball

Girls Softball

Girls CompetitiveCheer

DivingField EventsGirls Gymnastics

BowlingGolf

(3) Requires further evaluation before a final recommendation can be made.

Additional recommendations for the school or parents: _____________________________________________ ________________________________________________________________________________________

I have examined the above named student and completed the preparticipation physical evaluation. The athletedoes not present apparent clinical contraindications to practice and participate in the sport(s) as outlined above.A copy of the physical exam is on record in my office and can be made available to the school at the request of

the parents. If conditions arise after the athlete has been cleared for participation, the provider may rescind theclearance until the problem is resolved and the potential consequences are completely explained to the athlete

(and parents/guardians).

Examiner Signature: ________________________________________________ Date of Exam: ______________

COPY BOTH SIDES OF THIS SHEET FOR

THE STUDENT TO RETURN TO THESCHOOL AND KEEP THE ENTIRE FORMIN THE STUDENTS MEDICAL RECORD

Print Examiner Name: ___________________________________

Address: ______________________________________________

Office Telephone: _____ - _____ - ________ _________________

--------------------------------------------------- ----- < DETACH HERE IF NEEDED TO ACCOMPANY STUDENT ATHLETE > ------------------ ----------------------------------

EMERGENCY INFORMATION FOR: ______________________ Grade: ____ Allergies – Drug Reactions – Current Medications: _________________________________________________________

Other Special Medical Information: _____________________________________________________________________Emergency Contact: __________________________________________________ Relationship: ___________________

Telephone: (H) _____ - _____ - ________ (W) _____ - _____ - ________ (C) _____ - _____ - ________

www.mhsaa.com/schools/healthsafetyresources.aspx



INFORMATION CONSENT FORM

To be completed by parent/guardian or 18 year old or older student-athlete; please take time to completethe form to ensure the good health and safety of the student-athleteMust be signed in four (4) places by parent/guardian or 18 year old or older student-athlete (Below and on page 3)The exam date must be performed on or after April 15

th to be valid for the following school yearThe first two pages, Clearance Form and Information & Consent Form, must be kept on file with school athletic department

Student Name: ______________________________________________________________________________Last First Middle Initial

Sex:______ Grade:________ Age:_______ Date of Birth:_______________

School: ___________________________________ Sport(s): _________________________________________

Student’s Address: ___________________________________________________________________________Street City ZipFather’s/Guardian Name:_______________________________________________________________________

Phone (home):________________________ (work):__________________ (cell):__________________________

Mother’s/Guardian Name:_______________________________________________________________________

Phone (home):________________________(work): ____________________(cell):_________________________

SIGNATURES CONSENTING TO CONDITIONS OF PARTICIPATION

STUDENT DISCLOSURE AND ACCEPTANCE OF CONDITIONS TO PARTICIPATE: This applicationto participate in athletics is voluntary on my part and the information submitted is truthful to the best of my knowledge.

I have never received money or negotiable certificate for merchandise in any amount, nor any emblematic award ormerchandise worth more than twenty-five dollars ($25.00) for participating in athletic events, nor have I ever under an

assumed name. After I have represented my school in any sport, I will not compete in any outside athletic contest in thissport until after my school season has been completed.

I understand that I am expected to adhere firmly to all established athletic policies of my school district and the MichiganHigh School Athletic Association, such as those previously mentioned above as examples but which do not present all thepolicies to which I am subject.

Signature of STUDENT: ___________________________________________ Date: __________

INSURANCE STATEMENT: Our son/daughter will comply with the specific insurance regulations of the school district.

The student-athlete has health insurance: Yes No

If yes, Family Insurance Co: _________________________________ Contract #__________________________

CONSENT TO DISCLOSURE: I hereby give my consent for the above student to engage in interscholastic athleticsand for the disclosure to the MHSAA of information otherwise protected by FERPA and HIPAA for the purpose ofdetermining eligibility for interscholastic athletics; and I understand the possibility that serious injury may result fromparticipating in athletic activities. He/She has my permission to accompany the team as a member on its out-of-town trips.

I further understand that my son or daughter will be expected to adhere firmly to all established athletic policies of theschool district and the Michigan High School Athletic Association.

____________________________________________________________________ ________________Signature of PARENT OR GUARDIAN OR 18 YEAR-OLD Date

MEDICAL TREATMENT CONSENT: I, _______________________________________, an 18 year-old, or theparent or guardian of _________________________________, recognize that as a result of athletic participation, medicaltreatment on an emergency basis may be necessary, and further recognize that school personnel may be unable to contactme for my consent for emergency medical care. I do hereby consent in advance to such emergency care, includinghospital care, as may be deemed necessary under the then-existing circumstances and to assume the expenses of suchcare.

____________________________________________________________________ ________________

Signature of PARENT OR GUARDIAN OR 18 YEAR-OLD Date

_______________________________________________________________________________________________

N D f bi h



Name ___________________________________________________________________ Date of birth _______________________

Sex _________ Age ___________ Grade ____________ School ______________________ Sport(s) _________________________

Medicines and Allergies: Please list all of the prescription and over-the-counter medicines and supplements (herbal and nutritional) that you are currently taking.

Do you have any allergies? Yes No If yes, please identify specific allergy below.

Medicines Pollen Food Stinging Insects

Explain “Yes” answers below. Circle questions you don’t know the answers to.

GENERAL QUESTIONS Yes No

1. Has a doctor ever denied or restricted your participation in sports forany reason?

2. Do you have any ongoing medical conditions? If so, please identify

Asthma Anemia Diabetes Infections

Other: ____________________________________________________

3. Have you ever spent the night in the hospital?

4, Have you ever had surgery?

HEART HEALTH QUESTIONS ABOUT YOU Yes No

5. Have you ever passed out or nearly passed out DURING or AFTER

exercise?

6. Have you ever had discomfort, pain, tightness, or pressure in your

chest during exercise?

7. Does your heart ever race or skip beats (irregular beats) during

exercise?

8. Has a doctor ever told you that you have any heart problems? If so,

check all that apply:

High blood pressure A heart murmur

High cholesterol A heart infection

Kawasaki disease Other: _________________

9. Has a doctor ever ordered a test for your heart? (For example,

ECG/EKG, echocardiogram)

10. Do you get lightheaded or feel more short of breath than expected

during exercise?

11. Have you ever had an unexplained seizure?

12. Do you get more tired or short of breath more quickly than your

friends during exercise?

HEART HEALTH QUESITONS ABOUT YOUR FAMILY Yes No

13. Has any family member or relative died of heart problems or had an

unexpected sudden death before age 50 (including drowning, unexplained

car accident or sudden infant death s yndrome)?

14. Does anyone in your family have hypertrophic cardiomyopathy, long

QT syndrome, short QT s yndrome, Brugada syndrome, or

catecholaminergic polymorphic ventricular tachycardia?

15. Does anyone in your family have a heart problem, pacemaker, or

implanted defibrillator?

16. Has anyone in your family had unexplained fainting, unexplained

seizures, or near drowning?

BONE AND JOINT QUESTIONS Yes No

17. Have you ever had an injury to a bone, muscle, ligament, or tendon

that caused you to miss a practice or a game?

18. Have you ever had any broken or fractured bones or dislocated joints?

19. Have you ever had an injury that required x-rays, MRI, CT scan,

injections, therapy, a brace, a cast, or crutches?

20. Have you ever had a stress fracture?

21. Have you ever been told that you have or have you had an x-ray for

neck instability or atlantoaxial instability? (Down syndrome or dwarfism)

22. Do you regularly use a brace, orthotics, or other assistive device?

23.Do ouhavea bone muscle or oin t inur tha tbothers ou?

MEDICAL QUESTIONS Yes No26. Do you cough, wheeze, or have difficulty breathing during or after

exercise?

27. Have you ever used an inhaler or taken asthma medicine?

28. Is there anyone in your family who has asthma?

29. Were you born without or are you missing a kidney, an eye, a testicle

(males), your spleen, or any other organ?

30. Do you have groin pain or a painful bulge or hernia in the groin area?

31. Have you had infectious mononucleosis (mono) within the last month?

32. Do you have any rashes, pressure sores, or other skin problems?

33. Have you had a herpes or MRSA skin infection?

34. Have you ever had a head injury or concussion?

35. Have you ever had a hit or blow to the head that caused confusion,

prolonged headache, or memory problems?

36. Do you have a history of seizure disorder?37. Do you have headaches with exercise?

38. Have you ever had numbness, tingling, or weakness in your arms or legs

after being hit or falling?

39. Have you ever been unable to move your arms or legs after being hit or

falling?

40. Have you ever become ill while exercising in the heat?

41. Do you get frequent muscle cramps when exercising?

42. Do you or someone in your family have sickle cell trait or disease?

43. Have you had any problems with your eyes or vision?

44. Have you had any eye injuries?

45. Do you wear glasses or contact lenses?

46. Do you wear protective eyewear, such as goggles or a face shield?

47. Do you worry about your weight?

48. Are you trying to or has anyone recommended that you gain or loseweight?

49. Are you on a special diet or do you avoid certain types of foods?

50. Have you ever had an eating disorder?

51. Have you ever received tetanus-diphtheria-pertussis (Tdap) vaccine?

52. Are you missing any recommended vaccines (such as Tdap, MCV4,

HPV, Varicella, MMR, Flu, etc.)?

53. Do you have any concerns that you would like to discuss with a doctor?

FEMALES ONLY

52. Have you ever had a menstrual period?

53. How old were you when you had your first menstrual period?

54. How many periods have you had in the last 12 months?

Explain “ yes” answers here

PREPARTICIPATION PHYSICAL EVALUATION



PREPARTICIPATION PHYSICAL EVALUATION

PHYSICAL EXAMINATION FORM( The provider should keep this form in the chart )

Name __________________________________________________________________________ Date of birth _______________________

PHYSICIAN REMINDERS

1. Consider additional questions on more sensitive issues.

Do you feel stressed out or under a lot of pressure?

Do you ever feel sad, hopeless, depressed, or anxious?

Do you feel safe at your home or residence?

Have you ever tried cigarettes, chewing tobacco, snuff or dip? Do you drink alcohol or use any other drugs?

Have you ever taken anabolic steroids or used any other performance supplement?

During the past 30 days, did you use chewing tobacco, snuff or dip?

Do you drink alcohol or use any other drugs?

Have you ever taken anabolic steroids or used any other performance supplement?

Have you ever taken any supplements to help you gain or lose weight or improve your performance?

Do you wear a seatbelt, use a helmet and use condoms?

2. Please review questions on cardiovascular symptoms and family history (questions 5-16) with parent and/or student athlete

EXAMINATION

Height Weight Male Female

BP / ( / ) Pulse Vision R 20/ L 20/ Corrected Yes or No

MEDICAL NORMAL ABNORMAL FINDINGS

Appearance

Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height,hyperlaxity, myopia, MVP, aortic insufficiency)

Eyes/ears/nose/throat

Pupils equal

Hearing

Lymph nodes

Heart a

Murmurs (auscultation standing, supine, +/- Valsalva)

Location of point of maximal impulse (PMI)

Pulses

Simultaneous femoral and radial pulses

Lungs

Abdomen

Genitourinary (males only) b

Skin

HSV, lesions suggestive of MRSA, tinea corporis

Neurologic c

MUSCULOSKELETAL

Neck

Back

Shoulder/arm

Elbow/forearm

Wrist/hand/fingers

Hip/thigh

Knee

Leg/ankle

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Medical History

•

Medical History – Prior restriction from sports

–

Chronic conditions

• 75% of important medical

and orthopedic conditionsaffecting athletes can beidentified with the rightquestions

• 40% of histories given byathlete agreed withinformation from parents



Key Components of Medical History

•

Medication and Supplements•

Allergies to medications•

Previous Medical Illness – Heat Exhaustion/Illness – Infectious Mononucleosus –

Hepatitis

–

HIV –

DM –

Sickle Cell –

Asthma –

Allergic Reactions •

Neurologic conditions•

Dermatological conditions•

Eyes and Vision• Nutritional Concerns/Female Athlete Triad•

Musculoskeletal•

Cardiovascular Conditions



Asthma

•

EIA high prevalence inadolescents (10-50%)

• History and symptomsalone fail to identify

person with asthma/EIA46% of the time

• Athlete may present withsubtle symptoms – Headaches

–

Abdominal pain

– Muscle cramps

– Fatigue/dizziness



Dermatologic Conditions

• Contact sports (wresting) –

Herpes Gladiatorum

– Tinea Gladiatorum

–

MRSA

•

Focus on prevention –

Immediate shower afterpractice

–

Daily change of practice

clothes –

Mats/equipment hygiene



Neurological Conditions

• Concussions

• Seizures

• “Burners or

“Stingers” • Cervical Cord

Neuropraxia

•

Headaches



group.bmj.comon July 26, 2014 - Published bybjsm.bmj.comDownloaded from



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Heat Illness

•

Evaluating athletes who participate in hot andhumid environments

– Likelihood of recurrence

–

Athlete needs individual assessment to determinepredisposing conditions or unhealthy behavior

•

Sickle cell disease, Medication lists, Supplements, Caffeine

– Develop strategies that include acclimitazation (to the

environment and to exercise intensity and duration),conditioning, hydration, and salt intake



Nutritional Concerns

•

Female athletes most common (10:1)

• Screened with general questions of ideal weight andsatisfaction with current weight

• BMI <18.5 considered underweight by CDC/WHO

•

Female Athlete Triad: amenorrhea, eating disorder,osteopenia – Inquire about menstrual history, exercise patterns, stress fracture

– Menstrual irregularities are common in adolescent females• Menstrual cycle lengths outside the 95th percentile (90 days for the

first year, 50 days by the fourth year) should be evaluated



Cardiovascular Conditions

•

Sudden Cardiac Death – 1:200,000 to 300,000 athletes/year US

– 95% of sudden cardiac death in athletes <

age of 30 is caused by structural cardiacdisease leading to fatal arrhythmia

– Caused by primary structural cardiac disorderin 85% of young athletes

•

HCM 36%• 13% Anomalous coronary

arteries



Cardiovascular System

12-Element AHA recommendation

• Personal history1.

Exertional chest pain/discomfort2. Unexplained syncope/near syncope

3.

Excessive/unexplained exertional dyspnea/fatigueassociated with exercise4.

Prior heart murmur5. Elevated systolic BP

•

Family History6. Premature cardiac death before 50 in >1 relative

7.

Disability for heart disease in relative age <508.

Knowledge of cardiac condition in family: HCM/DCM, long-QT syndrome, Marfan, clinically importantarrhythmias



Hypertrophic Cardiomyopathy

•

1/3 of all SCD (US)

• Incidence 1:500 generalpopulation (0.2%)

•

80%, SCD initial symptom

•

A primary familial disease with

asymmetric hypertrophywithout dilation of LV

• Obstructive v Non-Obstructive

•

95% of patients with HCM willhave abnormal EKG



PPE Physical Exam

•

Height/Weight

• HEENT

• CV System

• Lungs

•

Abdomen

• Genitalia (males) – Testicular cancer leading

cause of cancer death men15 to 35

• Skin

•

Musculoskeletal



Height/Weight

•

www.cdc.gov/growthcharts

•

Extremely thin individualswarrants furtherquestioning

–

<5th percentile isunderweight

•

Impact of Obesity amongchildren and adolescents

–

At risk for overweight85-95 percentile

–

>= 95 consideredoverweight



Vision

•

Measured with SnellenEye Chart

• Should be better than20/40 per eye

•

Functionally one-eyedathlete requires eyeprotection –

Eye missing

–

Best corrected visionpoorer than 20/40

–

Hx of eye surgery orsignificant injury



HEENT

•

Standard exam

• Look for clues forpossible other

problems –

Eating disorders

–

Marfans

– Oral mucosa (tobacco

users)



Cardiovascular Exam

12 element AHA recommendations (8medical history/4 physical exam)

1. Heart Murmur

•

Auscultation in both supine and standing• Valsalva for dynamic LVOF obstruction

2. Femoral Pulses to exclude aortic coarctation

3. Stigmata of Marfan Syndrome

4.

Brachial Blood Pressure Measurement



Blood Pressure

•

Blood pressure withappropriately sized cuff! If elevated, repeat in few min! If still high, after lying down

for 10-15 min ask aboutstimulants

• Blood pressure norms are height(not weight) dependent

•

Children/Adolescents – Normal <90th percentile – High normal 90-95th

percentile – HTN >95th – 99th

percentile

–

Severe HTN > 99th

percentile• Adults

– Normal: < 120 and <80 – Pre HTN: 120-139 or

80-89 – Stage 1: 140-159 or

90-99 –

Stage 2: >160 or >100



Murmur

•

Suspicious – Diastolic or continuous

– Systolic murmur 3/6 or

more – Worse with valsalva or

standing



Marfan’s Syndrome

•

Kyphosis

• High-arched palate

• Pectus excavtum

• Arachnodactyly

•

Arm span > height

• Mitral valve prolapse

• Aortic insufficiency

• Myopia

•

Lenticular dislocation

•

“Thumb sign”

•

“Wrist sign”



Musculoskeletal

•

General Screening

• Joint-SpecificTesting

•

Sport SpecificTesting



General Screening

•

14 point screening• Only for

asymptomaticathletes



Joint Specific Exam

•

For athletes with: – Previous injury

– Symptoms of pain,

instability, oratrophy

– Problems noted inhistory or general

screening exam



Sport Specific Exam

•

Focus on high risk jointsin a given sport

• Strength, endurance, andflexibility tests

•

Shoulder:

– swimmers, throwers,tennis

•

Knee:

–

football, basketball,soccer



Medical Clearance

•

4 options –

Cleared

– Cleared withrecommendation for

treatment –

Not cleared

– Not cleared for certaintypes of sports

• 3.1% to 13.9% requirefurther evaluation

• 0.3-1.3% deniedparticipation





Cardiac Clearance

•

Most controversialaspect of PPE

• Sparked by high

profile deaths in themedia



PPE (Europe)

•

Early 1970’s Italy passed law mandating that allathletes engaging in competitive sports willundergo a clinical evaluation and receiveeligibility

•

History, Physical and EKG

• Sudden Cardiac Death Rates: –

1:200-300,000 athletes/year US

–

2.1:100,000 athletes/year Italy• Italy – twice as high with half the

numbers



Corrado et alJAMA 2006;296:1593-1601

•

Nationwide implementation of PPE screening

• Trends in SCD in athletes and non-athletes aged12-35 years in the Veneto region of Italybetween 1979 and 2004

• Among athletes rate of sudden deaths fell by89% –

PPE is effective at recognizing unsuspected heart disease

– Recognition reduces sudden cardiac deaths among athletes

–

With Screening death rate 0.4 per 100,000 (before program 1per 27,000 athletes)

–

US high school and college athletes between 1983and 1993, 0.44 per 100,000



Sudden Death in Athletes (U.S.)

•

Hypertrophic cardiomyopathy 36%

• Possible HCM 10%

• Aberrant coronary arteries 13%

•

Other coronary anomalies 6%

• Ruptured aortic aneurysm 5%

• Tunneled LAD coronary artery 5%

•

Aortic stenosis 4%

Maron et al. JAMA 1996; 276: 199-204



EKG?

•

Fuller et al Med Sci Sports Exerc. 1997;29:1131-1138 – 5,615 male and female US high school athletes were

screened prospectively

–

582 sent for ECHO based on screen –

146 distinctly abnormal EKGs– all had normal ECHO – 22 DQ : 1 with AR, 5 severe HTN, 1 SVT underwent

ablation, 15 lost to follow-up – 1 had cardiac arrest in 4 years and he had anomalous

CA not detected on EKG –

Sensitivity of 60-70% and Specificity of 97.4% forEKG to pick up cardiac disease that mightpredispose to SCD



EKG?

•

Italian PPE study, ECG had a 77% greaterpower to detect HCM than the history andphysical alone

• Corrado et al N Engl J Med. 1998;339:364-369

reported 75% of new HCM cases werediagnosed because EKG was part of screening• Nistri el al Am J Cardiol. 2003;91:1021-1023

– 32,910 male military personal in Italy from 1992 to1996 screened with H&P, EKG, CXR

–

2766 (8.4%) had a positive screen – HCM found in 19 (17 of 19 asymptomatic) – Sensitivity 68% and specificity 94%



EKG?

•

EKGs abnormal in >90% of patients withHCM

• False-positive EKGs have ranged from

10-25%•

EKG has relatively low sensitivity asscreening test in athletes – High frequency of EKG abnormalities

associated with normal physiologicadaptations of the trained athletesheart

D id l C di PPE



Does an ideal Cardiac PPE screenexist?

•

Arbitrary criteria for Abnormal EKG

• Varying definitions of LVwall thickness

•

Variations in testingprotocol and sample size

• Lack of true randomizedcontrol studies

Ideal Screening Test

• PPV greater than 90%

• NPV greater than 90%

•

Performance of test doesnot lead to potentiallyharmful medicalintervention

• Patient outcome studiessupport better results inthose tested



Screening Athletes for Heart Disease

•

The European Society of Cardiology(ESC) and International OlympicCommittee (IOC) have recommended that

pre-participation cardiovascular screeningof athletes should routinely include anEKG



Screening Athletes for Heart Disease

•

There are 5 million activeathletes at the high school,university, professional andmaster ’s levels in the UnitedStates

•

Estimated 10 million middle

and high school athletes•

AHA did not disagree with thisassertion, but they believe: – cost of EKGs versus the yield is

prohibitive – cost of evaluating false positives

(financial cost and psychological

impairment) are too great to makethis practice cost effective

– Better identification of high riskindividuals when the tests areused for directed cardiacevaluation rather than screening



Cost of Implementation

•

History, Physical, EKG for 10million high school and middleschool athletes $750 million

•

Estimated 15% (1.5 millionathletes) will have a (+) screen

•

Secondary evaluation includingnon-invasive cardiac testing$750 million

•

Administrative and operationalcosts to implement program ofthis magnitude (estimated 500

million)•

Total annual estimated cost of$2.0 billion



Conclusion

•

Goal is to maintain thehealth and safety of theathlete and promote safeparticipation

•

Importance of astandardized nationwidescreening exam

1997 41% of states had no formalscreening requirements or inadequatequestionnaire

2005 81% of states have adequate

questionnaire (>9 AHA items)64% of states can have non-physician

perform exam (18 states permitchiropractor or naturopathic physicianto screen)



References

•

Preparticipation Physical Evaluation, third edition, 2005. The Physician and Sports Medicine,McGraw-Hill Healthcare

• 36th Bethesda Conference: Eligibility recommendations for competitive athletes withcardiovascular abnormalities, J Am Coll Cardiol 2005;45(8):1-64

• 36th Bethesda Conference: Task Force 1: Preparticipation Screening and Diagnosis ofCardiovascular Disease in Athletes, J Am Coll Cardiol 2005;45(8):1322-1326

• Corrado D, Basso C, Pavei A, et al, Trends in sudden cardiac death in young competitive athletesafter implementation of a preparticipation screening program. JAMA Oct. 4,2006;296:1593-1601

•

Pelliccia et al. Prevalence of abnormal electrocardiograms in a large, unselected populationundergoing pre-participation cardiovascular screening. European Heart Journal 2007;28:2006-2009

• B. J. Maron; J. Shirani; L. C. Poliac; R. Mathenge; W. C. Roberts; F. O. Mueller. Sudden death inyoung competitive athletes. Clinical, demographic, and pathological profiles. JAMA 1996; 276:199-204

• Pelliccia A, Maron BJ, Culasso F, et al. Clinical Significance of Abnormal ElectrocardiographicPatterns in Trained Athletes. Circulation 2000; 1-2:278-284

• Fuller CM, McNulty CM, Spring DA, et al. Prospective screening of 5,615 high school athletes for

risk of sudden cardiac death. Med Sci Sports Exerc. 1997; 29:1131-1138• Winfiled K, Matheson GO, Meeuwisse WH. Preparticipation evaluation: an evidence-based review

Clin J Sport Med. 2004 May;14(3):109-22• Nistri S, Thiene G, Basso C, et al. Screening for hypertrophic cardiomyopathy

in young male military population. Am J Cardiol. 2003;91:1021-1023

Documents

PPE for HCM Presentation