Few doctors follow sudden cardiac death screening guidelines for young athletes

AHA Scientific Sessions

ORLANDO, Fla. — Less than 6% of physicians strictly follow national guidelines for assessing sudden cardiac death risk during high school sports physicals, data suggest. In fact, nearly half of the physicians and no athletic directors surveyed for a new study were aware that such guidelines exist.

Researchers sent a 36-question survey to 1,113 pediatricians and family doctors and 317 high school athletic directors in Washington to evaluate compliance with the American Heart Association guidelines for sudden cardiac death screening in youth. Physicians were questioned about preparticipation physical evaluations and athletic directors were asked about school requirements for physical evaluations. Published in 1996 and reaffirmed in 2007, the AHA guidelines consist of eight medical history questions and four physical examination elements, including listening to the heart and checking BP.

Physicians reported missing several critical questions during screenings:

• 28% did not always ask about chest pain during exercise.
• 22% did not always ask about unexpected fainting.
• 26% did not always ask about a family history of early death.
• 67% did not always ask about a family history of CVD.

None of the athletic directors said their schools required physical examinations to comply with the guidelines.

Study results did not differ based on physician specialty, level of experience or the athlete’s school size. Screening frequency, familiarity with the guidelines, number of physical examination per month and number of referrals to cardiology, however, were linked to greater overall compliance (P<.05).

“Despite the best efforts of many people and a considerable amount of financial resources, the majority of adolescent athletes are not receiving the type of quality history and physical recommended by national medical organizations such as the AHA. Consequently, before we can begin to consider adding new technologies to the screening of athletes that are both costly and logistically challenging, we should begin to standardize the current recommended process,” Nicolas Madsen, MD, MPH, pediatric cardiology fellow at Seattle Children’s Hospital and University of Washington School of Medicine, told Cardiology Today.

Physicians and athletic directors surveyed unanimously supported adopting a statewide form incorporating national screening guidelines. It is also suggested that parents ask physicians and schools whether a standardized form for sudden cardiac death screening is being used, the researchers said.

Of more than 7 million US high school athletes, one of every 30,000 to 50,000 dies from out-of-hospital sudden cardiac arrest each year, according to statistic from the AHA.

About 2,200 questionnaires were sent via mail and email to the physicians and athletic directors over 2 months. The “unusually high” response rate of 56% to 75% suggests interest in this issue, according to the researchers.

Looking ahead, Madsen and colleagues are working with the Washington Interscholastic Activities Association — the governing body of high school athletics in Washington — to mandate use of a standard form starting in the 2012-2013 school year. Thereafter, once a single form is utilized, Madsen said they can begin to measure the outcomes of this form/process to analyze the individual contents for their clinical value regarding sudden cardiac death screening. – by Katie Kalvaitis

For more information:

• Madsen NL. Abstract #10798. Presented at: Presented at: American Heart Association Scientific Sessions 2011; Nov. 12-16, 2011; Orlando, Fla.

Disclosure: Dr. Madsen reports no relevant financial disclosures.

Joseph Marek

This is a very nice and important study demonstrating the limitations of the pre-participation history and physical. An article published by Wilson et al in the British Journal of Sports Medicine in 2008 demonstrated pretty clearly that only taking a history and performing a physical are not very effective. As the attorneys say, res ipsa locutur (the thing speaks for itself). Dr. Madsen is quoted as saying, "Despite the best efforts of many people and a considerable amount of financial resources, the majority of adolescent athletes are not receiving the type of quality history and physical recommended by national medical organizations such as the AHA." The question is why hasn't the evaluation caught on? This is likely because physicians in the community feel that the evaluation isn't effective or that it is not practical. Whatever the reason, physicians have not embraced it after 15 years. At some point, we should change to another approach. Einstein said, "Insanity is doing the same thing over and over and expecting different results." The conclusion, however, should not be to "standardize the current recommended practice" before considering new technologies for screening. It is time for a fresh approach. Electrocardiogram testing is cheap - probably cheaper than the doctor's time spent doing the AHA-recommended evaluation - quick and more effective. We should rethink our approach.

Joseph Marek, MD
Cardiologist and Internal Medicine Specialist
Midwest Heart Foundation

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