**9. Pre-sports participation screening**

Pre-sports participation screening is commonly suggested by most medical societies [5, 48–52] including the American Academy of Pediatrics (AAP), American Heart Association (AHA), and the American College of Cardiology (ACC). Yet, the heart conditions which predispose to SCD happen in 5 in 100,000 persons and SCD occurs in 1 in 200,000 subjects. This degree of low risk makes the appraisal hard and the cost-effectiveness of screening techniques is low. The aim of any program is to discover individuals at risk for SCD during tough exercise without invasive testing and in a cost-effective manner. However, no generally established standards for screening are available at the present time. This issue was tackled differently in different countries. In the US, the pre-participation screening [5, 48, 51, 52] includes securing sports person's personal and family history and complete physical examination (**Tables 3** and **4**) without an ECG or any other imaging studies and if abnormalities are detected in this initial screening process, further workup is pursued. In Italy [49, 53], Israel [54], and Japan [55], an ECG is also performed along with history and physical examination; this is mandated by the respective country's laws. Screening of the athletes in other European countries is limited to the individuals participating in international, Olympic, or other professional sports [56]. Denmark, on the other hand

#### **Personal history**

1. Chest pain or discomfort during exertional activities

2. Unexplained syncope or near-syncope

3. Excessive exertional and unexplained dyspnea/fatigue or palpitations associated with exercise

4. Previously recognized heart murmur

5. Elevated systemic blood pressure

6. History of prior restriction from participation in sports

7. Results of prior testing of the heart by another physician/healthcare giver

#### **Family history**

8. History of premature death (sudden and unexpected, or otherwise) prior to age 50 years secondary to a cardiac issue in more than 1 relative.

9. Disability from heart disease in close relatives less than 50 years of age

10. History of hypertrophic or dilated cardiomyopathy, long-QT syndrome or other ion channelopathies, Marfan's syndrome, clinically significant arrhythmias, or genetic cardiac conditions in family members

#### **Table 3.**

*Personal and family history [5, 48, 51, 52].*

#### **Physical examination**

11. Complete physical examination including blood pressure in a sitting position\*

12. Palpation of femoral pulses to exclude coarctation of the aorta

13. Look for physical stigmata of Marfan's syndrome

14. Careful auscultation to exclude left ventricular outflow tract obstruction\*\*

*\*The numbering continues from Table 3.*

*\*\*Auscultation should be undertaken with the athlete in both the supine and standing positions (and with Valsalva maneuver) particularly to discover murmurs associated with HCM (dynamic left ventricular outflow tract obstruction).*

#### **Table 4.**

*Pre-participation physical examination [5, 48, 51, 52].*

completely rejected systematic screening for the athletes; their stated justification was a low event rate [57].

Some investigators employed screening studies utilizing ECG [58–61], echocardiogram [61–64], or MRI [65], and these investigators demonstrated that the prevalence of high-risk cardiac condition that is likely to predispose to SCD following exercise is low: ECG—0.33 to 11.5%; echocardiogram—1.26 to 5.1%; and MRI—1.25% of the athletic population screened [58–65].

The current recommendations by the AHA and ACC [5, 48, 51, 52] are to examine the personal history and family history (**Table 3**) and to carry out an orderly and complete physical examination (**Table 4**), whether it is undertaken in primary care doctors' clinic or in mass pre-participation screening programs. The rationale of the pre-participation screening is not to exclude youths from participation in sports, but to enable as many of them as possible to participate in sports to their full potential.

As mentioned above, the present AHA/ACC suggestions are that screening assessments are executed by trained examiners. This appraisal should consist of the 14-key

*Pre-Sports Participation Cardiac Screening Evaluation – A Review DOI: http://dx.doi.org/10.5772/intechopen.102942*

elements of personal and family history and physical examination (**Tables 3** and **4**). Such assessment should be carried out in a setting favorable for best auscultation of the heart. These all-inclusive screening assessments should be re-done in two years for high school athletes and in three years for the college student athletes. It is not realistic to presume that usual large-scale screening assessments are capable of excluding all clinically pertinent diseases. The writer of this chapter strongly believes that such appraisals should be undertaken by the primary care doctors (pediatricians, internists, family practitioners, and other primary care providers who care for children, adolescents and young adults) as a part of their annual regular physicals, but they should make sure that the AHA/ACC suggested 14-key elements of personal and family history and physical examination (**Tables 3** and **4**) are included.

If abnormalities are detected in the previously expressed, 14-Element AHA/ACC recommendations (**Tables 3** and **4**) for pre-participation cardiovascular screening, additional testing, as suitable, should be undertaken (**Table 5**).

### **9.1 Electrocardiogram**

ECG is the first test that should be performed if any abnormalities are detected in the 14-element screening (Routine pre-participation screening ECG is not recommended in the US and the justification for such will be reviewed in the next section of this chapter). The ECG may identify patients with HCM because, as mentioned in the HCM section, many patients with HCM exhibit ECG abnormalities although the ECG abnormalities are not diagnostic of HCM. The value of ECG in identifying coronary abnormalities is limited. However, the ECG is useful in detecting long QT syndrome, Wolf-Parkinson-White (WPW) syndrome, atrioventricular block, and Brugada syndrome.

#### **9.2 Echocardiogram**

Echocardiogram should be performed to investigate abnormalities detected during history taking, performing a physical examination, or unexplained ECG findings. However, it is absolutely impracticable to use the echocardiogram as a screening tool for SCD [2 22]. Hypertrophic cardiomyopathy (**Figures 1**–**9**) and other types of cardiomyopathies can easily be diagnosed by echo-Doppler studies. Aberrant CAs should be specifically imaged in an attempt to document normalcy (**Figures 10**–**12**) or to establish aberrancy (**Figures 13** through **17**). Echo is also useful in quantifying dilatation of the aortic root (**Figures 20** and **21**) in Marfan's syndrome. The presence of prolapse of the mitral valve and mitral valve insufficiency (**Figure 19**) can be detected easily in echo-Doppler studies.

#### **9.3 Other studies**

A number of other studies may be useful in investigating these patients and they should focus on specific issues/concerns discovered during the screening process (**Table 5**). Exercise testing may help resolve the significance of exercise-induced symptoms. Holter or Event monitors may be used to document arrhythmias. An invasive electrophysiology study may be needed in some children. Genetic screening for HCM, Marfan's syndrome, and long QT syndrome is currently available and may be performed as indicated for a given clinical scenario. MRI and CT scans may be

1. Secure careful personal and family history (**Table 3**)

2. Perform methodical pre-participation physical examination (**Table 4**)

3. Obtain a 12-lead electrocardiogram if any abnormalities are detected during history and/or physical examination (items 1 and 2)

4. If abnormalities are detected during history taking and physical examination or if unexplained ECG findings are seen, an echocardiogram should be performed. Particular focus should be paid to address the type of abnormality detected during items 1, 2, and 3

5. If problems are detected during items 1 through 4, additional studies, specifically addressing the detected abnormalities, are in order:


*CT, Computed tomography; HCM, Hypertrophic cardiomyopathy; MRI, magnetic resonance imaging.*

#### **Table 5.**

*Stepwise approach to cardiac screening evaluation.*

employed in specific situations, not resolved by echocardiography. Cardiac catheterization and cineangiography are rarely needed.

Given the easy accessibility of echocardiography and its utility in the detection and quantification of causes of sudden death in athletes (as reviewed in Sections 2–8 of this chapter), echocardiography has become the primary mode of investigation to address issues identified during history, physical examination and ECG screening. However, in subjects with poor echo windows, noninvasive studies such as MRI and CT scans may be utilized. These studies are particularly useful in evaluating aortic arch and pulmonary artery anomalies. Another condition in which MRI is useful is arrhythmogenic right ventricular cardiomyopathy; indeed, MRI criteria forms the basis for diagnostic confirmation of ARVC. In patients with Marfan syndrome, aortic dilatation can be quantitated and aortic dissection detected by MRI. MRI and CT scans are also useful in evaluating anomalous origin and course of the coronary arteries as well in assessing other coronary artery abnormalities listed in **Table 2**.
