In 2005, representatives from six medical organizations (i.e., American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine) convened a working group to update the Preparticipation Physical Evaluation monograph.¹ The goals of this group included standardizing the preparticipation evaluation; reviewing expert opinion and position statements from major organizations; developing a process that is applicable in all settings; making evidence-based recommendations; and, most importantly, enhancing the health and safety of athletes. The updated monograph includes descriptions of the preparticipation evaluation process and reviews the rationale for the patient history and physical examination. All sections have been updated, and sections on administrative concerns and athletes with special needs have been added.

The extent of screening that is needed in the preparticipation evaluation to prevent sudden cardiac death is controversial. For example, should electrocardiography (ECG) or echocardiography be a routine part of the evaluation? The European Society of Cardiology recommends ECG for all high school and college athletes before athletic participation.² A recent large population-based Italian study supports this approach.³ However, on careful review, the Italian study fails to support routine ECG testing for U.S. athletes during preparticipation screening.

Residents of the Veneto region of Italy (the setting of the Italian study) and the United States have different genetic considerations. Arrhythmogenic right ventricular cardiomyopathy is the predominant cause of exertion-related sudden death in Italy,⁴ whereas hypertrophic cardiomyopathy is the predominant cause of such deaths in the United States.^5,6 Arrhythmogenic right ventricular cardiomyopathy is less common in the United States.

All of the athletes who died in the Italian study were cleared for athletic participation after undergoing an extensive cardiac work-up.³ During the study, there were 1.9 reported deaths per 100,000 person-years among screened athletes.³ In the United States, the rate of reported sudden deaths among high school and college athletes is lower (0.44 deaths per 100,000 person-years).⁵

In the Italian study, 2 percent of athletes were disqualified from competition because of cardiovascular causes.³ Were these athletes at risk of an exercise-related cardiac event? There were no deaths in the disqualified group, and it is unlikely that all of the athletes in this group adopted a sedentary lifestyle to avoid sudden death.⁷ Therefore, the 2 percent athletic disqualification rate is unacceptably high.

A screening study that included patient history, cardiovascular auscultation, blood pressure measurement, and ECG in 5,615 U.S. high school athletes showed that 22 of the athletes (0.4 percent) needed further cardiac testing.⁸ Sixteen of these athletes (0.3 percent) were not cleared for sports participation because of an abnormal ECG test result. None of the athletes had hypertrophic cardiomyopathy.⁸

In the Italian study, a significant percentage of the 55 athletes who died suddenly after obtaining athletic eligibility had positive history findings: six athletes had a family history of cardiomyopathy, sudden death, or both; 10 had palpitations on exertion; seven had syncope; and two had chest pain.³ These data suggest that the history portion of the preparticipation evaluation, including asking the right questions, is one of the best tools to detect athletes at risk of sudden cardiac death.

The Italian study was also limited because it was a population-based, observational study instead of a controlled comparison of screened and nonscreened athletes.⁷ Also, there was no control group that received more limited cardiac screening (e.g., no ECG).⁷ Of interest, coronary artery disease was more common in athletes than in the control population; therefore, the groups were not comparable.

In this issue of American Family Physician, Giese and colleagues review the preparticipation cardiovascular assessment; they also conclude that routine ECG, echocardiography, and exercise testing is not recommended.⁹

The preparticipation evaluation continues to evolve. With improving technology we can more easily collect and analyze data and outcomes and continue to modify preparticipation evaluation guidelines. In doing so, we will continue to make the health and safety of athletes a priority.

editor's note: The Preparticipation Physical Evaluation monograph is currently out of print. The sponsoring organizations are considering ways to reissue it, or make it available online.