Editorials
The Preparticipation Evaluation: Evolving to Enhance the Health and Safety of Athletes
See related article on page 1008.
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.
Address correspondence to Dennis A. Cardone, D.O., at dacardone@earthlink.net. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
REFERENCES
1. Preparticipation Physical Evaluation. 3rd ed. Minneapolis, Minn.: McGraw-Hill/Physician and Sportsmedicine, 2005.
2. Corrado D, Pelliccia A, Bjornstad HH, Vanhees L, Biffi A, Borjesson M, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol: consensus statement of the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2005;26:516-24.
3. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 2006;296:1593-601.
4. Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339:364-9.
5. Van Camp SP, Bloor CM, Mueller FO, Cantu RC, Olson HG. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27:641-7.
6. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA 1996;276:199-204.
7. Thompson PD, Levine BD. Protecting athletes from sudden cardiac death. JAMA 2006;296:1648-50.
8. Fuller CM, McNulty CM, Spring DA, Arger KM, Bruce SS, Chryssos BE, et al. Prospective screening of 5,615 high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc 1997;29:1131-8.
9. Giese EA, O'Connor FG, Brennan FH, Depenbrock PJ, Oriscello RG. The athletic preparticipation evaluation: cardiovascular assessment. Am Fam Physician 2007;75:1008-14.
Cardiovascular Disease Prevention in Women
See related article on page 1096.
Recently, the American Heart Association (AHA) published an update to its 2004 guidelines for the prevention of cardiovascular disease in women.1 A summary of the update is available in this issue of American Family Physician.2
The updated guidelines have the support of many participating organizations, including the American Academy of Family Physicians (AAFP), and are a combination of evidence-based medicine and consensus opinion. Whenever such guidelines are written, it is important to consider how the balance between evidence and consensus affects the final product and how we, as family physicians, should view the update.
All of the recommendations specifically address women. This is in response to the neglect of issues that specifically address cardiovascular disease prevention in women; the initial evidence base primarily involved men. This history strengthens the importance of more recent studies that include women and increases the importance of these guidelines for the care of women. However, in focusing on the care of women, family physicians should ensure that they do not neglect the care of men.
Some of the AHA recommendations differ from those of the AAFP. We do not see this as a major flaw, but rather as slightly different lines drawn in shifting sand. For example, the updated AHA guidelines recommend that the A1C level should be less than 7.0 in patients with diabetes, but the AAFP recommends that A1C goals be individualized. These are not necessarily different recommendations because the evidence supporting the AHA's statement is based on consensus rather than on hard science, and this can be seen as supporting the AAFP's position of shared decision making.
Similarly, the AHA guidelines recommend that blood pressure be controlled to less than 130/80 mm Hg in patients with diabetes, whereas the AAFP makes no recommendation for blood pressure control in this group. Other organizations have argued for different cutoff points (e.g., 130/85 mm Hg), and, in fact, the threshold is somewhat arbitrary.3 The point is that blood pressure should be more tightly controlled in patients with diabetes than in those without diabetes, regardless of the sex of the patient.
A flow diagram in the updated guidelines provides another source of potential confusion. The reader should view the diagram as an overview and not as something that dictates a single course of action. The diagram states that glucose can be used to assess the risk of cardiovascular disease. This does not mean that blood glucose should be measured in all women, but rather that the glucose level, if obtained, can be used in risk stratification (e.g., patients with elevated glucose have a higher risk).
The most recent AHA statement on the prevention of cardiovascular disease in women is an important guideline that helps highlight this disease as the leading cause of morbidity and mortality in women. The recommendations provide evidence-based statements that can help inform us in our practice.
editor's note: Dr. Ganiats represented the AAFP on the guideline's expert panel/writing group. Dr. Campos-Outcalt is a scientific analyst for the AAFP.
Address correspondence to Theodore G. Ganiats, M.D., at tganiats@ucsd.edu. Reprints are not available from the authors.
REFERENCES
1. Mosca L, Banka CL, Benjamin EJ, Berra K, Bushnell C, Dolor RJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation [In press].
2. Damlo S. AHA publishes guidelines on CVD prevention in women. Am Fam Physician 2007;75:1089-92.
3. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al., for the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52.
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