The purpose of the cardiac portion of the preparticipation physical evaluation is to identify potential health risks in young athletes, particularly sudden cardiac death. The preparticipation evaluation begins with a detailed screening questionnaire. Sudden cardiac death in athletes is considered rare, but the incidence in athletes is higher than in the general population. Leading causes of sudden cardiac death include hypertrophic cardiomyopathy, coronary artery anomalies, myocarditis, arrhythmogenic right ventricular cardiomyopathy, and aortic dissection. It also can be due to ventricular fibrillation, sometimes preceded by ventricular tachycardia. Electrocardiogram results may be abnormal in athletes who are at risk for sudden cardiac death, but diagnosis is made using cardiac imaging. Guidelines exist with recommendations for return to play for athletes who are at risk for sudden cardiac death.
Case 2. AS is a 15-year-old patient brought to your office after passing out at soccer practice. He was running drills when he suddenly lost consciousness. He reports no prior syncope, and he has no history of chest pain or pressure with exercise.
Evaluation
The purpose of the preparticipation physical evaluation is to identify potential health risks in young athletes. The cardiac portion of the evaluation attempts to identify athletes who are at risk of sudden cardiac arrest.1
The evaluation includes a detailed history (questionnaire) and a physical examination.1 If abnormalities are identified on history or physical examination, additional testing or referral may be indicated. The heart health portion of the questionnaire (Table 11,2) focuses on athlete risk for sudden cardiac death.1 The physical examination should include auscultation for heart murmurs, palpation of femoral pulses, an examination for signs of Marfan syndrome, and blood pressure measurement.2 Auscultation for murmurs should be performed with the patient sitting and standing.
Additional evaluation may include obtaining an electrocardiogram (ECG) or echocardiogram, specialty consultation, and advanced cardiac imaging. Low positive predictive values for the questionnaire (0.3%) and screening ECG (13.6%) result in a high number of false-positive results.3
Table 1 Cardiac-Related Preparticipation Questions and Physical Examination Items
| Screening Questions |
| Have you ever passed out or nearly passed out during or after exercise? |
| Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise? |
| Does your heart ever race, flutter in your chest, or skip beats (irregular beats) during exercise? |
| Has a doctor ever told you that you have any heart problems? |
| Has a doctor ever requested a test for your heart? For example, electrocardiography or echocardiography. |
| Do you get lightheaded or feel shorter of breath than expected during exercise? |
| Have you ever had a seizure? |
| Has any family member or relative died of heart problems or had unexpected or unexplained sudden cardiac death before age 35 years (including drowning or unexplained car crash)? |
| Does anyone in your family have a genetic heart problem such as hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia? |
| Has anyone in your family had a pacemaker or an implanted defibrillator before age 35 years? |
| Physical Examination Items |
| Heart murmur examined both supine and standing, with and without Valsalva maneuver |
| Femoral pulses |
| Physical stigmata of Marfan syndrome |
| Blood pressure |
Information from references 1 and 2.
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