Case Scenario

A 14-year-old patient with a history of obesity presents to his primary care physician for a preparticipation physical evaluation for basketball. The patient is excited for the season to start, and his mother attributes his lower body mass index and improved grades to his growing motivation to play basketball.

The patient has no family history of premature death or congenital cardiac disease and does not have chest pain, syncope, or dyspnea. The patient’s heart rate and blood pressure are normal. The examination reveals normal femoral pulses, normal heart sounds without a murmur, and no stigmata of Marfan syndrome or other disease. The physician orders an electrocardiogram (ECG). The automated interpretation suggests first-degree atrioventricular block and left ventricular hypertrophy. Initially, the patient is counseled to avoid strenuous exercise and referred to a pediatric cardiologist. During the cardiology appointment several weeks later, results of a repeat ECG and echocardiography are normal, and the patient is diagnosed with “athlete’s heart.” He is cleared for strenuous activity and joins the basketball team after missing two weeks of practice, feeling out of shape and out of sync with his teammates.

Clinical Commentary

Children and adolescents who regularly participate in sports have a lower risk of obesity, chronic disease, alcohol and drug use, and criminal activity, and have higher self-esteem compared with nonparticipants.^1–3 However, only 24% of youth engage in the 60 minutes of physical activity per day recommended by national guidelines.⁴ Participation in structured sports has decreased from 45% to 38% in the past 10 years, and children in low-income households are one-half as likely to participate regularly in sports compared with children from higher-income households.⁴ The Aspen Institute found growing disparities in physical activity by income; the percentage of inactive children in households with annual incomes less than $25,000 increased from 24% in 2012 to 33% in 2018, whereas the percentage of inactive children in households earning more than $100,000 decreased from 14% to 9.9% during the same time frame.⁴

In the United States, 49 states and the District of Columbia require a preparticipation physical evaluation before participation in school sports (Vermont leaves the decision to screen to individual school districts).⁵ The major components of the preparticipation physical evaluation are a detailed family history, medical history, symptom history, and physical examination.^6,7

Concern about undiagnosed cardiac disease in athletes has grown over the past several decades following high-profile cases of sudden cardiac death.⁸ Rates of sudden cardiac death in young athletes range from 0.4 to 4 per 100,000 athlete-years.^8,9 One suggested role of the preparticipation physical evaluation is preventing these deaths through early identification of children at high risk. Recognizing that the incidence of sudden cardiac death and cardiac disease is generally highest in first-degree relatives of individuals with related cardiac disease,¹⁰ the American Heart Association (AHA), American Academy of Family Physicians, and American Academy of Pediatrics (AAP) have focused efforts on increasing the sensitivity of screening tools for affected relatives. The AHA 14-element screening tool (https://www.acc.org/latest-in-cardiology/articles/2014/09/15/14/24/acc-aha-release-recommendations-for-congenital-and-genetic-heart-disease-screenings-in-youth), which includes cardiovascular history and physical examination, is recommended.

RATIONALE FOR INCLUDING ECGS IN PREPARTICIPATION PHYSICAL EVALUATIONS

The sensitivity of preparticipation physical evaluations for significant cardiac disease, even when they include the AHA 14-element screening tool, is low (2% to 6%), and the false-positive rate is high (31%).^11,12 The most common causes of sudden cardiac death are hypertrophic cardiomyopathy, arrhythmias (e.g., long QT syndrome, Wolff-Parkinson-White syndrome), and coronary artery anomalies. Some of these causes can be identified with a screening ECG.^13,14 Other diagnoses do not cause ECG changes or cause transient changes that may not be evident during a screening ECG. Initial studies show that an ECG increases the sensitivity of the preparticipation physical evaluation for identifying significant cardiac disease to 50%.^11,15