The American College of Preventive Medicine (ACPM) supports an evaluation prior to participating in high school and collegiate sports using a standardized history and physical (H&P) (i.e., using standardized items as developed by the American Heart Association [AHA] to ensure uniformity and consistency in risk factor assessment [see the table below]). ACPM recommends against routine screening for potential sudden cardiac death (SCD) with electrocardiogram (ECG), echocardiography, and genetic testing in individuals without personal risk factors. The recommendations by ACPM address only mass screening approaches to detecting SCD and are not targeted toward individuals who may be identified by their healthcare provider as "above average" risk who may benefit from additional testing with the modalities mentioned above. ACPM supports the adoption of the National Heart, Lung, and Blood Institute (NHLBI) Working Group research agenda to evaluate the effectiveness of any screening program in reducing SCD, its cost–benefit ratio, and its impact on health outcomes (see Table 2 in the original guideline document).
Table: The 12-element AHA Recommendations for Pre-Participation Cardiovascular Screening of Competitive Athletes
aParental verification is recommended for high school and middle school athletes.
bJudged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion.
cAuscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
Sudden cardiac death (SCD)
Advanced Practice Nurses
To outline the American College of Preventive Medicine's (ACPM) perspective on critical preventive medicine issues, in a timely fashion, in order to exert a positive influence on policy, practice, and research dealing with screening for sudden cardiac death (SCD) before participation in high school and collegiate sports
Students playing high school and collegiate sports in the United States without personal risk factors
Note: This guideline does not include individuals who may be identified by their healthcare provider as "above average" risk.
Standardized history and physical (H&P):
- Personal history
- Family history
- Physical examination
Note: Electrocardiogram (ECG), echocardiography, and genetic testing were considered but not recommended.
- Instances of sudden cardiac death (SCD)
- Detection of underlying cardiac conditions and disease progression
- Mortality rates
- Specificity and sensitivity of screening tests
- Cost-effectiveness of SCD screening
Searches of Electronic Databases
PubMed, MEDLINE, and Google Scholar were the databases used for the qualitative literature search with a time frame of 1980 to 2013. No inclusion/exclusion criteria were used in the search.
The following search terms were used:
- Sudden cardiac death
- Screening for sudden cardiac death
- Sudden cardiac death in young athletes
- Pre-participation screening of sudden cardiac death
- Cost-effectiveness of pre-participation screening of sudden cardiac death
The American College of Preventive Medicine (ACPM) Prevention Practice Committee conducted a qualitative review of the literature on this topic to state the ACPM's position on sudden cardiac death screening.
The American College of Preventive Medicine (ACPM) Prevention Practice Committee reached consensus on these recommendations after an extensive literature review and examination of recommendations from other organizations.
- A limited number of studies suggest that combining history and physical (H&P) and electrocardiogram (ECG) screening for sudden cardiac death (SCD) may be cost effective. An Italian cost-effectiveness analysis of 33,735 athletes, using a more conservative approach (10% of affected athletes would live an additional 20 years), estimated the cost per year of life saved at approximately $20,000 for the Italian model (H&P and ECG) and about $53,350 for the U.S. model (H&P alone).
- The American Heart Association (AHA) estimates the cost of mass ECG screening, followed by echocardiogram and other indicated testing, to be $2.0 billion for 10 million middle and high school athletes. Pending further prospective studies involving U.S. participants, the cost effectiveness of routinely combining H&P and ECG in cardiovascular pre-participation screening in students cannot be conclusively determined.
Comparison with Guidelines from Other Groups
The guidelines from the following major professional and health organizations were used for comparison of recommendations on screening for sudden cardiac death before participation in high school and collegiate sports:
- American Heart Association
- European Society of Cardiologists
- International Olympic Committee
- American College of Sports Medicine
The type of evidence supporting the recommendations is not specifically stated.
Reduction in mortality from sudden cardiac death (SCD)
Although a history and physical (H&P) costs less, requires minimal resources, and is efficient to administer, it has low sensitivity in detecting hypertrophic cardiomyopathy and other asymptomatic cardiac diseases. Another limitation is the poor utilization of a standardized H&P for pre-participation sports evaluation.
The American College of Preventive Medicine (ACPM) acknowledges that studies addressing the efficacy of screening with clinical outcomes are lacking and that the utility of specific screening modalities remains unclear. However, at the present time, the history and physical (H&P) is the most widely used modality for pre-participation evaluation despite its limited sensitivity in detecting certain cardiac conditions. Promoting an H&P using standardized items as that developed by the American Heart Association (AHA) will ensure uniformity and consistency in risk factor assessment (see the table in the "Major Recommendations" field).
An implementation strategy was not provided.
|Mahmood S, Lim L, Akram Y, Alford-Morales S, Sherin K, ACPM Prevention Practice Committee. Screening for sudden cardiac death before participation in high school and collegiate sports: American College of Preventive Medicine position statement on preventive practice. Am J Prev Med. 2013 Jul;45(1):130-3. [23 references] PubMed|
Not applicable: The guideline was not adapted from another source.
American College of Preventive Medicine - Medical Specialty Society
American College of Preventive Medicine (ACPM)
American College of Preventive Medicine Prevention Practice Committee
Committee Members: Shamail Mahmood, MD, MPH; Lionel Lim, MD, MPH, FACPM; Yasir Akram, MD; Samantha Alford-Morales, MD, MPH, FACPM; Kevin Sherin, MD, MPH, MBA, FACPM
No financial disclosures were reported by the authors of this paper.
This is the current release of the guideline.
Print copies: Available from American College of Preventive Medicine, 1307 New York Ave, N.W., Suite 200, Washington, DC 20005-5603.
This NGC summary was completed by ECRI Institute on February 4, 2014. The information was verified by the guideline developer on March 13, 2014.
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria.
NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.