Preparticipation CV Screening: Who Gets the Red Card?

Bernard Gersh, MB, ChB, MD: Hello. I am Dr Bernard Gersh, professor of medicine at Mayo Clinic. During today's Mayo Clinic Heart Talk, we will be discussing the quite contentious issue of sports physicals for children. I am joined by my colleague and our expert in the area, Dr Jonathan Johnson, who is an associate professor of medicine and a pediatric cardiologist at Mayo Clinic. Welcome, Jonathan.

Before we move on to some of the specifics, what are the differences in attitudes about this in the United States compared with some other countries? I know Italy has quite a sophisticated program of regular testing.

Jonathan N. Johnson, MD: The differences around the world are striking. Many countries — Italy was the flag-bearer for many years — and certainly Israel and other countries in Europe now have mandated ECG screening as part of the preparticipation sports physical, in addition to the usual history and physical exam. In the United States and Canada, we have not necessarily mandated ECG, and none of the major cardiology organizations have so far put together any sort of guidelines that support that.

That does not mean that it is not happening in some local areas. There have been studies in Texas, Illinois, and Pennsylvania that have included ECG screening on a more systematic basis and found some interesting results.

Does Screening Have a Downside?

Gersh: I can understand the upside, but what is the downside? Why do we not screen everybody with an ECG and an echo — all of that — other than cost?

Johnson: The real problematic downside of testing everyone for any particular condition is going to be the number of false positives and false negatives. Particularly with ECG screening, we do get a fair number of false positives. With some of the more sophisticated methods, we can push that rate of false positives down fairly low, to between 1% and 3%. Some time ago, we conducted a screening study at a private school in Minnesota, offering free ECG and echo screening to all of their athletes, and we had about a 10% false-positive rate on the ECG.

With some of the more modern techniques and different analyses, that rate has been cut down quite a bit. But if you conducted screenings in a school or a town with thousands of children, and even 1%-3% of them have an abnormal test, you then must conduct a whole series of other tests, potentially echocardiograms, stress tests, visits with cardiologists, and it ends up being quite a costly endeavor.

Gersh: From a personal perspective, particularly when I worked at Georgetown in Washington, DC, I saw a number of professional athletes, and not just for screening, where "abnormalities" had been picked up. I found these to be some of the most challenging patients I have ever had to deal with, because it is very easy to tell someone they cannot play, but you could be talking to a kid whose pathway out of the ghetto is the basketball court or the football field. I found it to be a very difficult decision. On the one hand, you may deprive them of earning a living or a scholarship, but on the other hand, you do not want to miss something that leads to a sudden death on the field.

Johnson: Absolutely. Those have been some of our toughest cases. The study I just mentioned, at the private school here in Minnesota, was at a boarding school for athletes. Athletes, particularly hockey and soccer players, would come from different states. They would do 4 hours per day of athletic training and then do their schooling. The students were from middle school through high school ages. We offered ECG and echo screening to those patients for free, but we only had 50% of families agree to it.

We surveyed the other 50% and asked why they did not want to have this screening; it was free, and we did not see any downside to it. Far and away the majority responded that they did not want anything found that would prevent the child from doing the sport they wanted to do.

Gersh: I can understand that. And I believe that there is a lot of shopping around. Sooner or later, they will find a doctor who says, "You can play." Just a quick comment before we get on to some specific questions. What is the false-positive rate among African American vs non–African American athletes? I know that a large study from the United Kingdom looked at Caribbean African, North African, and West African athletes and found a high rate of ECG abnormalities.

Johnson: We absolutely see the same thing in African American athletes in the United States and Canada, and particularly those of Caribbean origin. We have had a lot of problems trying to get ECG screening to accurately pick up those patients without having that false-positive number reach between 10% and even 20% in certain populations. With some of those more sophisticated methods, we have been able to cut that percentage down a bit, but it is absolutely higher in some of those different ethnic populations.

Is There a Standard for Screening?

Gersh: What is standard in the United States for kids who are going to play sports at school?

Johnson: The standard is still the preparticipation history and physical exam. There is typically a form that the physician or other clinician who is seeing the patient that day has to fill out to permit them to play. The form varies from state to state, which makes for an interesting situation when you are seeing patients from multiple different states, because the requirements for what you have to fill out are different; but the historical components and the physical exam components are actually fairly similar.

They are looking for any major family history of sudden death, anything that could pin you into a specific genetic diagnosis of any kind that could cause an increased risk for sudden death, looking for any historical symptoms of any kind — syncope, other symptoms with exercise — trying to pick up those patients who may have had a symptom once or twice but did not necessarily have others, and who could be at risk for sudden death. Most of the forms ask the practitioner to say that the athlete is either completely cleared or will be cleared once they do X, Y, or Z. Usually that involves a referral to a pediatric cardiologist or sports medicine specialist.

Gersh: Who are the referring practitioners?

Johnson: Most often it is the family medicine practitioners or pediatricians around the country. Earlier today, however, I was googling sports physicals to see what would come up, and the first three results were local stores and pharmacies that were offering free screenings at a low cost, with a note on the bottom of that advertisement that the examiner would sign your forms that day. I think a lot of people are trying to get into the business of clearing people as part of a marketing strategy, too.

Gersh: Sounds dangerous.

Johnson: I would agree with you. In some of those situations, as long as the people are appropriately trained and know to ask for assistance if they find anything concerning, it may be okay. But in most of those situations, having someone who is properly trained in pediatrics or family medicine is going to be the best screener by far.

Gersh: Where is most screening carried out?

Johnson: For the most part, it is in our pediatric offices, but it absolutely also happens in schools. A lot of schools will contract with a team to come through and do the screening. A lot will contract with some of these outside organizations as well, but the majority by far is done by pediatricians.

Gersh: Are there schools that just do not require it?

Johnson: Not really. Almost always, the screening is a state mandate, so the children have to have these forms filled out before they can play.

Gersh: Can you put a number on the proportion of red flags that are raised using this nonspecific, general kind of screening?

Johnson: I cannot give you a specific number, but I would guess in the 10% range.

Gersh: As much as that?

Johnson: Maybe a little less. The form includes any family history of early myocardial infarction, in someone under the age of 50 years, and early family history of cardiomyopathy.

Gersh: So if the family history is positive, these individuals will then come to you?

Johnson: They are typically referred to the next level of specialty support. If they are seeing a family medicine nurse practitioner, they may then see the pediatrician in their local area and then be sent to us for clearance.

Gersh: But it is mandated that they will follow up on that?

Johnson: On the form, the examiner states that they will not sign off until the child is seen by that next level of care.

What Abnormalities Are Disqualifying?

Gersh: That leads to my next question: What happens if the sports physical is abnormal? Does that mean the child will never get to play sports again?

Johnson: The child is sent to us and, even over the phone before we see them and after we see them, we are fairly reassuring to families, that just because the child has this abnormal screening history or physical or ECG does not mean that he or she will be disqualified. But we have to do this testing to be 100% sure. We do end up finding some of those disqualifying conditions, but it is a fairly low likelihood. Of all the patients we see for this kind of a thing, less than 10% end up being restricted in any way.

Gersh: Obviously, an echo and ECG are the next steps.

Johnson: It is almost always an echo and ECG, and then it depends on the symptoms and the history. If there are symptoms with exertion, we partner with the exercise lab here. They will take children as young as 6 years old, put them on a treadmill or an exercise bicycle, get a good exercise stress test to make sure there are no stress-inducible arrhythmias or ischemia, and try to pick up those other rare conditions as well. But if there is no history of a symptom with exercise of any kind, then usually it is echo, ECG, and a really good history.

Gersh: What conditions are disqualifying? Obviously, hypertrophic cardiomyopathy (HCM).

Johnson: That is probably the most common condition that most of our national guidelines say is disqualifying for most competitive sports, with the exception of some lower-intensity ones.

Gersh: I work in the cardiomyopathy clinic, and those patients accept that they cannot play competitive sports, but they want to be active. I used to play tennis with some guys, and this was middle-aged warriors playing tennis on a Sunday. They were so competitive. When does a noncompetitive sport become competitive?

Johnson: That is a great question. Most of the guidelines that pertain to competitive sports are meant for high school–, teenage-, and college-level sports and are not necessarily meant for recreational sports, even though we all know that my basketball league in residency was one of the most physical things I had ever done in my life. That being said, there are some papers and some guidelines for recreational sporting activities, even for patients with some of those cardiomyopathies, that give relative rates of risk, and they recommend avoiding certain activities.

We run into this with other patients; we do not want to tell them not to exercise at all, because we do not want them to be obese and unhealthy and reduce their life expectancy. So we do advise them to be active, but we advise them to do it in a safe environment, when they are around other people in gyms and places that have AEDs available — things like that.

Gersh: I will also tell them that if they are in a gym or out biking, or even if they like to run cross-country, if they cannot have a conversation with the person they are with because of shortness of breath, that is too much. As long as you can go out and walk, hike, bike, whatever, and have a conversation, that is okay.

Johnson: That is reasonable. I have used a similar parameter for patients with enlarged aortas when they ask whether they can lift weights. I usually tell them not to lift so much that they are straining and cannot talk to anybody. If you are lifting that much, it is too much. But small weights here and there are probably not going to hurt all that much.

Gersh: With patients with HCM, I always say that anything that makes you bulk up may make your heart bulk up. So keep to the light weights. Isotonic and not isometric. What other conditions have you picked up? Obviously HCM and arrhythmogenic right ventricular dysplasia. What else?

Johnson: We will pick up dilated cardiomyopathy in some patients, or a history of myocarditis, other noncompaction cardiomyopathies, and a wide variety of congenital heart diseases, which are distinctive; each has its own specific variation. Many of the guidelines have tried to parse out these different conditions and what they put the patient at risk for. In the end, the general consensus is that even after you have had surgery to repair some of these, as long as you have a functioning two-ventricle heart with appropriate outflow tracts, and without obstruction, for the most part you can do most anything. When there is obstruction to the flow going out of the heart, if there is a single-ventricle physiology — for example, one of our patients has had a Fontan procedure — then there are more restrictions.

Gersh: You mentioned noncompaction. That is a condition I would have thought is a matter of degree. I saw someone yesterday with apical noncompaction who probably had it all his life; it was very definite, in the apex. I would not restrict him from any activity. When is enough too much?

Johnson: I completely agree with you. In kids especially, we tend to treat the patients with noncompaction much as we treat our patients with dilated cardiomyopathy. As long as the function is okay and there are no other signs, no other history of arrhythmias, no arrhythmia on a Holter monitor or a stress test, I pretty much let them do anything athletic.

Gersh: I do too. What other cardiac conditions are compatible with very active sport? For mild noncompaction or bicuspid valve, I would not restrict activity as long as the aorta looks fine.

Johnson: I completely agree. Most of our patients with repaired congenital hearts — patients who have had a coarctation of the aorta but it has been repaired — we let them do anything. Our patients who have had holes in their hearts, tetralogy of Fallot, atrial septal defect, ventricular septa defect, we let them participate.

Even our patients who are post–heart transplant. That puts us into a bit of a quandary with the infection risk of certain sports — for example, wrestling — with some of the different viruses you can pick up; but other than that, we let our transplant patients do just about any sport.

Gersh: I did not realize that. Really?

Johnson: I have two transplant patients in Michigan who are playing high school football right now.

Gersh: My first reaction was no, but as I think about it, why not?

Johnson: Why not? I mean, you would worry about the suture lines and the aorta and such with the direct contact, but a couple of years ago, I surveyed about 20 colleagues who take care of heart transplant patients, including kids. At that time I did not let these patients play contact sports. I would try to get them to not play hockey or football if they had had a transplant, or wrestling because of the infectious question at the time. Eighteen of the 20 said they would let these patients play hockey and football, and I realized, why am I holding them back? As long as the aorta is not enlarged, the function is okay, and they are not having rejection...

Gersh: The suture line is not going to be disrupted.

Johnson: Exactly.

Gersh: Of course, I would not let them do it a week after the transplant. I know this is a little off the topic, but what about patients with implantable cardioverter defibrillators (ICDs)? My own feeling has been no, mainly because we test out the ICD in a particular environment that is not in the heat of battle, so to speak. Just because it defibrillates appropriately when you are lying on a table does not mean that it will do that at peak exercise. And then other people are involved and there may be lead fractures, and so on. So I have tended to say no, but I suppose opinion is pretty divided. What is your feeling?

Johnson: It's very controversial. I try to encourage my patients with ICDs not to play most contact sports because of the potential for lead fractures. Especially as kids are growing, they are already at risk for those things to happen; we do not need any other reason to make it happen. Mayo, Yale, and some other sites have been collecting data in a registry of patients who have ICDs and have been participating in sports. Mike Ackerman, from Mayo, is involved in that. They have found that, for the most part, patients tend to do fairly well — with some notable exceptions here and there, depending on their risk — and it is, at least partially, more about their underlying heart disease and their risk of having something happen rather than the ICD itself.

Gersh: In terms of HCM, I have seen a nationwide study that showed a surprisingly low rate of complications with competitive sport.I have said no, because you do not want a sudden death on your conscience, and there is no doubt that sudden deaths occur with HCM and they get a large amount of visibility. But this was a multinational registry of patients who had ICDs in place and were as likely to get a shock doing nothing as they were on the sports field. That does not really change it for me, though.

Johnson: It's a tough question. I think we have all been in the clinic with a family talking about their child playing a sport, and you are put in the position of deciding whether you would allow them to play. All of a sudden, it is on you to make that call and to be comfortable with that decision. The field is probably moving into what Dr Ackerman would call shared decision-making, where we present the risks to the families and the patients, try to ensure as best we can that they understand the risks they have, and then help them make the decision about athletic activities. I do tend to be more paternalistic than many others. I tend to hold back patients with certain conditions. But to your point, we have published a paper showing that many patients with long QT syndrome can play sports and do quite well, with a very low rate of complications. So it is possible that some of those limits are going to change over the next 10-20 years.

Gersh: So the trend is less restriction?

Johnson: Exactly.

Gersh: The area that I am most involved with is HCM, and I do not think they should play competitive sports — period.

Johnson: I personally do not disagree with you, but I also can tell you that I have one or two kids playing hockey goalie who have HCM.

Gersh: I know of a rugby player in South Africa who eventually found a doctor who cleared him to play. He is playing professionally. I have seen his MRI and it makes me nervous.

Johnson: Those are such tough situations.

Gersh: You probably already covered this, Jonathan, but who is the average patient who comes to your sports cardiology clinic?

Johnson: We see a mix of patients who have some sort of symptom when playing sports, and they want us to make sure they are not going to have sudden death or to have as low a risk of sudden death as possible. We also see a fair number of patients who are participating in sports and something has changed, such as, they used to be able to run a 5-minute mile and now, all of a sudden, they cannot get below a 6.5-minute mile and they do not know why. They are trying to figure out the mechanisms of why that is and whether there is anything else that could be affecting things.

Gersh: And what do you usually find in that situation?

Johnson: Most of the time, not much. Sometimes we will pick up on exercise-induced asthma or something like that, something that is a noncardiac issue. A lot of teenagers can develop abnormal disordered breathing that nobody knows much about, and we tend to pick up on those once they get into our sports clinics.

Johnson: It's more common than you would ever realize.

Gersh: I like to ski, and I ski a lot at high altitude in cold weather, and there is no doubt that this brings it on. It is a cough, not a wheeze.

Johnson: In the old exercise lab, we used to have a cold air funnel and we would blast cold air into the mouthpieces of our pediatric patients having exercise tests to try to induce exactly that. Sure enough, the asthmatics and other patients absolutely would tighten up when we did that.

Gersh: Jonathan, it has been fascinating talking to you. What are some take-home messages?

Johnson: The biggest message is to make sure that your pediatric patients are having this type of a screening with an appropriate professional, even if it is just the basic history and physical. We absolutely can catch some things that could put patients at risk. Also, even though we sometimes catch things, that does not always mean that the child cannot participate in sports. We are trying our best to help our patients be healthy and live long lives, and sports often are an important part of that.

Gersh: It is tough when you have someone for whom this is a career or livelihood. For other patients or families, I try to emphasize that maybe you cannot play competitively, but you are not playing for the NFL or the NHL; it is not a livelihood. And by the age of 30, most everyone has become a weekend warrior. What I think is important is to be able to enjoy playing sports at school and at college in a safe way, and they can do that without being competitive.

Johnson: Absolutely. I could not agree more.

Gersh: Thank you very much, Jonathan, for these important and interesting insights. Thank you for joining us on theheart.org | Medscape Cardiology.

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