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      Performance of the American Heart Association (AHA) 14‐Point Evaluation Versus Electrocardiography for the Cardiovascular Screening of High School Athletes: A Prospective Study

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          Abstract

          Background

          Preparticipation cardiovascular screening in athletes is fully endorsed by major medical societies, yet the most effective screening protocol remains debated. We prospectively compared the performance of the American Heart Association ( AHA) 14‐point screening evaluation and a resting ECG for cardiovascular screening of high school athletes.

          Methods and Results

          Competitive athletes participating in organized high school or premier/select level sports underwent cardiovascular screening using the AHA 14‐point history and physical examination, and an ECG interpreted with the Seattle Criteria. A limited echocardiogram was performed for all screening abnormalities. The primary outcome measure was identification of a cardiovascular disorder associated with sudden cardiac death. From October 2014 to June 2017, 3620 high school athletes (median age, 16 years; range 13–19; 46.2% female; 78.6% white, 8.0% black) were screened. One or more positive responses to the AHA 14‐point questionnaire were present in 814 (22.5%) athletes. The most common history responses included chest pain (8.1%), family history of inheritable conditions (7.3%), and shortness of breath (6.4%). Abnormal physical examination was present in 356 (9.8%) athletes, and 103 (2.8%) athletes had an abnormal ECG. Sixteen (0.4%) athletes had conditions associated with sudden cardiac death. The sensitivity (18.8%), specificity (68.0%), and positive predictive value (0.3%) of the AHA 14‐point evaluation was substantially lower than the sensitivity (87.5%), specificity (97.5%), and positive predictive value (13.6%) of ECG.

          Conclusions

          The AHA 14‐point evaluation performs poorly compared with ECG for cardiovascular screening of high school athletes. The use of consensus‐derived history questionnaires as the primary tool for cardiovascular screening in athletes should be reevaluated.

          Abstract

          See Editorial Maron et al

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          Most cited references21

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          Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles.

          Liviu Poliac, R Mathenge, David Roberts … (1996)
          To develop clinical, demographic, and pathological profiles of young competitive athletes who died suddenly. Systematic evaluation of clinical information and circumstances associated with sudden deaths; interviews with family members, witnesses, and coaches; and analyses of postmortem anatomic, microscopic, and toxicologic data. A total of 158 sudden deaths that occurred in trained athletes throughout the United States from 1985 through 1995 were analyzed. MAIN OUTCOME MEASURES--Characteristics and probable cause of death. Of 158 sudden deaths among athletes, 24 (15%) were explained by noncardiovascular causes. Among the 134 athletes who had cardiovascular causes of sudden death, the median age was 17 years (range, 12-40 years), 120 (90%) were male, 70 (52%) were white, and 59 (44%) were black. The most common competitive sports involved were basketball (47 cases) and football (45 cases), together accounting for 68% of sudden deaths. A total of 121 athletes (90%) collapsed during or immediately after a training session (78 cases) or a formal athletic contest (43 cases), with 80 deaths (63%) occurring between 3 PM and 9 PM. The most common structural cardiovascular diseases identified at autopsy as the primary cause of death were hypertrophic cardiomyopathy (48 athletes [36%]), which was disproportionately prevalent in black athletes compared with white athletes (48% vs 26% of deaths; P = .01), and malformations involving anomalous coronary artery origin (17 athletes [13%]). Of 115 athletes who had a standard preparticipation medical evaluation, only 4 (3%) were suspected of having cardiovascular disease, and the cardiovascular abnormality responsible for sudden death was correctly identified in only 1 athlete (0.9%). Sudden death in young competitive athletes usually is precipitated by physical activity and may be due to a heterogeneous spectrum of cardiovascular disease, most commonly hypertrophic cardiomyopathy. Preparticipation screening appeared to be of limited value in identification of underlying cardiovascular abnormalities.
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            International criteria for electrocardiographic interpretation in athletes: Consensus statement.

            Jonathan A. Drezner, Sanjay Sharma, Aaron L Baggish … (2017)
            Sudden cardiac death (SCD) is the leading cause of mortality in athletes during sport. A variety of mostly hereditary, structural or electrical cardiac disorders are associated with SCD in young athletes, the majority of which can be identified or suggested by abnormalities on a resting 12-lead electrocardiogram (ECG). Whether used for diagnostic or screening purposes, physicians responsible for the cardiovascular care of athletes should be knowledgeable and competent in ECG interpretation in athletes. However, in most countries a shortage of physician expertise limits wider application of the ECG in the care of the athlete. A critical need exists for physician education in modern ECG interpretation that distinguishes normal physiological adaptations in athletes from distinctly abnormal findings suggestive of underlying pathology. Since the original 2010 European Society of Cardiology recommendations for ECG interpretation in athletes, ECG standards have evolved quickly, advanced by a growing body of scientific data and investigations that both examine proposed criteria sets and establish new evidence to guide refinements. On 26-27 February 2015, an international group of experts in sports cardiology, inherited cardiac disease, and sports medicine convened in Seattle, Washington (USA), to update contemporary standards for ECG interpretation in athletes. The objective of the meeting was to define and revise ECG interpretation standards based on new and emerging research and to develop a clear guide to the proper evaluation of ECG abnormalities in athletes. This statement represents an international consensus for ECG interpretation in athletes and provides expert opinion-based recommendations linking specific ECG abnormalities and the secondary evaluation for conditions associated with SCD.
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              Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association.

              Barry J Maron, Jennifer Atkins, B. L. Clark … (1996)
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                Author and article information

                Contributors
                Jonathan A. Drezner: jdrezner@uw.edu
                Journal
                Journal ID (nlm-ta): J Am Heart Assoc
                Journal ID (iso-abbrev): J Am Heart Assoc
                Journal ID (doi): 10.1002/(ISSN)2047-9980
                Journal ID (publisher-id): JAH3
                Journal ID (hwp): ahaoa
                Title: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
                Publisher: John Wiley and Sons Inc. (Hoboken )
                ISSN (Electronic): 2047-9980
                Publication date (Electronic): 09 July 2019
                Publication date Collection: 16 July 2019
                Volume: 8
                Issue: 14 ( doiID: 10.1002/jah3.2019.8.issue-14 )
                Electronic Location Identifier: e012235
                Affiliations
                [ 1 ] Sports Medicine Section Department of Family Medicine University of Washington Seattle WA
                [ 2 ] Department of Sports Medicine Hospital of Special Surgery New York NY
                [ 3 ] Division of Cardiology Department of Medicine University of Washington Seattle WA
                [ 4 ] Division of Cardiology Department of Pediatrics University of Washington Seattle WA
                Author notes
                [*] [* ] Correspondence to: Jonathan A. Drezner, MD, Department of Family Medicine, Center for Sports Cardiology, 3800 Montlake Blvd NE, UW Box 354060, Seattle, WA 98195. E‐mail: jdrezner@ 123456uw.edu
                Article
                Publisher ID: JAH34090
                DOI: 10.1161/JAHA.119.012235
                PMC ID: 6662133
                PubMed ID: 31286819
                SO-VID: 90d26bf6-8079-445f-a62f-cf076e02ed62
                Copyright © © 2019 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
                License:

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                Date received : 31 January 2019
                Date accepted : 09 April 2019
                Page count
                Figures: 1, Tables: 5, Pages: 9, Words: 6750
                Categories
                Subject: Original Research
                Subject: Original Research
                Subject: Preventive Cardiology
                Custom metadata
                source-schema-version-number 2.0
                component-id jah34090
                cover-date 16 July 2019
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:5.6.5 mode:remove_FC converted:16.07.2019

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: athlete,ecg,preparticipation,screening,sudden cardiac death,secondary prevention,cardiomyopathy,electrocardiology (ecg)
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: athlete, ecg, preparticipation, screening, sudden cardiac death, secondary prevention, cardiomyopathy, electrocardiology (ecg)

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