Glover DW, Maron BJ. Profile of Preparticipation Cardiovascular Screening for High School Athletes. JAMA. 1998;279(22):1817-1819. doi:10.1001/jama.279.22.1817
From the Ambulatory Care Division, St Luke's Hospital, Kansas City, Mo (Dr Glover); and the Minneapolis Heart Institute Foundation, Minneapolis, Minn (Dr Maron).
Context.— Sudden death in young competitive athletes due to unsuspected cardiovascular
disease has heightened concern and interest in the preparticipation screening
available to high school athletes in the United States.
Objective.— To assess the potential adequacy of the preparticipation screening process
for detecting or increasing the suspicion of cardiovascular abnormalities.
Design.— Current guidelines and requirements for implementation of preparticipation
screening from each of the high school jurisdictions in the 50 states and
the District of Columbia were analyzed and compared with the 1996 American
Heart Association (AHA) consensus panel guidelines on screening.
Outcome Measures.— Items contained on preparticipation screening questionnaires; the examiners
designated to perform screening.
Results.— Eight states (16%) have no approved history and physical examination
questionnaires to guide examiners, including 1 state without a formal screening
requirement. Of the remaining 43 states, several items relevant to cardiac-related
problems were frequently omitted from the questionnaires. Exertional dyspnea
or chest pain, prior limitation from sports, family history of heart disease,
or Marfan syndrome were included in 0% to 56% of the state forms. Specific
cardiovascular items on physical examination were included in forms from only
5% to 37% of states, including documentation of a heart murmur, irregular
heart rhythm, peripheral pulses, or stigmata of Marfan syndrome. Seventeen
(40%) of 43 states had history and physical questionnaires judged to be most
adequate with at least 9 of the 13 AHA recommendations, whereas 12 states
(28%) were least adequate with 4 or less of these recommended items. Therefore,
a total of 20 (40%) of the 51 states have no approved history and physical
examination questionnaires, or formal screening requirement, or forms that
were judged to be inadequate. In addition to physicians, 21 states also permit
nurses or physician assistants to administer examinations, and 11 states specifically
provide for practitioners with limited cardiovascular training (such as chiropractors).
Conclusions.— Preparticipation athletic screening for cardiovascular disease with
standard history and physical examination, as presently employed in US high
schools, is highly dependent on the state-approved questionnaires, which frequently
are abbreviated and may be inadequate; is implemented by a variety of health
care workers with varying levels of expertise; and may be severely limited
in its power to detect potentially lethal cardiovascular abnormalities. These
observations should represent an impetus for change and improvement in the
preparticipation cardiovascular screening process for high school athletes.
SUDDEN DEATHS in young competitive athletes have become highly visible
events that cause great public concern.1- 9
Most of these deaths occur in athletes of high school age2- 4,7
and documented causes include mostly congenital cardiovascular malformations,2- 9
with hypertrophic cardiomyopathy (HCM) as the most common responsible lesion.2- 4,7,9
Athletic field catastrophes have stimulated considerable interest in
the role and efficacy of preparticipation screening10- 16
and procedures for the identification of potentially lethal cardiovascular
abnormalities with the expectation that disqualification of selected athletes
from competition probably will reduce their risk for sudden death during sports
activities.16 However, before the potential
effectiveness of preparticipation screening can be judged, it is necessary
to determine the current status of medical evaluations for athletes. In this
article, we assess the preparticipation screening procedures that are currently
available to US high school athletes, and estimate the adequacy of this process
for detecting or raising the suspicion of cardiovascular abnormalities.
We contacted directors of high school athletic associations from the
50 states and the District of Columbia (in this report we refer to the 51
jurisdictions that constitute this analysis [the 50 states and the District
of Columbia] as "states") to obtain the most recent approved history and physical
examination questionnaires required or recommended for preparticipation screening
of athletes in interscholastic sports in both public and private high schools
for grades 9 through 12, and to obtain detailed information regarding administration
of the screening process including the designated examiners. We analyzed portions
of these questionnaires relevant to the cardiovascular system with respect
to the clinical information requested from the athletes (or parents) and examiners.
We also compared the composition of the history and physical examination forms
against the 13 specific 1996 American Heart Association (AHA) consensus panel
recommendations for preparticipation cardiovascular screening,10
which included the following: (1) family history of premature sudden death
or heart disease in surviving relatives, (2) personal history of heart murmur,
systemic hypertension, excessive fatigability, syncope, exertional dyspnea
or chest pain, as well as parental verification of the history, (3) physical
examination for heart murmur, femoral pulses, stigmata of Marfan syndrome
or blood pressure measurement, which includes the recommendation of precordial
auscultation in both the supine or sitting and standing positions to identify
heart murmurs consistent with left ventricular outflow tract obstruction.
Of the 51 US jurisdictions, 50 formally require an examination prior
to participation in high school athletics, except for Rhode Island. Eight
(16%) of 51 states do not have recommended history and physical questionnaires
to serve as guidelines for examiners (ie, California, Georgia, Maine, Mississippi,
New Hampshire, New Jersey, Oregon, and Rhode Island). History and physical
examination forms approved for preparticipation screening were obtained from
42 states and the District of Columbia (as of June 1, 1997). Composition of
the 43 state history and physical questionnaires varied widely in content,
length, and comprehensiveness, ranging from abbreviated clearance forms composed
of only a simple statement of acceptability (Pennsylvania, Wisconsin) to detailed
documents with up to 37 items (District of Columbia); the average number of
items per form was 12.
Assessment of the historical questions that constitute the approved
questionnaires and require responses from athletes or parents demonstrated
that the following potentially important cardiovascular items appear in only
0% to 56% of the 43 state forms: personal history of exertional dyspnea or
chest pain or prior limitation from sports, and family history of heart disease
or Marfan syndrome (Table 1).
Only 26 (60%) of the 43 states require direct verification and approval of
the personal and family history by a parent. Items most commonly included
were history of medications or syncopal episodes in 88% and 86% of the state
Assessment of the approved physical examination form demonstrated that
only 5% to 37% of states included items specifically directed toward documenting
a heart murmur, irregular heart rhythm, physical stigmata of Marfan syndrome,
or peripheral pulses (ie, for detection of coarctation of the aorta) (Table 1). Physical examination items most
commonly included were blood pressure and heart rate, in 86% and 70% of the
state forms, respectively.
History and physical questionnaires were mostly developed by state high
school athletic associations, often in collaboration with state medical associations.
Of the 39 states with available information, the questionnaires had been developed
or revised and updated within the previous 5 years in 23 states, whereas 16
states had not revised their forms in more than 5 years, and 6 of those states
had not altered their forms in more than 10 years.
Comparison of the composition of the history and physical examination
forms with the 13 specific AHA consensus panel recommendations10
revealed that 17 (40%) of the 43 state forms contained at least 9 of the 13
recommended items (greatest number of items in Missouri [n=12], Kansas [n
= 11], and the District of Columbia [n=11]), whereas 12 state forms (28%)
included only 0 to 4 recommended items. Five of these 12 states had none or
1 AHA panel item (ie, Florida, Nebraska, Pennsylvania, Wyoming, and Wisconsin)(Figure 1).
Of the 50 states requiring preparticipation screening, 45 provide specific
recommendations regarding examiners, and 5 states have no stated recommendations,
restrictions, or requirements governing who may perform screening examinations.
State high school athletic associations sanction a variety of examiners; each
of the 45 states recommend that screening examinations be performed by medical
or osteopathic physicians. However, nurse practitioners or physician assistants
are eligible to administer the medical evaluations (without the direct involvement
of a physician) in 21 states. Eleven states specifically provide for practitioners
with no or limited cardiovascular training (such as chiropractors [n=10] or
naturopathic clinicians [n=1]) to perform preparticipation medical evaluations.
A total of 25 states sanction nonphysician examiners for athletic screening;
no state offers specific qualifications and standards for examiners or describes
guidelines for the setting of the screening examinations. Annual preparticipation
screening is recommended in 33 states (65%).
The causes of sudden death in young competitive athletes have been well
defined over the last several years.2- 9
These catastrophes are usually caused by a variety of congenital and unsuspected
cardiovascular disorders, with HCM17,18
the most common lesion responsible for these sudden deaths.2- 4,7,9
Preparticipation screening with noninvasive tests, such as electrocardiograms
or echocardiograms,10- 14,19- 22
could increase the chances of detecting cardiovascular abnormalities, particularly
HCM. However, such screening proposals would be impractical and costly for
most schools to provide consistently, especially when considering that cardiovascular
deaths occur among high school athletes at an estimated frequency of only
These considerations focus increased attention on the role and potential
efficacy of standard preparticipation screening (ie, personal and family history
and physical examination) that has been in place in many US high schools for
more than 30 years. We believe that it is timely and prudent to analyze this
screening process to assess its potential for detecting or raising the suspicion
of cardiovascular disease in athletes.
The history and physical examination questionnaire forms developed by
state high school athletic and medical associations constitute the specific
guidelines for designated examiners and, therefore, may be assumed to represent
the objectives of cardiovascular screening for any particular jurisdiction.
We found that these forms often demonstrated limitations that could reduce
the chances of detecting or suspecting cardiovascular disease during the screening
process. Fully 40% of the state high school associations do not offer approved
history and physical examination questionnaires, have no screening requirement,
or have screening forms that could be considered deficient compared with the
1996 AHA scientific statement on preparticipation screening recommendations.10 That AHA document includes consensus expert panel
recommendations for preparticipation cardiovascular screening and was used
in the present analysis as a "gold standard." Even though history and physical
examination forms have been widely acknowledged (since 1992),15
these questionnaires have not been generally used and appear to be the basis
of the screening forms in only 8 states.
Although no prospective data are available to permit a direct assessment
of the efficacy of large-scale athletic screening, a retrospective analysis2 of 134 young athletes who died suddenly from a variety
of cardiovascular diseases showed that only 3% of those exposed to standard
preparticipation screening had been suspected of having cardiac disease by
virtue of these examinations, and less than 1% received an accurate diagnosis.
Based on these observations, and those in this study, the preparticipation
screening process as currently structured and carried out in US high schools
appears to lack sufficient power to consistently recognize clinically important
cardiovascular abnormalities in many athletes.
Nevertheless, it should be emphasized that screening by standard history
and physical examination has the potential to identify or raise the suspicion
of cardiovascular disease in some at-risk athletes. For example, genetically
transmitted diseases such as HCM17,18
and Marfan syndrome24 and some cases of arrhythmogenic
right ventricular dysplasia,25 dilated cardiomyopathy,
and premature atherosclerotic coronary artery disease may be suspected from
the family history or by recent onset of symptoms such as exertional dyspnea
and chest pain. Marfan syndrome and systemic hypertension are identifiable
from physical examination, as are cardiac diseases associated with left ventricular
outflow obstruction by virtue of a loud heart murmur (such as aortic valvular
stenosis and some cases of HCM).
We also identified potential limitations in the implementation of cardiovascular
screening in US high schools. Although each state that designates specific
examiners recommends that physicians be responsible for preparticipation screening,
approximately 50% sanction alternative clinicians, such as nurse practitioners,
physician assistants, or chiropractors (and in 1 state, naturopathic clinicians)
to provide clearance for sports competition. At present, no systematic training
or accreditation criteria are required to provide assurance that such designated
health care workers achieve a satisfactory level of expertise.
Based on our evaluation of preparticipation cardiovascular screening
as presently constituted in US high schools (with standard history and physical
examination), it would appear that although such efforts have the theoretic
capability to detect or raise the suspicion of potentially lethal cardiovascular
diseases in some athletes, screening is unlikely to achieve its full potential
within the current format and methodology. In many states, crucial items are
often absent from questionnaires used as guidelines by the examiners. These
data also emphasize that it is not possible to assume that medical clearance
for sports competition precludes the possibility of all potentially lethal
cardiovascular diseases, and there should not be a false sense of security
on the part of the general public in matters related to athletic screening.
Nevertheless, it is reasonable to expect that improvement and optimization
of the preparticipation screening process will permit more frequent detection
of cardiovascular lesions associated with sudden death and morbidity in young
competitive athletes. We suggest that serious consideration be given to national
standardization of the history and physical examination forms for preparticipation
screening of high school athletes.