Pfister GC, Puffer JC, Maron BJ. Preparticipation Cardiovascular Screening for US Collegiate Student-Athletes. JAMA. 2000;283(12):1597-1599. doi:10.1001/jama.283.12.1597
Author Affiliations: Cardiovascular Research Division, Minneapolis Heart Institute Foundation, Minneapolis, Minn (Mr Pfister and Dr Maron), and Division of Sports Medicine, Department of Family Medicine, UCLA School of Medicine, Los Angeles, Calif (Dr Puffer).
Context Sudden death in young competitive athletes due to unsuspected cardiovascular
disease has heightened interest in preparticipation screening.
Objective To assess screening practices for detecting potentially lethal cardiovascular
diseases in college-aged student-athletes.
Design, Setting, and Participants A total of 1110 National Collegiate Athletic Association member colleges
and universities were surveyed between 1995 and 1997, with 879 (79%) responding
to the questionnaire.
Main Outcome Measures Information on the administration and scope of the preparticipation
screening process was obtained from the team physician or athletic director;
preparticipation screening forms were evaluated for content and compared with
12 items recommended by the 1996 American Heart Association (AHA) consensus
panel screening guidelines.
Results Preparticipation screening was a requirement at 855 (97%) of 879 schools,
was performed on campus at 713 schools (81%), and was required annually by
446 schools (51%). Team physicians were responsible for examinations at 603
(85%) of 713 schools with on-campus screening, although 135 of these schools
(19%) also approved nurse practitioners and 244 schools (34%) allowed athletic
trainers to perform examinations. Of the history and physical examination
screening forms analyzed from 625 institutions, only 163 schools (26%) had
forms that contained at least 9 of the recommended 12 AHA screening guidelines
and were judged to be adequate, whereas 150 (24%) contained 4 or fewer of
these parameters and were considered to be inadequate. Smaller Division III
schools were more likely than larger Division I schools to have inadequate
screening forms (30% vs 14%; P<.001). Relevant
items that were omitted from more than 40% of the screening forms included
history of exertional chest pain, dyspnea, or fatigue; familial heart disease
or premature sudden death; and physical stigmata or family history of Marfan
Conclusion The preparticipation screening process used by many US colleges and
universities may have limited potential to detect (or raise the suspicion
of) cardiovascular abnormalities capable of causing sudden death in competitive
The occurrence of unexpected sudden death in student-athletes due to
unsuspected cardiovascular disease1- 6
is an uncommon but often highly visible event that has heightened public concern
and that of the medical community.7,8
Indeed, such catastrophes have stimulated considerable interest in the role
of preparticipation screening.9- 12
In this regard, we previously analyzed the status of screening in US high
schools and judged that process to be deficient.10
Because the status of preparticipation cardiovascular screening available
to student-athletes in college is unresolved, we believe it is timely to evaluate
the strengths and limitations of this process.
We distributed survey questionnaires to the team physician or the athletic
director or athletic trainer of the 1110 National Collegiate Athletic Association
(NCAA) colleges and universities between 1995 and 1997.13
In these questionnaires, we solicited detailed information regarding the administration
and scope of preparticipation screening, including credentials of team physicians
and examiners, and the frequency and site of evaluations.
In a similar fashion, we contacted each institution by telephone to
request the most recent version of the approved history and physical examination
forms currently in use for preparticipation screening of varsity student-athletes.
The content of these forms represents a guide to examiners and is the basis
for screening at that institution. Those portions of the screening forms that
were relevant to the cardiovascular system were analyzed and items pertaining
to the history and physical examination were tabulated by one of us (G.C.P.)
and compared with the 12 American Heart Association (AHA) 1996 consensus panel
recommendations9 for preparticipation cardiovascular
screening of athletes, which included the following: family
history of (1) premature sudden death or (2) heart disease in surviving
relatives; personal history of (3) heart murmur,
(4) systemic hypertension, (5) excessive fatigue, (6) exertional syncope,
(7) exertional chest pain, or (8) excessive exertional shortness of breath; physical examination for (9) heart murmur, (10) femoral
pulses, or (11) stigmata of Marfan syndrome; and (12) blood pressure measurement.
Proportions were compared with the χ2 test.
Of the 1110 NCAA institutions initially surveyed, 879 (79%) returned
the questionnaire including 286 Division I (schools with larger undergraduate
enrollments that provide athletic scholarships), 256 Division II (institutions
generally intermediate with respect to enrollment and scholarships), and 337
Division III (schools with the smallest enrollments that do not offer athletic
scholarships.) A total of 855 (97%) of the 879 schools indicated that formal
screening with a personal family history and physical examination was an absolute
requirement prior to participation in varsity intercollegiate sports. Most
institutions (713/879 [81%]) performed screening examinations in a college
health care facility on campus, while the remainder (164/879 [19%]) occurred
at off-campus sites administered by nonuniversity health care personnel, with
the athlete often having sole discretion for identifying the examining physician.
A designated team physician(s) was usually responsible for performing
the evaluations at 603 (85%) of the 713 schools with screening on-campus,
either alone or in association with nurse practitioners (n = 135) or athletic
trainers (n = 244). Most of the team physicians specialized in orthopedic
surgery (n = 451), while the others were most commonly in family practice
(n = 348), internal medicine (n = 149), or pediatrics (n = 32). Physicians
with formal cardiovascular training conducted examinations in only 33 of the
Preparticipation screening evaluations were required each year by 446
(51%) of 879 schools, whereas 433 schools (49%) required a screening evaluation
only on college entry. Only 58 schools (7%) routinely performed noninvasive
testing (either 12-lead or exercise electrocardiograms, chest x-ray, or echocardiogram).
The most recent versions of the screening history and physical examination
forms were obtained from 625 institutions. Of these, 205 (33%) were from NCAA
Division I schools, 176 (28%) were from Division II schools, and 244 (39%)
were from Division III schools.
The content of the history and physical screening forms pertinent to
the cardiovascular system are shown in Table 1. Certain clinically relevant AHA-recommended items were
included in only 9% to 52% of these forms: family history of Marfan syndrome,
excessive fatigue, prior limitations placed on sports participation, excessive
exertional shortness of breath, and exertional chest pain.
Approved physical examination forms also demonstrated important omissions.
For example, examination of the femoral pulses (ie, for detection of coarctation
of the aorta) and recognition of Marfan stigmata were each included in only
2% of the forms.
Forms arbitrarily regarded as adequate by containing at least 9 of the
12 AHA-recommended items were present for 163 schools (26%), including 10
institutions with 11 or 12 items (Figure 1). In contrast, forms arbitrarily judged to be inadequate with 4
or less AHA recommendations came from 150 schools (24%), including 46 with
only 0 to 2 items. The remaining 312 schools (50%) used forms that were intermediate
by virtue of addressing 5 to 8 AHA recommendations (Figure 1). Of note, inadequate forms were more frequent in NCAA
Division II and Division III schools (49 [28%] and 72 [30%], respectively)
and less common (29 [14%]) in Divison I (P< .001).
Sudden death due to cardiovascular disease in trained athletes is most
common in high school and college-aged participants.1- 7
High-intensity physical activity may act as a trigger to increase the risk
of sudden death in predisposed athletes with underlying cardiovascular disease.1 These observations have raised awareness of preparticipation
screening in the lay public and physician community9- 12
as a vehicle for detecting cardiovascular abnormalities responsible for these
catastrophes, and as a stimulus for withdrawal of selected athletes from competition
to reduce risk.14
We previously assessed the preparticipation cardiovascular screening
process in US high schools by analyzing approved history and physical examination
forms as well as designated examiners in each state.10
In that study, 40% of states either had no screening requirement, no approved
examination forms, or forms that were judged inadequate with respect to consensus
With these observations as a premise, we believed that it was timely
to analyze in a similar fashion preparticipation screening in US colleges
and universities. We considered the history and physical forms developed by
these institutions to constitute the designated guidelines for examiners and
thereby represent their specific objectives of cardiovascular screening.
This study shows that, similar to high school athletes, collegiate student-athletes
may be exposed to a flawed preparticipation cardiovascular screening process
that reduces the reasonable expectation of detecting pertinent cardiovascular
abnormalities in some athletes. When AHA consensus panel recommendations9 were used as the "gold standard" for comparison, about
25% of the NCAA schools were considered to have inadequate screening forms.
Indeed, the forms of a substantial number of institutions omitted items that
are crucial to the cardiovascular evaluation, such as exertional dyspnea and
chest pain, prior limitation from competitive sports, excessive fatigue, or
family history of Marfan syndrome.
Of the colleges surveyed, 85% used a designated team physician(s) as
the approved examiner to perform preparticipation evaluations. Nevertheless,
the majority (75%) of these team physicians were orthopedic surgeons, clinicians
who are often not as familiar with cardiovascular evaluations as are primary
care physicians or trained cardiovascular subspecialists. A substantial proportion
of institutions surveyed also permit nurse practitioners and athletic trainers
to perform preparticipation examinations, alone or in association with physicians;
these observations emphasize the importance of establishing minimum standards
of expertise for nonphysician (and physician) clinicians performing screening
Nevertheless, when performed optimally, preparticipation screening with
customary history and physical examination9
has the potential to identify cardiovascular abnormalities such as hypertrophic
cardiomyopathy, Marfan syndrome, some cases of arrhythmogenic right ventricular
dysplasia, dilated cardiomyopathy, and atherosclerotic coronary artery disease.15,16 Marfan syndrome and systemic hypertension
are identifiable from physical examination,16,17
as are diseases with a systolic heart murmur (eg, aortic valvular stenosis
and obstructive hypertrophic cardiomyopathy).9,18
Schools in NCAA Division I, which generally have the largest intercollegiate
sports programs, award athletic scholarships, and place a priority on athletic
achievement, were more likely to have comprehensive screening evaluations
than Division II and III schools, which have generally smaller enrollments
and intercollegiate sports programs and are permitted no or limited numbers
of athletic scholarships.
While it is customary for preparticipation screening in US colleges
and universities to consist of only standard history and physical examination,
noninvasive tests such as the 12-lead electrocardiogram and echocardiogram
could increase the liklihood of identifying important cardiovascular abnormalities,
particularly hypertrophic cardiomyopathy.18
However, such screening tests are costly and impractical for most schools,
particularly when considering the infrequency of sudden cardiac death for
student-athletes (about 1 per 200,000 per academic year).2,19
Our observations should represent an impetus for change and improvement
in the preparticipation cardiovascular screening process for college-aged
athletes. We expect that improved screening would ultimately increase the
potential for more frequent detection of certain cardiovascular lesions associated
with sudden death in collegiate athletes.