7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate Screening to prevent sudden cardiac death in competitive athletes : Mark S Link, MD, Antonio Pelliccia, MD : Peter J Zimetbaum, MD, Scott Manaker, MD, PhD, Francis G O'Connor, MD, MPH, FACSM, FAMSSM : Todd F Dardas, MD, MS Contributor Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jun 2023. This topic last updated: Jun 21, 2023. INTRODUCTION In individuals with latent cardiac conditions, participation in athletic activity may provoke a potentially fatal arrhythmia. Athletes engaged in competitive athletics may be particularly prone to sudden cardiac death (SCD) as the result of pressure to perform at a high level. As a result, there is great interest in identification of individuals who may be at risk of SCD and whose risk of SCD may be decreased by implementing appropriate exercise restrictions or proper medical management. This topic reviews approaches to screening for cardiac abnormalities in competitive athletes. Screening in recreational athletes is discussed separately. (See "Exercise for adults: Terminology, patient assessment, and medical clearance", section on 'Medical assessment and clearance for exercise' and "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease", section on 'The exercise prescription'.) Issues related to the management of athletes with known cardiovascular disease (CVD) as well as the broader range of arrhythmias and conduction disturbances that occur in athletes are discussed separately. (See "Athletes: Overview of sudden cardiac death risk and sport participation" and "Athletes with arrhythmias: Treatment and returning to athletic participation".) Return to sports after recovery from coronavirus disease 2019 (COVID-19) is discussed separately. (See "COVID-19: Return to sport or strenuous activity following infection".) https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 1/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate DEFINITIONS Athletes may be classified by their age and by the competitive nature of their exercise activity: Young athletes Most commonly, the term "young athletes" refers to those in high school and college but applies in general to individuals under age 35 in whom SCD is usually due to a congenital or inherited heart disease (eg, channelopathy, anomalous coronary artery). Masters athletes Adult, or "masters," athletes include individuals 35 years of age and older in whom SCD is most commonly due to coronary artery disease (CAD). These athletes are apparently normal and healthy individuals, although many are greater than 50 years of age. These athletes may also prioritize winning and ignore specific warning symptoms. Competitive athletes Competitive athletes engage in organized team or individual sports in which there is regular competition that places a premium on achievement. This definition implies that such individuals may not appreciate symptoms or limitations indicative of underlying CVD nor have the will or judgment to limit their activity in response to symptoms of CVD. This most frequently applies to high school, college, and professional sports, but may apply to certain occupations (eg, military service, firefighters, underwater industrial work, specific roles in law enforcement). Recreational athletes Recreational athletes generally participate for health or enjoyment purposes and do not typically have the same pressures to excel compared with competitive athletes. Nonetheless, activity levels in recreational sports may be vigorous, and in some individuals or sports, the difference in intensity of exercise between recreational and competitive athletics may be minimal (eg, mountaineering). GOALS OF SCREENING As with screening for any condition, the primary purpose of screening athletes for cardiac pathology is to identify patients at higher risk of SCD whose prognosis may be improved with an intervention such as exercise modification or specific therapy targeted at the underlying pathology. ATHLETES LESS THAN 35 YEARS OLD https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 2/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate History and physical examination In competitive athletes 34 years or younger, we suggest screening with a complete history, family history, social history, and physical examination rather than no screening. Ideally, this assessment should occur prior to participation and should be performed by a trained clinician. The elements of the history and physical examination related to cardiac screening include: History Syncope, presyncope, palpitations. Chest discomfort and dyspnea. History of murmur or valve disease. Exercise tolerance and limitations. Family history Known genetic diseases of the myocardium. Family history (eg, first- or second-degree relatives) of SCD or unexplained death with features suspicious for SCD before the age of 50. Family history of CAD before the age of 50 or heart failure, heart transplantation, pacemaker placement, or internal-cardioverter defibrillator placement at any age. Social history Substance use (eg, tobacco, methamphetamine, alcohol) Physical examination Blood pressure (both arms), heart rate. Chest wall abnormalities, cardiac displacement or enlargement. Cardiac murmurs at rest and with Valsalva or change in position. Signs of heart failure (eg, jugular venous distension, edema). Signs of malperfusion (eg, cyanosis, clubbing). Radial or femoral arterial pulse deficits or differences. https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 3/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate Stigmata of Marfan syndrome. (See "Genetics, clinical features, and diagnosis of Marfan syndrome and related disorders", section on 'Clinical manifestations of MFS'.) Screening with a history and physical examination is consistent with most professional guidelines (eg, American Heart Association, American College of Cardiology, European Society of Cardiology [ESC]) [1,2]. Of note, North American guidelines provide specific historical and examination elements that may be required depending on the location of screening [3]. In contrast, Denmark does not screen athletes with a history or examination, and the American College of Sports Medicine and the American Academy of Family Physicians guidelines do not recommend an evaluation in patients who are active, asymptomatic, and without CVD risk factors [4,5]. Our preference for screening with a history and examination is based on our experience and the prevailing norms in the United States. The evidence on screening with history and physical examination alone is limited to observational studies [6]. Most screening studies also performed an electrocardiogram (ECG) [7]. ECG screening (controversial) Additional screening with an ECG prior to participation is controversial, and the authors and editors of this topic have differing approaches to screening: Most of the authors and editors of this topic do not perform ECG screening for competitive athletes less than 35 years of age. This approach agrees with North American professional guidelines [1,8], which do not recommend broad national screening with ECG, echocardiography, or exercise testing. However, one guideline-writing group did not oppose smaller-scale screening programs, provided that they are "well designed and prudently implemented" [1]. The National Collegiate Athletic Association describes ECG screening as an option for screening that should only be conducted under standards set by North American professional societies [9]. Our experts who do not endorse ECG screening interpret the evidence on screening as inconclusive regarding its efficacy (eg, low event rates of SCD among competitive athletes, presumed high false negative and false positive rates). In addition, they note that large-scale screening is unattractive for reasons that include prohibitively high expense due to the large number of competitive athletes (eg, difficulties in large-scale implementation, including test interpretation), assignment of responsibility and liability (eg, false negative and false positive screens) to individual clinicians, and questionable https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 4/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate ethical standing given the similar rate of SCD in noncompetitive athletes and nonathletes who would not receive screening. Some experts, including one contributor to this topic, obtain ECG screening for all competitive athletes less than 35 years of age. These experts repeat screening at least every two years after the initial screen. Thus, the ECG prior to participation is likely the most important evaluation, and after participating in competitive athletics without signs or symptoms of cardiovascular disease, the value of continued screening decreases. The ESC guidelines, most international federations, and the International Olympic Committee endorse screening with an ECG prior to competitive sport participation for all young athletes [2,10]. Experts who support routine ECG screening interpret the yield and efficacy of ECG screening to be sufficiently high. In addition, the low cost and wide availability of ECGs make such screening an attractive option. While our experts have differing views of the same evidence, there is agreement that the incidence of SCD related to competitive sports is generally low, but may be higher in the presence of specific diseases (eg, arrhythmogenic cardiomyopathy, catecholaminergic polymorphic ventricular tachycardia). The evidence on the yield and efficacy of ECG screening is composed of cross-sectional studies that have conflicting findings: In a study that included 22,324 children (62 percent males; mean age 12 years at first screening) who underwent a total of 65,397 annual evaluations (median 2.9 per child), cardiovascular diseases increasing the risk of SCD were identified in 69 children (0.3 percent) [11]. The diseases detected included congenital heart diseases (n = 17), channelopathies (n = 14), cardiomyopathies (n = 15), nonischemic left ventricular scar with ventricular arrhythmias (n = 18), and others (n = 5). Among those who had CVD detected by screening, most were 12 years old (n = 63, 91 percent) and were detected by repeat evaluation (n = 44, 64 percent). The estimated cost per diagnosis was 73,312 euros. One child with normal screening studies experienced a cardiac arrest during sports activity and was resuscitated. In an observational study that recorded SCD in athletic and nonathletic populations after the advent of screening in 1982, the annual incidence of SCD in athletes decreased from 3.6/100,000 person-years in 1979 to 1980 to 0.4/100,000 person-years in 2003 to 2004 [12]. Notably, there was no change in the incidence of SCD among nonathletes who were not screened over the same time period. https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 5/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate In a population of athletes who underwent preparticipation screening beginning in 1996, the estimated incidence of SCD in athletes was similar after the onset of screening (2.54 versus 2.66 events/100,000 person years) [13]. In a study that included 11,168 adolescent athletes (mean age 16.4 years) who underwent comprehensive cardiac screening (including a health questionnaire, physical examination, ECG, and echocardiography), 42 athletes (0.4 percent) were found to have disorders associated with SCD, and 225 (2 percent) were found to have a congenital or valvular abnormality [14]. After screening began, SCD occurred in eight athletes after a mean interval of 6.8 years (approximately one SCD event per 14,800 person-years). A total of six athletes with a previously negative screen suffered SCD within approximately seven years of their initial screening evaluation. Among the eight athletes who suffered SCD, six had normal initial screening results and died from cardiomyopathies. Repeat evaluations were not performed after the initial evaluation. The yield and efficacy of ECG screening depends on the population screened, tests used for screening, definition of a cardiac abnormality, and frequency of testing. In general, cardiac abnormalities are detected by screening in approximately 2 to 5 percent of individuals screened, and there is evidence that repeat screening increases the number of cardiac abnormalities detected by threefold: In a systematic review and meta-analysis of screening strategies that included data from 15 studies and 47,137 athletes, there were 160 potentially lethal abnormalities identified (0.3 percent). Screening athletes with an ECG was more sensitive than history alone or physical examination alone, and ECG, history, and physical examination had similar specificity (ie, >90 percent) [7]. There was a moderate amount of heterogeneity among the studies reviewed, and the criteria for an abnormal ECG result varied between studies. Among a series of 32,652 young people who underwent routine preparticipation screening that included an ECG, the prevalence of ECG patterns suggestive of significant structural heart disease was <5 percent [15]. In a series of 33,735 athletes who were screened with history, physical examination, ECG, and modified stress test over a 17-year period, an abnormal ECG was found in 8.9 percent of persons screened [16]. The most common cardiovascular abnormalities were arrhythmias and conduction abnormalities (38 percent), hypertension (27 percent), and mitral valve disease (21 percent). https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 6/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate ATHLETES 35 YEARS OR OLDER History and physical examination In asymptomatic athletes 35 years of age who plan to participate in competitive sports, we suggest a complete personal history, family history, and physical examination rather than no screening. Ideally, this assessment should occur prior to participation. The components of the history and physical examination are the same as those in younger patients. (See 'History and physical examination' above.) We also perform an age-appropriate evaluation for atherosclerotic cardiovascular disease (ASCVD). The approach to primary prevention of ASCVD is discussed separately. (See "Atherosclerotic cardiovascular disease risk assessment for primary prevention in adults: Our approach".) Our approach is based on norms in North America and Europe [15,17]. The yield of screening with history, physical examination, and age-appropriate ASCVD testing is unknown, and there are no high-quality studies of the efficacy of screening in this population. Additional testing For this group of athletes, the approach to additional screening is determined by age, 10-year risk of ASCVD (calculator 1), and intensity of exercise ( figure 1): Age 35 to 64, low ASCVD risk, and low- to moderate-intensity sports In patients 35 to 64 years of age with a 10-year risk of ASCVD <5 percent and who plan to compete in low- to moderate- intensity sports, we suggest screening with an ECG alone. Age 35 to 64, elevated ASCVD risk, or high-intensity sports Our authors and editors have different approaches to screening in this group of patients: Most authors and editors screen with an exercise stress ECG in patients 35 to 64 years of age who have a 10-year risk of ASCVD 5 percent or who plan to compete in high- intensity sports. In the United States, treadmill stress testing is the most common, while in Europe, bicycle stress testing is the norm. Another contributor to this topic screens such patients with a resting ECG but does not obtain an exercise stress ECG. Age 65 and above Similar to patients 35 to 64 years of age, our authors and editors have differing approaches; most screen with an exercise stress ECG, while another contributor screens with only a resting ECG. https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 7/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate Repeat screening with an ECG or exercise stress ECG is controversial. Most of our experts do not advocate for repeat screening, and one expert recommends repeat screening approximately every four years with the test initially used to screen; the precise interval may be less or more frequent depending on ASCVD risk. Many professional societies provide recommendations on preparticipation screening in older athletes, and there are varying approaches to ECG and exercise treadmill testing. The European guidelines advocate for ECG screening in all athletes prior to competition ( algorithm 1) [2]. Other societies advocate for no ECG screening [17]. Some societies advocate for ECG screening in older patients at low ASCVD risk who plan to participate in low- to moderate-intensity exercise and exercise ECG testing in patients with higher age, ASCVD risk, or participation in high-intensity sports [1,2]. There are no North American guidelines that recommend repeat screening. There are few studies that evaluate the effect of screening in athletes 35 years or older. Those who support screening in this age group note the higher incidence of CAD in this population that may increase the risk of SCD, while those who do not support screening note that most competitive athletes in this age group have exercised for many years without adverse cardiovascular effects. INTERPRETATION OF SCREENING TESTS History and examination In patients who undergo screening appropriate for age and risk, patients with a normal history and examination may participate in competitive sports with the knowledge that screening does not completely exclude the presence of conditions that may lead to SCD. Patients with an abnormal screening history or examination require further testing appropriate for any diseases suspected. ECG In patients with a normal screening ECG, no further testing is required, and athletes can participate with the knowledge that screening does not completely exclude the presence of conditions that may lead to SCD. In athletes with an abnormal screening ECG, participation in competitive athletics should be restricted until review of the ECG by a clinician experienced in the interpretation of athletes ECGs. Competitive athletes (especially young athletes) may have seemingly abnormal ECG findings that may be appropriate for age or level of training. The specialized approach to ECG interpretation in athletes is discussed in detail separately. (See "Athletes with arrhythmias: Electrocardiographic abnormalities and conduction disturbances".) https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 8/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate Exercise stress ECG In asymptomatic patients who undergo screening with an exercise treadmill test, the test findings include: Negative for ischemia In patients with an exercise treadmill test negative for ischemia, no further testing for ischemia is required, and athletes may participate with the knowledge that screening does not completely exclude the presence of conditions that may lead to SCD. Positive for ischemia In patients with a test that suggests the presence of ischemia, the specific findings from the exercise test (eg, downsloping ST depression) and the pretest probability of CAD are used to guide further testing for ischemia. Such patients require a diagnostic assessment from a cardiologist before engaging in recreational or competitive exercise. Poor exercise tolerance In patients whose exercise treadmill test is negative for ischemia but who have poor exercise tolerance (eg, unable to reach 85 percent of age- predicted heart rate, short exercise effort), we provide the patient an individualized exercise prescription and encourage appropriate training before participation in competitive athletics. The markers of poor cardiovascular fitness that can be obtained from a standardized exercise test and the approach to exercise prescription are discussed separately. (See "Prognostic features of stress testing in patients with known or suspected coronary disease", section on 'Exercise ECG' and "Exercise prescription and guidance for adults".) Nondiagnostic test In patients with a nondiagnostic test (eg, uninterpretable ECG), the approach to further testing is individualized. SOCIETY AND GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Exercise in adults".) SUMMARY AND RECOMMENDATIONS Competitive athletes This topic covers cardiovascular screening for competitive athletes who engage in organized team or individual sports in which there is regular competition that places a premium on achievement. This definition implies that such individuals may not appreciate symptoms or limitations indicative of underlying https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 9/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate cardiovascular disease (CVD) nor have the will or judgment to limit their activity in response to symptoms of CVD. This most frequently applies to high school, college, and professional sports, but may apply to certain occupations (eg, military service, firefighters, underwater industrial work, specific roles in law enforcement). (See 'Definitions' above.) All athletes In competitive athletes, we suggest screening with a complete history, family history, social history, and physical examination rather than no screening (Grade 2C). (See 'History and physical examination' above.) Additional screening For competitive athletes, the approach to additional screening (eg, ECG, stress testing) is determined by age, 10-year risk of atherosclerotic cardiovascular disease (ASCVD) (calculator 1), and intensity of exercise ( figure 1) (see 'Additional testing' above): Age <35 years ECG screening is controversial. Most of the authors and editors of this topic do not perform ECG screening for competitive athletes less than 35 years of age. Some experts, including one contributor to this topic, endorse ECG screening for all competitive athletes less than 35 years of age. Both approaches to screening are supported by professional guidelines, which differ in their recommendations. (See 'ECG screening (controversial)' above.) Age 35 to 64, low ASCVD risk, and low- to moderate-intensity sports In patients 35 to 64 years of age with a 10-year risk of ASCVD <5 percent and who plan to compete in low- to moderate-intensity sports, we suggest screening with an ECG (Grade 2C). Age 35 to 64, elevated ASCVD risk, or high-intensity sports In patients 35 to 64 years of age who plan to participate in competitive sports, we suggest screening, at minimum, with a resting ECG (Grade 2C). Our authors and editors have different approaches to exercise testing in this group of patients. Most contributors to this topic screen with an exercise stress ECG in patients who have a 10-year risk of ASCVD 5 percent or who plan to compete in high-intensity sports. In the United States, treadmill stress testing is the most common, while in Europe, bicycle stress testing is more common. Another contributor to this topic obtains a resting ECG but does not obtain an exercise stress ECG in older adults. https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 10/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate Age 65 and above Similar to patients 35 to 64 years of age, our authors and editors have differing approaches; most screen with an exercise stress ECG, while another only screens with a resting ECG. Repeat screening with an ECG or exercise stress ECG is controversial. (See 'Additional testing' above.) Normal screening test results Competitive athletes with a normal screening history, physical examination, ECG, or exercise stress ECG require no further testing and can participate with the knowledge that screening does not completely exclude the presence of conditions that may lead to sudden cardiac death (SCD). Abnormal screening test results Competitive athletes with abnormal test results require further testing and evaluation that may include specialist interpretation of the ECG or detailed evaluation of the exercise stress ECG results. (See 'Interpretation of screening tests' above.) Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Maron BJ, Levine BD, Washington RL, et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015; 66:2356. 2. Pelliccia A, Sharma S, Gati S, et al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J 2021; 42:17. 3. Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 Years of Age): a scientific statement from the American Heart Association and the American College of Cardiology. Circulation 2014; 130:1303. 4. Maron BJ. Diversity of views from Europe on national preparticipation screening for competitive athletes. Heart Rhythm 2010; 7:1372. https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 11/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate 5. Riebe D, Franklin BA, Thompson PD, et al. Updating ACSM's Recommendations for Exercise Preparticipation Health Screening. Med Sci Sports Exerc 2015; 47:2473. 6. Stormholt ER, Svane J, Lynge TH, Tfelt-Hansen J. Symptoms Preceding Sports-Related Sudden Cardiac Death in Persons Aged 1-49 Years. Curr Cardiol Rep 2021; 23:8. 7. Harmon KG, Zigman M, Drezner JA. The effectiveness of screening history, physical exam, and ECG to detect potentially lethal cardiac disorders in athletes: a systematic review/meta-analysis. J Electrocardiol 2015; 48:329. 8. American Academy of Family Physicians, American Academy of Pediatrics, American Coll ege of Sports Me. Preparticipation Physical Evaluation, 4th ed, Bernhardt D, Roberts W (E ds), American Academy of Pediatrics, Elk Grove Village, IL 2010. 9. Hainline B, Drezner J, Baggish A, et al. Interassociation consensus statement on cardiovascular care of college student-athletes. Br J Sports Med 2017; 51:74. 10. Ljungqvist A, Jenoure PJ, Engebretsen L, et al. The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes, March 2009. Clin J Sport Med 2009; 19:347. 11. Sarto P, Zorzi A, Merlo L, et al. Value of screening for the risk of sudden cardiac death in young competitive athletes. Eur Heart J 2023; 44:1084. 12. Corrado D, Basso C, Pavei A, et al. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA 2006; 296:1593. 13. Steinvil A, Chundadze T, Zeltser D, et al. Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death proven fact or wishful thinking? J Am Coll Cardiol 2011; 57:1291. 14. Malhotra A, Dhutia H, Finocchiaro G, et al. Outcomes of Cardiac Screening in Adolescent Soccer Players. N Engl J Med 2018; 379:524. 15. Pelliccia A, Culasso F, Di Paolo FM, et al. Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J 2007; 28:2006. 16. Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998; 339:364. https://www.uptodate.com/contents/screening-to-prevent-sudden-cardiac-death-in-competitive-athletes 12/13 7/6/23, 1:43 PM Screening to prevent sudden cardiac death in competitive athletes - UpToDate 17. Maron BJ, Ara jo CG, Thompson PD, et al. Recommendations for preparticipation screening and the assessment of cardiovascular disease in masters athletes: an advisory for healthcare professionals from the working groups of the World Heart Federation, the International Federation of Sports Medicine, and the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation 2001; 103:327. 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