ORLANDO, Fla. — Less than 6% of physicians strictly follow national
guidelines for assessing sudden cardiac death risk during high school sports
physicals, data suggest. In fact, nearly half of the physicians and no athletic
directors surveyed for a new study were aware that such guidelines exist.
Researchers sent a 36-question survey to 1,113 pediatricians and family
doctors and 317 high school athletic directors in Washington to evaluate
compliance with the American Heart Association guidelines for
sudden cardiac death screening in youth. Physicians were
questioned about preparticipation physical evaluations and athletic directors
were asked about school requirements for physical evaluations. Published in
1996 and reaffirmed in 2007, the AHA guidelines consist of eight medical
history questions and four physical examination elements, including listening
to the heart and checking BP.
Physicians reported missing several critical questions during
- 28% did not always ask about chest pain during exercise.
- 22% did not always ask about unexpected fainting.
- 26% did not always ask about a family history of early death.
- 67% did not always ask about a family history of CVD.
None of the athletic directors said their schools required physical
examinations to comply with the guidelines.
Study results did not differ based on physician specialty, level of
experience or the athlete’s school size. Screening frequency, familiarity
with the guidelines, number of physical examination per month and number of
referrals to cardiology, however, were linked to greater overall compliance
“Despite the best efforts of many people and a considerable amount
of financial resources, the majority of adolescent athletes are not receiving
the type of quality history and physical recommended by national medical
organizations such as the AHA. Consequently, before we can begin to consider
adding new technologies to the screening of athletes that are both costly and
logistically challenging, we should begin to standardize the current
recommended process,” Nicolas Madsen, MD, MPH, pediatric cardiology
fellow at Seattle Children’s Hospital and University of Washington School
of Medicine, told Cardiology Today.
Physicians and athletic directors surveyed unanimously supported
adopting a statewide form incorporating national screening guidelines. It is
also suggested that parents ask physicians and schools whether a standardized
form for sudden cardiac death screening is being used, the researchers said.
Of more than 7 million US high school athletes, one of every 30,000 to
50,000 dies from out-of-hospital
sudden cardiac arrest each year, according to statistic from
About 2,200 questionnaires were sent via mail and email to the
physicians and athletic directors over 2 months. The “unusually high”
response rate of 56% to 75% suggests interest in this issue, according to the
Looking ahead, Madsen and colleagues are working with the Washington
Interscholastic Activities Association — the governing body of high school
athletics in Washington — to mandate use of a standard form starting in
the 2012-2013 school year. Thereafter, once a single form is utilized, Madsen
said they can begin to measure the outcomes of this form/process to analyze the
individual contents for their clinical value regarding sudden cardiac death
screening. – by Katie Kalvaitis
For more information:
Disclosure: Dr. Madsen reports no relevant financial disclosures.
This is a very nice and important study demonstrating the limitations of the pre-participation history and physical. An article published by Wilson et al in the British Journal of
Sports Medicine in 2008 demonstrated pretty clearly that only taking a
history and performing a physical are not very effective. As the attorneys say,
res ipsa locutur (the thing speaks for itself). Dr. Madsen is quoted as saying,
"Despite the best efforts of many people and a considerable amount of financial
resources, the majority of adolescent athletes are not receiving the type of
quality history and physical recommended by national medical organizations such
as the AHA." The question is why hasn't the evaluation caught on? This is
likely because physicians in the community feel that the evaluation isn't
effective or that it is not practical. Whatever the reason, physicians have not
embraced it after 15 years. At some point, we should change to another
approach. Einstein said, "Insanity is doing the same thing over and over and
expecting different results." The conclusion, however, should not be to
"standardize the current recommended practice" before considering new
technologies for screening. It is time for a fresh approach. Electrocardiogram
testing is cheap - probably cheaper than the doctor's time spent doing the
AHA-recommended evaluation - quick and more effective. We should rethink our
Joseph Marek, MD
Cardiologist and Internal
Midwest Heart Foundation