Cardiologist: Screening and evaluation for participation in sports activities
When we refer to participation in a sports activity, we mean participation in sports lasting > 30min at a time, at least 3 times a week and at moderate or greater intensity (40-60% of the maximum predicted frequency or 3-6 Mets) and for a period of 3 months or more.
The purpose of cardiovascular pre-athletic screening is the early diagnosis of congenital and hereditary heart diseases responsible for sudden death and the timely treatment and guidance of patients.
Incidents of sudden cardiac death in young people and athletes are due to hypertrophic cardiomyopathy (HCM), congenital coronary artery anomalies, myocarditis, arrhythmogenic right ventricular dysplasia (ARVD), mitral valve prolapse (MVP), arrhythmogenic syndromes (S. Brugada, Long QT, Short QT, CPVT, Idiopathic ventricular fibrillation), aortic syndromes such as S. Marfan.
Sudden cardiac death is a rare and dramatic event with a frequency of <1/100,000 per year in athletes, but >1/100,000 in young people.
For this reason, in July 2021, the American Academy of Pediatrics officially announced that all children, regardless of sport, should be evaluated for heart disease every 3 years and when they change levels in education.
Participation in sports activity also requires a comprehensive pre-athletic cardiac examination every 2 years on average (1-3 years).
The comprehensive pre-athletic check-up includes:
- TTaking a family history (with the presence of a parent)
We must investigate for the possible existence of a sudden death at the age of <50 years in relatives, unexpected drowning, strange car accident, sudden infant death, disability from cardiovascular disease, defibrillator or pacemaker in young people, known hereditary disease in relatives of the wider family environment and not only in 1st degree relatives.
- TThe individual anamnesis
Search for symptoms indicative of cardiovascular diseases such as precardiac pain, dyspnea, syncope or presyncope, especially when these symptoms are associated with exercise, hypertension, previous exclusion from sports or a pre-existing medical diagnosis.
- The thorough clinical examination
This includes palpation of the chest and suprasternal fossa, femoral pulses, auscultation in the supine and sitting positions, checking for evidence indicative of syndromes such as Marfan’s syndrome, and measuring blood pressure.
The inclusion or exclusion of ECG in pre-sport screening is a point of differentiation between the American Heart Association and the European Pediatric Cardiology Society.
The American Heart Association does not recommend the inclusion of ECG except on indications, due to increased costs for screening a very large population and false positive ECGs. However, the revised Seattle criteria of 2015 reduced this percentage to <5% from almost 16% previously.
The European Society of Pediatric Cardiology has incorporated the ECG into the official guidelines.
Special mention is made in the guidelines for patients with myocarditis who do not stop exercising, because they have a high rate of sudden death of 6-12% regardless of the severity of the attack, as exercise promotes myocardial damage. The general recommendation is to stop exercising for 6 months.
To summarize, children, regardless of their sporting activity, should be evaluated for cardiovascular disease every 3 years and at the change of educational level. A complete pre-sports check is recommended for children and adolescents who participate in organized sports before starting it and every two years on average.
The screening includes a cardiological assessment, a clinical examination, and an ECG. This strategy appears to prevent the majority of cases of sudden cardiac death. However, it should be emphasized that there is no strategy that can completely eliminate this tragic event in young people.
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