Sports Physical Guidelines from the American Heart Association

A recent article in the American Medical News (1) states that only 50% of physicians are aware of the American Heart Association Guidelines for preparticipation screening exams for competitive atheletes (2) and that only 6% of physicians follow those quidelines completely. The purpose of the guidelines is to try and find student-athletes who are at increased risk of sudden death to hopefully reduce that risk with treatment.

I would argue that primary care physicians who actually perform the high school preparticipation sports physicals are aware of all of the assumptions that underline the guidelines.

Only a small fraction of primary care physicians who are aware of the guidelines follow them completely. I believe that is because the guidelines only represent the opinion of the physicians who made up the guideline panel. And the primary care physicians believe that some of the recommendations are incorrect.

For example, item number 10 is the recommendation that femoral pulses be palpated [simultaneously with the radial pulse] to detect a congenital heart defect called coarctation of the aorta. This is simply not possible in the circumstances of most preparticipation physicals. And although femoral pulse abnormalities may be useful in the diagnosis of coarcation of the aorta in infants, they may be less useful (reliable) in teens and adults.

Further, “The vast majority of coarctations are identified and treated in the first year of life and adult presentation is becoming less frequent.(3)

Teens with significant coarctation of the aorta will often have heart murmurs or hypertension.

TABLE. The 12-Element AHA Recommendations for Preparticipation Cardiovascular Screening of
Competitive Athletes

Medical history*

Personal history

1. Exertional chest pain/discomfort
2. Unexplained syncope/near-syncope†
3. Excessive exertional and unexplained dyspnea/fatigue, associated
with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure

Family history

6. Premature death (sudden and unexpected, or otherwise) before age
50 years due to heart disease, in first degree relative
7. Disability from heart disease in a close relative  less than 50 years of age
8. Specific knowledge of certain cardiac conditions in family members:
hypertrophic or dilated cardiomyopathy, long-QT syndrome or other
ion channelopathies, Marfan syndrome, or clinically important

Physical examination

9. Heart murmur‡
10. Femoral pulses to exclude aortic coarctation
11. Physical stigmata of Marfan syndrome
12. Brachial artery blood pressure (sitting position)§
*Parental verification is recommended for high school and middle school
†Judged not to be neurocardiogenic (vasovagal); of particular concern when
related to exertion.
‡Auscultation should be performed in both supine and standing positions (or
with Valsalva maneuver), specifically to identify murmurs of dynamic left
ventricular outflow tract obstruction.
§Preferably taken in both arms.

(1) Many physicians unfamiliar with student-athlete heart screening guidelines. American Medical News. Nov. 21, 2011.

(2) Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007 Update A Scientific Statement From the American Heart Association Council on Nutrition, Physical Activity, and Metabolism.

(3) Coarctation of the aorta from fetus to adult: curable condition or life long disease process? Heart 2005;91:1495-1502.

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