Introduction:
Cardiovascular screening in athletes remains a challenging issue, and it is a debatable topic. Sudden cardiac deaths in the athletic population are rare, with an incidence of 0.61 in 100,000. Although these events are rare, it is important to recognize the causes of sudden cardiac death in young athletes and prevent them. Considering the common causes of sudden cardiac death in athletes, the American Heart Association (AHA) has developed a screening tool to detect and prevent cardiovascular issues in young athletes.
What Is the Importance of Pre-Exercise Cardiac Screening in Athletes?
Most cardiologists encourage regular, moderate exercise for athletes to reduce their long-term risk of heart disease. When an athlete performs strenuous exercise with undetected or silent cardiovascular conditions, there is a high risk of sudden cardiac death. Such individuals should take adequate precautions before engaging in intense sports. Pre-exercise cardiac screening aims to identify these silent and high-risk cardiovascular conditions that increase complications such as sudden death due to high-intensity exercise.
Sudden cardiac death or collapse during sports is a complication of acute cardiac failure, as the heart cannot maintain proper blood flow to vital organs.
This can occur due to any one of the following mechanisms:
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Electrical heart issues due to unstable heart rhythms.
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Structural heart issues due to abnormal or weakened heart muscles.
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Inadequate blood supply to the heart muscles.
Intense physical activities in athletes with abnormalities may act as a trigger to expose any underlying heart conditions and suddenly deteriorate them, leading to life-threatening complications. The key to avoiding such complications is to undergo preparticipation cardiac screening in athletes.
When Is Cardiac Screening Recommended?
The ideal time for cardiac screening in athletes is during pre‐participation. Potential medical issues preventing athletic activity or requiring further treatment can be identified by the individual involved in sporting activities. The American Heart Association recommends pre‐participation examinations for high school and college athletes and suggests repeating screenings every two years.
The American Heart Association, in a 12-point screening procedure, recommended the following:
Personal Medical History
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Exertional chest pain or discomfort.
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Increased blood pressure.
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Excessive unexplained exertional dyspnea or fatigue.
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History of a heart murmur.
Family Medical History
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Premature death is related to cardiovascular disease.
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Hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmias, Marfan syndrome, channelopathy (e.g., long QT).
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Disability from cardiovascular disease.
Physical Examination
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Heart murmur.
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Brachial artery blood pressure
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Physical stigma of Marfan syndrome.
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Femoral versus radial pulses to exclude aortic coarctation.
These points should be considered a minimal criterion, and a complete physical examination of the athletes should be encouraged. For instance, examination producers like palpation of the carotid pulses and precordium are not included in the points suggested by the American Heart Association. Still, they may provide vital information regarding the athletes' heart health. Also, any history of medication or recreational drug use should be collected.
On the other hand, the European Society of Cardiology has taken a different approach. It suggests an ECG (electrocardiogram) should be performed with each evaluation, as an ECG is believed to detect most cases of hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy.
However, no comparative data is available for the two approaches, and there is minimal data to support the efficiency of the approach in significantly reducing the risk of sudden athlete death, as it is impossible to achieve zero risk in sports. If cardiovascular or other health abnormalities are found during the screening procedure of an individual, an estimation should be formulated of how much physical exercise can be safely tolerated by the athlete, for which knowledge of the exercise type the individual will perform, how much static and dynamic exertion is needed; and how vigorous the training program is, should be known.
For an older athlete who participates in competitive master's level sports or wants to embark on a fitness program, the screening test poses a different challenge. The athletes should check for the health benefits of exercise versus the risk of triggering heart issues in those with unsuspected cardiovascular disease.
The overall risk of sudden death due to cardiac illness is decreased with regular exercise. Elderly athletes should be screened for coronary artery disease risk. If more than one risk factor is present, an exercise test or other screening test for coronary artery disease should be performed. An exercise test would determine a person's overall fitness for participation in sports. If an individual has known coronary artery disease, even if they have been revascularized, sports with high intensity should not be limited.
How Is Pre-exercise Cardiac Screening Performed?
During the pre-exercise cardiac screening, healthcare providers provide basic advice and screening through a brief history and physical examination. Also, athletes may perform a few simple self-screening questionnaires available online and seek further medical consultation if there are abnormal responses to the questionnaires.
The following groups of athletes may require consultation with a cardiologist for further assessment:
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People with high cardiovascular risk or sedentary lifestyles plan to participate in high-intensity sports or competitions.
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People with a history of cardiovascular conditions such as ischemic heart disease, chronic heart failure, valvular heart disease, etc.
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People with ongoing cardiac symptoms such as palpitations, chest pain, unusual breathlessness, or abnormal clinical findings such as an abnormal electrocardiogram.
Depending on the clinical circumstances, the healthcare professional may suggest any of the following cardiac tests:
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Electrocardiogram (ECG) - This helps record the heart's electrical activity, such as the heart rate and rhythm, by attaching 10 to 12 wires to the legs, arms, and chest and hooked up to a machine. This helps to read the electrical activity of the heart. The results are printed out on paper and read by your doctor. It also projects any potential underlying structural heart conditions.
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Echocardiogram - This is an ultrasound study of the heart. It uses ultrasound waves to look for damage, disease, or structural heart issues. It records live moving images at rest.
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Exercise Treadmill Test (ETT) - This is an ECG test performed while undergoing a run on the treadmill machine. It helps to detect underlying heart conditions with physical stress. Various parameters are measured to assess the heart health of an individual.
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CT Coronary Angiogram -This is a non-invasive form of imaging with a CT (computed tomography) scanner, assisted by an intravenous dye. It helps to detect any blocks of the heart arteries.
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Advanced Functional Cardiac Imaging - These are second-line scans available only in hospitals. It combines stress testing with imaging modalities such as ultrasound, CT scan, and MRI to assess for ischemic heart disease.
After checking the test results, the specialist may recommend whether it is safe for the athletes to proceed with sports participation or if any other further clinical interventions are required based on the test findings.
Conclusion:
Cardiac screening for athletes is necessary as it has the potential to identify high-risk individuals and may undergo a further assessment before high-intensity physical activities. Also, based on the results, the healthcare provider will provide the best exercise options. In high-risk individuals, cardiac screening will help prevent sudden cardiac death through other treatment options.
