Should High School Athletes Get Preseason Cardiac Screenings?

Though rare, sudden cardiac death is the most common cause of death in young athletes.

The American Academy of Pediatrics (AAP)—using data from the Centers for Disease Control and Prevention (CDC)—estimates that about 2,000 individuals younger than age 25 die each year of sudden cardiac arrest in the United States.

Sudden cardiac arrest (SCA) occurs when an electrical abnormality in the heart creates an irregular heartbeat, disrupting the heart’s pumping action. This leads to a loss of consciousness and an absent pulse. If not treated within minutes, sudden cardiac death (SCD) is likely to occur. When people under age 35 die of cardiac arrest, it’s most often because of a congenital (present at birth) issue, and it’s not unusual for them to not even know they had a heart condition.

We spoke with Yale Medicine’s Cheyenne Beach, MD, a pediatric cardiologist, about whether teen athletes should have cardiac screenings.

The AAP recommends that all kids receive a preparticipation physical evaluation (PPE) before their first preseason practice. The frequency and specifics of a PPE are determined by each state.

Most schools and pediatricians evaluate children according to the system developed by the AAP and other organizations, including the American College of Sports Medicine. This system typically requires annual documentation on a standard paper form. Doctors point out that even children who don’t participate in an organized sport can benefit from a sports physical, which can be done during an annual well-child visit.

The standard sports physical includes an in-depth medical history that considers cardiovascular, neurologic, respiratory, musculoskeletal, and mental health, among other factors. The goal is to identify symptoms that can be warning signs of an underlying risk. These symptoms may include syncope (fainting), unexplained seizures, chest pain, or shortness of breath.

In addition to reviewing family history, primary care physicians check for physical findings that may indicate risk, such as abnormal heart sounds heard with a stethoscope. “These sports physicals can identify many children who need additional evaluation,” Dr. Beach says.

A standard sports physical does not include an electrocardiogram (also known as an ECG or EKG). This test measures the heart’s electrical activity and can detect some heart conditions that may put people at risk for life-threatening arrhythmias or hemodynamic collapse (unstable blood pressure, resulting in inadequate blood flow to organs).

While the AAP does not recommend routine ECGs for all children, it does advise doing one if their physical exam or medical or family history suggests a risk for sudden cardiac death or sudden cardiac arrest.

Some experts, however, do think that ECGs should be used routinely to catch heart conditions that can be missed by the standard sports physical exam. "It’s a simple test that takes only a few minutes to perform but can provide valuable information. In some cases, it saves lives,” says Dr. Beach.

An ECG involves placing small stickers on a patient’s chest to measure the heart’s electrical activity. “An ECG allows us to identify cardiac abnormalities that could potentially lead to abnormal heart rhythm problems or, in the most serious circumstance, sudden cardiac death,” Dr. Beach says. “However, not all heart abnormalities are identifiable with an ECG.”

It’s also important to note that many ECG findings are minor and do not necessarily require restriction from sports. But, sometimes additional evaluation is needed to ensure that sports participation is safe, she adds.

Depending on the individual, whether an underlying heart condition is diagnosed, and what type of heart condition it is, there may be a medication that allows the child to exercise without restrictions. There may even be a procedure that cures the condition entirely, Dr. Beach explains.

“If a cardiac condition is identified, it may be that the child needs to recognize the onset of certain symptoms, avoid lifting a certain amount of weight, avoid certain types of activities, or take other precautions,” Dr. Beach says.

In many cases, the cause of sudden cardiac arrest is unknown. However, the following conditions are associated with it:

• Hypertrophic cardiomyopathy: Most often hereditary, this condition is the most common cardiovascular cause of SCA in young people. It leads to thickened muscle cells in the heart’s lower chambers, or ventricles, which can create an abnormal heart rhythm, especially during exercise.
• Coronary artery abnormalities: People born with coronary artery abnormalities may not notice or experience any symptoms until they are older. If the abnormalities cause decreased blood supply to the heart during exercise, SCA can occur.
• Genetic arrhythmia syndromes: The most common of these is long-QT syndrome, a condition in which abnormal electrical activity in the heart can cause sudden and life-threatening arrhythmias.
• Wolff-Parkinson-White syndrome: In this condition, there is an extra electrical pathway that can cause fast and, occasionally, unstable arrhythmias.
• Arrhythmogenic cardiomyopathy: Usually inherited, this condition causes some of the heart’s muscle cells to be replaced with scar tissue over time.
• Myocarditis: This condition, in which the walls of the heart are inflamed, is most often caused by a viral infection. This can cause heart rhythm problems that are more likely to occur during exertion.
• Marfan syndrome: This inherited connective tissue disease can lead to dilation and even tears in the walls of the heart’s blood vessels.
• Commotio cordis: This can arise when a person with a normal, healthy heart receives a blow to the chest directly over the heart at a specific time in the cardiac cycle, triggering a life-threatening arrhythmia.

As noted above, not all cardiac conditions—including several of those included here—can be identified with an ECG.

“In an ideal world, all children, whether they participate in sports or not, would intermittently receive ECG screenings,” Dr. Beach says. However, this is not typically done, she notes. “One barrier is cost. While a single ECG is not very expensive, the cost of screening all children adds up quickly and is not yet something that can be done universally.”

Another issue is the quality of the ECG reading, adds Dr. Beach. “Over time, ECG screening criteria have been adjusted to improve their sensitivity and specificity. Having an experienced and well-informed ECG reader reduces the rate of false negatives and false positives, thereby improving the overall effectiveness of the ECGs,” she says.

Plus, if an ECG shows an abnormality, the next step is often to get additional testing, such as an echocardiogram (an ultrasound that checks the structure and function of the heart), which adds cost and time for patients and medical providers. “Often, patients with abnormal screening ECGs end up having additional tests and are found not to have any cardiac problems requiring specialized care,” Dr. Beach says. “Fortunately, we are learning more about screening criteria and expect that their efficiency will continue to improve over time.”

While screening children for cardiac and other issues before playing sports is important, being prepared for emergencies is just as critical, experts say. The importance of preparedness gained national attention recently when professional football player Damar Hamlin experienced sudden cardiac arrest and was saved by prompt cardiopulmonary resuscitation (CPR) and an automated external defibrillator (AED), which restored his normal heart rhythm.

“Damar Hamlin’s sudden cardiac arrest and successful resuscitation serve as a reminder that a serious cardiac event could happen to anyone,” Dr. Beach says. “This demonstrated the importance of community preparedness with emergency action plans and adequate presence of and training in the use of AEDs.”

Another key safety feature when kids play sports is having people on hand who are trained in CPR, including athletic trainers, who specialize in managing and preventing injuries in athletes and are often on the sidelines of sports events.