Preparticipation Physical Update

Educational Objectives

The goal of this program is to improve preparticipation sports evaluations. After hearing and assimilating this program, the clinician will be better able to:

1. Assess patients with hypertension as part of a preparticipation physical examination.
2. Optimize diagnosis of Marfan syndrome.
3. Interpret electrocardiography findings for various conditions during athletes' preparticipation screening.

Summary

Goal of sports physical: to prevent sudden cardiac death (SCD) and screen for it; provides entry into the health care system for those who may not have access to it otherwise; although there is no evidence that shows preparticipation cardiovascular screening reduces mortality or has any definitive positive impact on the health and wellness of young competitive athletes, the US Health and Human Services recommends that children should engage in 60 min of daily physical activity with vigorous intensity and strength training 3 days/wk, so the speaker proposes all children should be screened

Setting: the American Academy of Family Physicians states that the preparticipation physical evaluation should take place in the athlete’s primary care medical home during an office visit and not in a group setting, which is better for providers, but mass examinations may be the only option for patients without insurance and may help individuals enter the health care system; a study (Carek et al [1999]) on high school athletes undergoing sports physicals found that only 19% of students’ answers were in complete agreement with their parents’ responses, suggesting value in parental presence

History (American Heart Association [AHA] guidelines): exertional chest pain, exertional syncope, or presyncope needs further workup; excessive fatigue or unexplained fatigue can be challenging to judge and needs further workup; ask about any prior heart murmur, elevated blood pressure (BP), restriction from participation in sports, or prior testing for heart disease; family history includes any premature sudden death at <50 yr of age, any disability from heart disease at <50 yr of age, or a history of hypertrophic obstructive cardiomyopathy (HOCM), long-QT syndrome, Marfan syndrome, and arrhythmias

Physical examination: listen to a heart murmur while standing and supine, with and without Valsalva, to help differentiate benign murmurs (with changes in preload); murmurs need further evaluation; this is one element that is better in an office setting; check femoral pulses, physical stigmata (Marfan syndrome), and BP; the musculoskeletal examination requires a dynamometer for accurate measurements, which is difficult in a mass setting

Electrocardiography (ECG): Corrado et al (2006) compared mortality rates before and after ECG screening and found a 90% decline in sudden death rates, from 4 per 100,000 person-years in the prescreening period to <1 per 100,000 person-years after ECG use; the study's prescreening period was 2 yr, while the postscreening period was 22 yr, and the initial incidence of sudden death in Italy was higher than expected; a subsequent study comparing sudden death in athletes from Italy with ECG and in Minnesota with history and physical examination only, from 1993 to 2004, showed no differences in mortality; in Italy, arrhythmogenic right ventricular cardiomyopathy was the most common cause of death, while in the United States, HOCM predominates, suggesting the Italian study may not be easily extrapolated to the US population; a similar study in Israel found no benefit for screening ECG; it is not clear whether including ECG leads to fewer SCDs

History and physical with ECG: a study showed that history and physical alone are not effective in detecting cardiovascular disorders associated with SCD; the sensitivity and specificity of history and physical alone were low; however, when combined with ECG, the sensitivity and specificity were much higher (even higher with ECG alone); ECG might show abnormalities that are not clinically significant but still prevent participation in sports; ECG is also an added cost

Guidelines: the AHA and American College of Cardiology do not recommend ECG screening but, in 2015, suggested ECG could be performed, if resources were adequate, in athletes between 12 and 25 yr of age; the American Academy of Family Physicians does not recommend ECG; the European Society of Cardiology, the International Olympic Committee, the International Federation of Association Football, and the National Basketball Association recommend ECG

Aspects to consider: athletes' risk for SCD varies; resources play a huge role; assess potential benefits and harms (which can lead to restrictions on sports, potentially impacting BP, blood sugar, and social atmosphere); risk factors — the National Collegiate Athletic Association (NCAA) athletes are at higher risk than the general population, with male athletes, Black athletes, and basketball players at the highest risk; tailor the discussion with patients based on their risk level

Disqualification

Hypertension (HTN): the most common reason for disqualification; adults — athletes with stage 1 HTN are allowed to play; treat and improve their BP; athletes with stage 2 HTN (BP >160/100 mm Hg) should be restricted from playing until BP is improved; pediatrics — athletes with stage 1 HTN (95th to 99th percentile plus 5 mm Hg) can play with treatment; stage 2 HTN (≥99th percentile plus 5 mm Hg) should be restricted from play; calculating percentiles depends on sex, age, and height

Vision: the second most common reason; patients whose best-corrected vision with glasses is worse than 20/40 in one eye need to wear eye protection and are banned from playing high-risk sports, eg, boxing, wrestling, martial arts

Asthma: an athlete who is well-controlled and asymptomatic at rest and exertion is allowed to play sports; the patient should have an asthma action plan and inform the staff to manage any flare-ups

Single organ: less common; for people with one ovary or testicle, the benefits are high and the risk is relatively low; encourage these individuals to play any sport with protective equipment; one kidney is more difficult; discuss risk vs benefit; the athlete can play any sport but should use protective equipment, especially in hockey, rugby, or football; advise the athletes that certain sports may not be the best fit for them

Sickle cell: sickle cell screening is mandated for NCAA athletes; sickle cell trait has an increased risk for sudden death, especially with strenuous exercise; athletes are allowed to play any sport without restriction but are at risk for SCD, especially in hot, humid environments, with dehydration, or at elevation; athletes with sickle cell disease are banned from high-exertion, contact, and collision sports

Marfan syndrome: concerns include aortic problems, mitral valve prolapse, and heart complications; features include arachnodactyly, flat feet, a high-arched palate, and striae on the skin; the wrist sign (Walker Murdoch sign) is positive if the fifth finger can overlap the distal phalanx of the thumb around the wrist; the thumb sign (Steinberg sign) is positive if the thumb extends past the palm in a fist

Skin: bacterial infections — must have no skin lesion for 48 hr and completed 72 hr of antibiotic therapy; cannot be covered; close contact sports (eg, wrestling); viral infection — no new blisters for 72 hr and antiviral therapy for 120 hr; cannot be covered and allowed to play; fungal infection — 72 hr of treatment; if in a coverable area, then allowed to play even if 72 hr of treatment is not achieved; can treat and cover molluscum and warts

ECG screening: normal changes — left ventricular hypertrophy and right ventricular hypertrophy, an incomplete right bundle branch block, early repolarization, ST elevation following T-wave inversion (TWI) in V1-V4 (in Black athletes), TWI in V1-V3 (in patients <16 yr of age), sinus bradycardia, heart block (more benign forms), and Mobitz type I (first- and second-degree) atrioventricular block; left axis deviation, right axis deviation, left and right atrial enlargement, and complete right bundle branch block in isolation can be acceptable, but multiple findings are abnormal; red flags — pathologic T waves, ST depression, pathologic Q waves, complete left bundle branch block, QRS >140 ms, and more pathologic heart blocks (second degree type II and third degree) need further evaluation

Hypertrophic cardiomyopathy: 90% of patients have abnormal ECG; prominent Q waves, TWI in V2-V6, and increased QRS voltage with ST depression can be seen; HOCM — left and right atrial enlargement could be normal in isolation; left ventricular hypertrophy could be fine; deep TWI and ST depression are always abnormal

Long QT syndrome: the computer-generated QTC is frequently inaccurate; normal QTC in men is 470 ms and in women 480 ms, but >500 ms is abnormal; there are some people who are normal with a longer QT and some people with genetic QT syndrome with a normal QT interval; T-wave changes and prominent U waves are often seen

Arrhythmogenic right ventricular cardiomyopathy (ARVC): inherited defect in desmosomes for myocyte cell adhesion; leads to fibrofatty replacement of the right ventricle and can lead to arrhythmias and SCD; 50% of patients have a known family history, and 90% have an abnormal ECG; the epsilon wave is the most common finding (50% of ECGs); T-wave inversion can often be seen

Wolf-Parkinson-White: may have a shortened PR interval with an upsloping delta wave

COVID-19: myocarditis and pericarditis can be common causes of SCD in athletes; the COVID vaccine or infection can increase this risk; screening recommendations — mild forms allow athletes to continue activity without issues, moderate forms require an ECG and further workup, and if hospitalized, follow by echocardiography and cardiology consultations; recommendations are rapidly evolving

Anomalous coronary artery: often difficult to detect through history, physical examination, ECG, and stress testing; often requires cardiac CT or cardiac MRI; an anomalous left coronary artery is less common than the right but has a higher risk for sudden death; it can cause narrowing of the left coronary artery and compression, leading to ischemia

Readings

Alblaihed L, Kositz C, Brady WJ, Al-Salamah T, Mattu A. Diagnosis and management of arrhythmogenic right ventricular cardiomyopathy. Am J Emerg Med. 2023;65:p146–153. doi:10.1016/j.ajem.2022.12.010. View Article; Armand CE, Loder E, Ropper AH. Migraines — treatment and preventive therapies. New Engl J Med. 2022;387(15):p1413. doi:10.1056/NEJMp2212749. View Article; Carek PJ, Futrell M, Hueston WJ. The preparticipation physical examination history: Who has the correct answers? Clin J Sport Med. 1999;9(3):p124–p128. View Article; Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006;296(13):p1593–p1601. View Article; Drezner JA, Sharma S, Baggish A, et al. International criteria for electrocardiographic interpretation in athletes: Consensus statement. Br J Sports Med. 2017;51(9):p704–p731. doi: 10.1136/bjsports-2016-097331. View Article; Harmon KG, Asif IM, Maleszewski JJ, et al. Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association athletes: A decade in review. Circulation. 2015;132(1):p10–p19. doi:10.1161/CIRCULATIONAHA.115.015431. View Article; Hedman K, Moneghetti KJ, Christle JW, et al. Blood pressure in athletic preparticipation evaluation and the implication for cardiac remodelling. Heart. 2019;105(16):p1223–p1230. doi:10.1136/heartjnl-2019-314815. View Article; MacDonald J, Schaefer M, Stumph J. The preparticipation physical evaluation. Am Fam Phys. 2021;103(9):p539–p546. View Article; Pelliccia A, Corrado D. Can electrocardiographic screening prevent sudden death in athletes? Yes. BMJ. 2010;341:pc4923. doi:10.1136/bmj.c4923. View Article; Spencer M. Marfan syndrome. Nursing. 2024;54(4):p19–p25. doi: 10.1097/01.NURSE.0001007604.09204.9a. View Article.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Mayer-Blackwell was recorded at the 67th Annual Postgraduate Symposium, held June 28-30, 2024, in San Diego, CA, and presented by the San Diego Academy of Family Physicians. For more information about upcoming CME activities from this presenter, please visit sandiegoafp.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

FP724102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation