Expert Review of Cardiovascular Therapy

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ierk20

Current controversies in pre-participation

cardiovascular screening for young competitive
athletes

Bradley J. Petek & Aaron L. Baggish

To cite this article: Bradley J. Petek & Aaron L. Baggish (2020): Current controversies in
pre-participation cardiovascular screening for young competitive athletes, Expert Review of
Cardiovascular Therapy, DOI: 10.1080/14779072.2020.1787154

To link to this article: https://doi.org/10.1080/14779072.2020.1787154

Accepted author version posted online: 29

Jun 2020.

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Publisher: Taylor & Francis & Informa UK Limited, trading as Taylor & Francis Group

Journal: Expert Review of Cardiovascular Therapy

DOI: 10.1080/14779072.2020.1787154

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Current controversies in pre-participation cardiovascular screening for young competitive

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athletes

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Bradley J. Petek1, Aaron L. Baggish2

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Department of Medicine1, Cardiovascular Performance Program2

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Massachusetts General Hospital, Boston, MA, USA
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Corresponding author:
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Aaron L. Baggish, MD, FACC, FACSM

Cardiovascular Performance Program
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Massachusetts General Hospital

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Yawkey Suite 5B
55 Fruit Street
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Boston, MA 02114
Phone: +1 617-643-7117
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Fax: +1 617-643-7222
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Email: abaggish@partners.org

Abstract
Introduction: Pre-participation cardiovascular screening (PPCS) in athletes is recommended by
numerous medical and sporting societies. While there is consensus that young athletes should
be screened prior to participation in competitive sports, there are on-going debates regarding
the true incidence of sudden cardiac death (SCD), the most frequent causes of SCD, and the
optimal methods for PPCS.
Areas Covered: This review focuses on the current evidence for the incidence of SCD, causes of
SCD, and the pros and cons of a history and physical exam (H&P) and electrocardiogram (ECG)

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in PPCS of young competitive athletes.

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Expert Opinion: With significant controversy surrounding PPCS in athletes, a large-randomized
trial powered for mortality is needed to assess the utility of PPCS and to define the optimal

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screening methods to detect cardiovascular diseases that may lead to SCD in competitive

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athletes. Until a trial of this caliber is created, controversy will remain and heterogeneity in care
will exist. Future research should also define the optimal timing and frequency of PPCS given

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age-related penetrance of certain diseases, create evidence-based history questionnaires,
continue to optimize ECG screening criteria, and create more learning modules for ECG
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interpretation in athletes.
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Keywords: Preparticipation Screening, Athletes Heart, Sports Cardiology, Sudden Death,

Exercise
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Article highlights
• The most common cause of SCD in young athletes is debated but thought to be from
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autopsy-negative SCD (e.g. primary channelopathy or arrhythmia) or HCM.

• A focused H&P is currently recommended for PPCS by all major cardiovascular and
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sporting governing societies.

• The H&P is limited by a low sensitivity, high false positive rate, heterogeneity in physical
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exam skills among providers, questionnaires are based on expert opinion, and the
history requires honest reporting from athletes.
• ECG screening is currently recommended by European guidelines and most sporting
societies, but only under certain circumstances in US guidelines.
 • Significant limitations of ECG screening include: high costs of testing, significant
experience needed to perform adequate interpretation, higher than optimal FPR in
certain populations, and potential false negatives in certain conditions (e.g. coronary
anomalies).
• A large-randomized clinical trial powered for mortality is needed to assess the true

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impacts of PPCS

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1. Introduction

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Pre-participation cardiovascular screening (PPCS) in competitive athletes is performed to screen

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for cardiovascular abnormalities that are associated with an increased risk of sudden cardiac
death (SCD) during exercise. While the overall incidence of SCD in this population is relatively

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low, the death of a young, otherwise healthy athlete is tragic. PPCS has been common practice
in many countries over the last several decades, and has been pivotal in the growth of the field
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of sports cardiology [1-3]. During this time, there has been a steady accumulation of more data
defining its efficacy. Nonetheless, fundamental questions remain unanswered and more work
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will be needed to arrive at definitive conclusions regarding the optimal role of PPCS. In this
review, we highlight the history and major on-going controversies surrounding PPCS in young
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competitive athletes using major studies from the PubMed database.

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2. History of PPCS in Athletes

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The first large-scale mandatory PPCS program in athletes was developed in Italy in the 1970-
1980’s after increasing awareness of the devastating impacts of SCD in competitive athletes.
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The original law, which was passed in 1971 and then revised in 1982, stated that Italian athletes
participating in competitive sports must perform PPCS consisting of a medical history and
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physical examination (H&P), 12-lead electrocardiogram (ECG), and 3-minute exercise step test
[4]. This method gained rapid public awareness after a ground-breaking study by Corrado et. al
in 2006 showed the annual incidence of SCD in Italian athletes decreased by 89% after the
institution of mandatory PPCS in 1982 [5]. In line with these important but provocative data,
the International Olympic Committee (IOC) recommended the inclusion of an ECG to PPCS in
2004, followed by the European Society of Cardiology (ESC) in 2005.

Israel implemented a similar mandatory PPCS program in 1997, that required all athletes and
military conscripts to undergo a complete H&P, baseline ECG, and exercise stress test. Steinvil

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et. al published the results assessing the efficacy of their mandatory screening program from

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1985-2009 and found the incidence of SCD was 2.54/100,000 person-years in the decade prior
to the 1997 legislation and 2.66/100,000 person-years in the decade following the legislation

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[6]. They therefore concluded that mandatory ECG screening of athletes had no apparent effect

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on the risk of cardiac arrest.

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The American Heart Association (AHA) has consistently recommended against a universal ECG-
inclusive PPCS method throughout the time of mandated screening in Italy and Israel. In lieu,
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this United States-based organization recommended PPCS confined to a targeted H&P [7-9]. In
the most recent update of the AHA/American College of Cardiology (ACC) guidelines in 2015,
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the authors continued to recommend against universal ECG-inclusive PPCS of athletes, but
endorsed the use of a 12-lead ECG in conjunction with an H&P in cohorts of young healthy
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people 12-25 years old who are supported by adequate expertise and resources (Class IIb; Level
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of Evidence C) [10].
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3. Incidence and Causes of SCD in Young Athletes

The true incidence of SCD in young competitive athletes remains debated, with estimates
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varying widely throughout the literature [11-20]. Estimates on the higher end of the spectrum
have been reported at ~1/50,000 athlete years (AYs) among United States collegiate athletes
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[12,19], while a single study of high school athletes in Minnesota estimated the rate of SCD to
be as low as 1/917,000 AYs over the prior decade [15]. Overall, the incidence of SCD among
competitive high school athletes from recent large-scale studies have ranged from ~1/46,000 to
1/917,000 AYs [11-16], while the incidence of SCD among college athletes has ranged from
~1/43,000-1/83,000 AYs [17-20]. Certain characteristics including male sex, African American /
black race, and participation in certain sports (i.e. basketball, American-style football) have
emerged as independent risk factors for SCD [19]. Significant focus is now being placed on
these subgroups as the incidence of SCD among college basketball players has been estimated
to be as high as 1/5200 AYs [19]. There is a clear sex difference in the incidence of SCD, as male
athletes have been quoted as having a 10-fold higher risk of SCD compared to their female

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counterparts [21]. Studies have also suggested that there may be similar risks of SCD among

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competitive and noncompetitive athletes in certain cohorts [22]. Explanation for the variability
of reported SCD incidence rates extend beyond these factors with imperfections in the data

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acquisition techniques playing an important role. Imprecision of both the numerator (i.e.

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number of SCDs) and the denominator (i.e. true size of the source population) continue to
plague the field and must be considered in the appraisal of all available data sets.

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There are numerous reported causes of SCD in young competitive athletes (Table 1).
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Historically, the most frequent cause of SCD among competitive athletes below the age of 35
was thought to be hypertrophic cardiomyopathy (HCM). However, recent studies have provided
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conflicting results [19,20,23-25]. Harmon et. al assessed the incidence and causes of SCD in
NCAA athletes from 2003-2013, and found that unexplained autopsy-negative sudden death
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accounted for 25% of cases followed by congenital anomalous coronary arteries (11%),
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myocarditis (9%), and coronary atherosclerosis (9%) [19]. HCM was only diagnosed in 8% of
autopsies. These data suggest that primary channelopathies or other electrical disturbances in
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the absence of structural heart disease may be more common than previously reported. In
contrast, Maron et. al performed another recent study assessing the incidence and causes of
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SCD in NCAA athletes from 2002-2011 which attributed 21/47 (45%) confirmed cardiovascular-
related deaths to be due to HCM [20]. Interestingly, the incidence of HCM may also be less than
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previously reported as many athletes with LVH on autopsy in the past have been thought to
have HCM, but now idiopathic LVH appears to be a distinct entity from HCM [26]. While
explanations for this inconsistency are of academic interest, the clinical imperative is to
remember that HCM is an important cause of SCD, but perhaps more common etiologies exist
in parallel.
4. Should we be performing any form of PPCS in athletes?
Most major medical and sporting societies currently recommend PPCS in elite athletes for
detection of potential conditions leading to SCD. Broad-based screening of athletes at all levels
of performance is currently isolated to the United States, Italy and Israel, while most European

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countries perform PPCS in primarily elite athlete cohorts. Available guidelines also vary as a

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function of which screening strategy they endorse with some supporting H&P in isolation [10],
and some recommending H&P with additional testing including ECG [27-29], and

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echocardiography [30]. A concise overview of current controversies in screening methodologies

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is presented in Table 2. The role of PPCS in athletes remains a topic of considerable debate as
there remains a lack of randomized clinical trial data to truly assess the benefit or harm of
available screening techniques.
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4.1 Arguments in favor of PPCS
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Enthusiasm for PPCS has long been driven by communities who are devastated by the loss of a
young, otherwise healthy athlete. These tragic occurrences almost universally stimulate a call to
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action with the development or improvement of screening techniques representing a common

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actionable step. Proponents of PPCS espouse the logic that most diseases responsible for SCD
are readily detectable, and treatment or sport restriction can subsequently save lives.
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Additionally, PPCS may hold value above and beyond the detection of high-risk cardiovascular
disease. Recent recommendations from the NCAA provide additional justification for PPCS [31].
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Specifically, the PPCS encounter provides the opportunity to forge athlete-clinician

relationships, to review medications for the necessity of therapeutic use exemptions, to screen
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for mental health and other non-CV disease, and to provide education pertaining to behavioral
risk reduction. There are also readily available guidelines for ECG interpretation [32],
cardiovascular imaging [33], and screening methods that can aid in PPCS of young competitive
athletes [10,27,28,30].
4.2 Argument against PPCS
To date, there have been no randomized controlled trials showing that PPCS reduces mortality
or has any definitive positive impact on the health and wellness of young competitive athletes.
Opponents of PPCS also argue that the social and medical implications of false positive testing,

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the low overall incidence of SCD in athletes, and unnecessary costs of PPCS outweigh the

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potential benefits.

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False positive testing, the finding of an abnormal screening result in the absence of true

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disease, generates costly unnecessary downstream clinical testing and may also result in
significant psychological distress and time lost to sport for athletes involved. Studies calculating

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the financial cost of PPCS have yielded inconsistent results, and cost estimates have been used
to advocate for various discrete screening strategies including an H&P in isolation [34], ECG in
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isolation [35], and the combination of H&P + ECG [36,37]. Notably, a recent study projected
that a 20-year United States screening system for high school and college athletes would cost
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between $51-69 billion, with a cost per life saved ranging from $10.6-14.4 million [38]. While
some experts argue that prevention of the death of young athletes is worth any cost, others
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have posited that the rare incidence of SCD does not justify the resources of PPCS [24]. Certain
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studies have also found that athletes may not be at higher risk of SCD compared to non-
athletes in some cohorts [24,39], which brings up the ethical dilemma if only athletes should be
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tested. It is important to remember that the money used in such a program diverts funds away
from other healthcare needs in the setting of a constrained national healthcare budget, and
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that costs vary widely between different countries.

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Another frequently cited potential limitation of PPCS in young athletes relates to the
unpredictable age-dependent penetrance of cardiovascular disease. Specifically, some of the
pathologic cardiovascular phenotypes responsible for SCD in athletes may not develop
sufficiently to be detected by PPCS at the young ages for which screening is commonly applied.
Therefore, an athlete may initially have a normal PPCS exam, but subsequently may be at risk
for SCD due to the emergence of pathology. This has led many experts to question the optimal
age for PPCS, and also the role for serial screening exams after initial testing. Current
institutions, such as the United Kingdom Football Association, are now providing serial testing,
so results from longitudinal studies are eagerly awaited. At present, the optimal timing and

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frequency of PPCS for athletes remains completely unsubstantiated by rigorous scientific data

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leading to significant variations in practice patterns.

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5. Is H&P an effective PPCS strategy?
All large sporting and medical societies who support PPCS for athletes recommend a screening

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strategy that includes a history and physical exam [10,27,28,30]. While multiple additional
screening modalities (e.g. ECG, TTE) are recommended by some governing bodies, a complete
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H&P remains the cornerstone of screening methods for PPCS in athletes. Most providers
evaluate athletes using standardized personal and family history questionnaires with the pre-
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participation examination monograph (PPE-5) [40], the American Heart Association 14 (AHA-14)
questions [9,31], or the 36-item ESC and IOC questionnaire [27,41]. Each of these options have
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been developed by expert consensus and include personal and family history questions that are
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designed to screen for the presence of congenital and genetic cardiovascular diseases.
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5.1 Arguments in favor of H&P-based PPCS

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The H&P is a core competency for clinicians in all fields. Thus, it’s use as a tool during PPCS can
be performed by physicians and allied health specialists with minimal additional training. The
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fundamental rationale for the ascertainment of a focused medical history is that diseases
associated with SCD often produce exertional symptoms. Thus, the focused questions
contained in the AHA-14 and PPE-5 monograph are design to query for the presence of
symptoms during exercise, which may help practitioners correctly identify previously
unrecognized diseases. In a similar fashion, a focused medical examination may reveal signs of
pathology. Recommendations pertaining to the physical examination recognize its utility in
identifying conditions that produce murmurs (valvular heart disease and the obstructive HCM),
asymmetric hypertension (i.e. aortic coarctation), or signs of connective tissue diseases (i.e.
Marfan syndrome).

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5.2 Argument against H&P-based PPCS

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While logical and simple to perform, the efficacy of a H&P alone for the detection of relevant
disease has been questioned. Critics cite limited sensitivity and specificity resulting in both high

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false positive rates and unacceptable false negative rates. In a recent meta- analysis by Harmon

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et. al, the overall false positive rates were 8% for history and 10% for the physical exam
portions of the PPCS exam, and the sensitivity of the H&P was reported as ~20% [42]. Recent

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studies assessing the utility of history questionnaires in high school athletes have also reported
a false-positive rate of 31.3% for the PPE-4 monograph [43], and a positive predictive value of
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0.3% for the AHA-14 questions [44]. False negative rates are similarly problematic, and perhaps
more concerning. The accuracy of a history questionnaire relies on honest reporting from
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athletes who may elect to underreport symptoms due to familial or societal pressure to
perform. Inaccurate reporting may also stem from a failure of the questionnaire tools to
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adequately account for variable demographic, socioeconomic and cultural factors that may
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affect the accuracy of athlete responses. A recent study in 8602 college athletes also showed
that a H&P with the addition of ECG is 6 times more likely to detect a cardiovascular condition
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associated with SCD than a H&P only strategy [45]. The history questionnaires have also been
created by expert consensus and not by definitive scientific evaluation, thus, they may not be
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optimized for all populations. Data suggest that the physical examination may also suffer from
significant inaccuracy and heterogeneity across different clinicians [46,47]. In a study assessing
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cardiac auscultation for PPCS of 101 cadet-athletes at West Point, two primary care sports
medicine fellows each referred 6 cadets (5.9%) for further evaluation, however, only one cadet
was referred by both fellows, and a separate cardiologist referred no athletes [48]. Therefore,
there was no clinical agreement between the cardiologist and the fellows, and the kappa
statistic for the fellows was extremely poor at 0.114 (95% CI, -0.182 to 0.411).
6. Should an ECG be used during PPCS?
Electrocardiographic screening for athletes has been one of the most intensely debated topics
in the field of sports medicine in the United States. In contrast, an ECG-inclusive PPCS strategy
is currently supported by most European and professional sporting societies due in large part to

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early hints of efficacy emerging from the Italian-based mandatory screening program [27-30]. In

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2015, there was a paradigm shift in the US guidelines, as the AHA/ACC now has endorsed the
addition of an ECG to the H&P among young athlete cohorts (12-25 years old) with adequate

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resources and expert oversight [10].

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6.1 Argument in favor of ECG-inclusive PPCS
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Compared to a H&P, the ECG is a relatively objective test that can be performed in less than 5
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minutes in virtually any location. The addition of an ECG to a H&P-based PPCS protocol has also
been consistently shown to increase the detection of underlying cardiovascular diseases
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associated with SCD in athletes [42,43,45,49-51]. A recent consensus statement from the ESC
concluded that the ECG is abnormal in >80% of the top 2/3 of conditions leading to SCD in
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young competitive athletes [28]. Importantly, the ECG has also been shown to be abnormal in
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>90% of patients with underlying HCM [52,53] and > 80% of athletes with ARVC [54], which are
amongst the most common causes of SCD in young athletes in the United States and Europe
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[19,20,24]. However, ECG interpretation is an expertise that requires dedicated training and
practice to achieve competency. This reality is compounded by the fact that the conventional
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teaching of ECG interpretations skills, even among cardiology trainees, fail to address the
myriad of ECG findings that are unique to trained athletes. Collaborative efforts between the
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sports medicine and sports cardiology communities have worked to address this issue through
the generation of athlete-specific ECG interpretation criteria and corollary education platforms
to improve clinician interpretation skills. Since the first ECG criteria for use in athletes were
proposed by the European Society of Cardiology (ESC) in 2005, there have been multiple
iterations most recently culminating in the ‘International Criteria’ [32,41,55-57]. While ECG
criteria have been recommended in young athlete cohorts, a recent study has also suggested
that ECG criteria may also be applied to Master’s athletes for screening [58]. The hope is that
these criteria provide a simple algorithm for local providers to accurately assess an athlete’s
ECG.

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6.2 Argument against ECG-inclusive PPCS
The most common and compelling criticism of ECG use during PPCS is that ECG screening has

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historically had significantly high false positive rates. Initial studies assessing the performance

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of ECG screening based on the use of the ESC 2005 and 2010 ECG interpretation criteria yielded
a wide range of false positive rates across different studies from 5-46%

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[34,35,43,49,51,55,57,59-75]. This level of inaccuracy was simply prohibitive as it is impractical
to apply a screening test that generates such a high false positive rate when screening for rare
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diseases with prevalence estimates of less than 1 in 500 athletes. In part, this issue has been
addressed by subsequent iterations of ECG screening criteria which have markedly reduce false
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positive rates to reported ranges between 1.3-6.8%, and also increased specificity (93-98%)
while maintaining sensitivity (62-86%)[69,76-78]. While false positive rates have been reduced,
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interobserver variability and reliability of ECG interpretation in athletes remain concerning [79-
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82]. In a recent study designed to compare the performance of cardiologists with experience in
athlete ECG interpretation (n=4) to those without (n=4) among 400 young athlete’s ECGs, the
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inexperienced cardiologists were more likely to classify an ECG as abnormal (odds ratio= 1.44;
95% CI 1.03–2.02) [82]. This observed increase in abnormal ECGs also led to significantly
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increased costs for screening per athlete for inexperienced cardiologists given the need for
secondary evaluation ($175, 95% CI $142–$228 vs. $101, 95% CI $83–$131). While secondary
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testing through false positive ECG screening increases overall costs of screening, cost-
effectiveness studies have published mixed results with some favoring an H&P + ECG technique
[36,37], and others an ECG only method of screening [35]. ECG interpretation software for
athletes has been created in attempts to aid providers in PPCS, however, preliminary studies
have suggested that ECG interpretation software still has a higher false positive rate than
expert ECG analysis [76]. Another significant concern with ECG screening is the potential for
false negatives. Some conditions, such as congenital coronary anomalies, account for a
significant proportion of SCD in young athletes but cannot be detected by ECG. In addition,
some key forms of pathology may be electrically silent (i.e. HCM, inheritable Long QT
syndrome, ARVC) in a small but significant number of athletes [52-54]. ECG yield is also affected

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by conditions with age-related penetrance if athletes undergo PPCS before the emergence of a

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pathologic phenotype. Given these limitations, there is still significant controversy in the United
States about whether to include an ECG to H&P-based screening. Therefore, some experts are

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advocating for the adoption of a risk-based approach in resource-limited settings as certain

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athlete cohorts known to be at high-risk of SCD (male, black, basketball, soccer, or American
football) may significantly benefit from ECG screening [83,84].

7. Conclusion U
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While there have been significant advancements in the field of PPCS in young athletes over the
last few decades, controversy remains over numerous topics. Estimates of SCD incidence
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among young athletes remain highly variable making definitive determination of the scope of
the problem inconclusive. In parallel, what constitutes the most common causes of SCD among
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young athletes (HCM vs. autopsy-negative sudden unexplained death) remains unclear. The
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H&P, despite inherent limitations with respect to sensitivity and specificity, constitutes the
foundation of PPCS for the United States, while European and other sporting societies
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recommend the additional use of an ECG given the limitations of H&P-only screening. The role
of the ECG during PPCS remains controversial in the United States based on continual concerns
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about the low incidence of SCD in athletes, interobserver reliability secondary to variable
provider training and experience, and the additional financial costs and resources needed for its
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inclusion in PPCS. In the face of continued uncertainty, decisions about how and when to
perform PPCS will rely on provider opinions that take into consideration the availability of
resources and expertise. In the future, a comprehensive randomized trial of screening practices
coupled with multi-national outcomes registries will provide the best opportunity to answer key
questions that continue to plague the field.
8. Expert Opinion
Future research in the field of PPCS represents an important scientific priority. While some
data, including the Italian experience, support the notion that PPCS may have a signal towards
mortality benefit [5], definitive data are lacking. Ideally, future efforts and resources should be

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directed to the creation of randomized clinical trials of differing PPCS strategies that are

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adequately powered to examine the PPCS impact on mortality. The creation of these trials
could inform sports providers on the effects of screening on mortality and define the optimal

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screening method (H&P vs. H&P + ECG vs. other). Given the low incidence of SCD in many

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athletic populations, screening trials would likely need a significant number of patients to be
adequately powered for mortality.

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Significant work is also needed in established screening practices that account for the
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outstanding controversies outlined in Table 2. For medical history questionnaires, evidence-
based questions that account for demographic, societal and socioeconomic factors that may
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affect the accuracy of responses to questions are needed to accurately tailor an H&P to an
individual athlete. Future research should also continue to improve ECG screening criteria.
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While significant strides have been made since the initial ESC 2005 criteria, the current
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International Criteria continues to have a higher than optimal false positive rate (6.8%) in some
populations [77]. ECG interpretation software for an athlete’s ECG have also been developed
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and shown promise in preliminary studies, although these platforms are still not as effective as
expert visual interpretation [76]. Interpretation software could potentially reduce costs and
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improve interpretation for non-expert providers, so should continue to be a research focus.

With continual advancement in screening practices, emphasis should also be placed on creating
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more educational tools for providers on interpretation of ECGs in competitive athletes given
that provider training and experience significantly affect performance on ECG interpretation
[79-82]. Another area of uncertainty which deserves future study is the optimal timing and
frequency of PPCS, given that age-related penetrance make some diseases manifest at different
time points in life. As many sporting societies such as the United Kingdom Football Association
are now providing serial screening for athletes, longitudinal data could lead to more robust
answers on the optimal timing of initial and repeat screening for competitive athletes. Careful
analysis of current data and additional cost-effectiveness studies will be needed to ensure
optimal PPCS for young athletes, and should be interpreted in context of total healthcare
spending and individualized cost for each country involved. As controversy still exists in the

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United States about whether to include an ECG for PPCS, continual epidemiologic and cost-

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effectiveness research is needed to decide on the optimal screening approach. Since certain
populations of athletes are known to be at high-risk of SCD (male, black, basketball, soccer, or

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American football), a risk-based approach could be considered in resource-limited settings in

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the United States as a screening ECG has the potential to significantly benefit these high-risk
populations [83,84]. While significant strides have been made to better understand PPCS in

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young competitive athletes, continual work is needed to optimize current practices.
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Funding
This paper was funded by the National Institute of Health/ National Heart, Lung, and Blood
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Institute (1R01HL125869-01A1), the National Football Players Association, and the American
Heart Association and A Baggish receives compensation for his role as team cardiologist from
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the US Olympic Committee / US Olympic Training Centers, US Soccer, US Rowing, the New
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England Patriots, the Boston Bruins, the New England Revolution, and Harvard University.
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Declaration of interest
This paper was funded by the National Institute of Health/ National Heart, Lung, and Blood
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Institute, the National Football Players Association, and the American Heart Association and AL
Baggish also receives compensation for his role as team cardiologist from the US Olympic
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Committee / US Olympic Training Centers, US Soccer, US Rowing, the New England Patriots, the
Boston Bruins, the New England Revolution, and Harvard University. The authors have no other
relevant affiliations or financial involvement with any organization or entity with a financial
interest in or financial conflict with the subject matter or materials discussed in the manuscript
apart from those disclosed.
Conflicts of interest are correct per above.

Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

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Papers of special note have been highlighted as:
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**A comprehensive textbook covering major topics in the field of sports cardiology.
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2. Baggish AL, Battle RW, Beckerman JG et al. Sports cardiology: core curriculum for
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Cardiol, 70(15), 1902-1918 (2017).

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3. Wilson MG, Drezner JA, Sharma S. IOC manual of sports cardiology (John Wiley & Sons,
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** Corrado et. al present a ground-breaking study which showed potential mortalitly benefit of
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Tables

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Table 1. Cardiovascular Conditions Associated with Sudden Death During Exercise Among Competitive Athletes.

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Cardiomyopathies
Hypertrophic Cardiomyopathy

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Arrhythmogenic Right Ventricular Cardiomyopathy
Familial/Idiopathic Dilated Cardiomyopathy
Left Ventricular Noncompaction Cardiomyopathy

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Toxic Cardiomyopathy (Alcohol, Illicit Anabolic Steroids, etc.)
Acute and Subacute Myocarditis

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Complex Congenital Heart Disease
Arrhythmias
Ventricular Pre-Excitation/Wolff-Parkinson White Syndrome

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Congenital Long QT Syndrome
Brugada Syndrome

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Catecholaminergic Polymorphic Ventricular Tachycardia
Idiopathic Ventricular Tachycardia
Commotio Cordis
Coronary Disease
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Congenital Anomalies of Coronary Arterial Origin and Course
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Acquired Atherosclerotic Disease

Valvular Disease
Bicuspid Aortic Valve (with ≥ Moderate Stenosis +/- Aortopathy)
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Pulmonic Stenosis (with ≥ Moderate Stenosis)

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Mitral Valve Prolapse (with Corollary Arrhythmogenicity)

Aortic Disease
Bicuspid Aortic Valve Aortopathy
Idiopathic Aortopathy/ Thoracic Aortic Aneurysm
Marfan Syndrome
Loeys-Dietz Syndrome
Turner Syndrome
Ehlers-Danlos Vascular Type (IV)

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Table 2. Concise Overview of Current Controversies in Pre-participation Screening Methods for Young Competitive Athletes
Screening Method Argument For Testing Argument Against Testing
Any Screening • Death of young athletes is tragic for families and • No randomized trial has shown a mortality benefit
communities from PPCS
• SCD may be preventable for athletes with • Age-related penetrance of certain diseases makes

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cardiovascular disease by withdrawal from sport, ideal timing + frequency of testing unknown
medical or surgical management • False negative testing provides false reassurance to

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• PPCS testing is non-invasive and can be performed athletes and medical providers
rapidly • False positive testing may lead to significant

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• Prospective data derived from the Italian experience unnecessary psychological stress and time lost to
suggest potential mortality benefit sport for athletes

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• The PPCS encounter provides an opportunity to forge • Any form of screening confers significant costs to a
the athlete-clinician relationship, screen for mental healthcare system
illness, and provide guidance on behavioral • Athletes may have a similar risk of SCD than non-

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modification athletes in some cohorts

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H&P • Medical history and physical exam are core skills for • Low sensitivity, high FPR
providers and do not require significant extra training • Significant heterogeneity exists across providers for

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• Standardized questionnaires (AHA-14, PPE-5 physical exam skills
monograph) can detect athletes with CVD leading to • Questionnaires are based on expert opinion, and do
appropriate secondary testing not account for differing demographic,

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• Physical examination is inexpensive and portable socioeconomic or other societal factors
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ECG • Increases sensitivity and specificity in combination • Higher than optimal FPR in some cohorts
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with the H&P • Potential of false negatives in certain conditions
• Objective test (e.g. coronary anomalies)
• Evidence-based ECG interpretation criteria are readily • Significant heterogeneity in interpretations based
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available and have improved over time on provider training and experience
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Bolded arguments apply to all screening modalities

Definition of Abbreviations: ECG= electrocardiogram, FPR= false positive rate, H&P= history and physical, SCD= sudden cardiac death