Preparticipation Physicals: How Much Is Saving a Life Worth?

Laird Harrison

Disclosures

November 18, 2016

A Better Way to Screen Athletes?

For years, sports-medicine specialists have debated the best way to screen athletes for participation in sports. In recent years, much of the debate has focused on the use of electrocardiograms (ECG). Researchers disagree on how much information they should add to a medical history and a physical exam, and whether they're worth the cost.

Now a group of Canadian investigators has come up with a radical proposal: Do the ECG and skip the physical exam. Their reasoning? Doctors' time is expensive, and physical exams don't actually tell you much about which athletes are going to have the heart problems that pose the greatest threat of death during competition. The team put the approach to the test in a large study, and their cost/benefit analysis makes the approach look pretty good.

"The history and physical do not have strong value to detect heart disease," says lead investigator James McKinney, MD, MSc, a sports cardiologist at the University of British Columbia in Vancouver, Canada. "The ECG is by far the most sensitive way."

But on closer inspection, the study reveals just how weak the evidence for any sort of screening is, and how much depends on the context of the healthcare system in which the screening takes place.

Is Screening Really Efficacious?

The argument for preparticipation screening begins with the premise that athletes often get hurt—and sometimes even die—because of the demands they put on their bodies. In theory, the right sort of screening could predict which athlete is most likely to suffer which kind of injury. These athletes could then be advised to refrain from the activity or to take steps to strengthen the body part in question.

On the basis of that argument, most organizations tasked with developing guidelines for healthy sports participation in Western countries have supported the concept of screening. But then the consensus breaks down.

The problem is that no one has shown that preparticipation screening of any kind actually prevents injuries. When two of the world's leading authorities on the topic—the American College of Sports Medicine (ACSM) and the Fédération Internationale du Médicine du Sport (FIMS)—met in 2014 to hammer out their differences, they noted that, "to date, no large scale prospective controlled tracking programs have examined outcomes of the [preparticipation physical evaluation] with respect to injury prevention, sudden cardiac death (SCD) reduction, or other consequences of exercise and competition."[1]

To look at every kind of injury that might befall an athlete would be a herculean task. So much of the research has focused on the part of the screening that seems likely to yield the most important result: detecting heart abnormalities that could put athletes at risk for SCD.

SCD kills about 66 athletes a year, more than any other medical cause.[2] The deaths occur when exertion triggers life-threatening ventricular arrhythmias.[3] But up to 80% of at-risk athletes show no symptoms before an arrhythmia is triggered.[3]

Faced with this challenge, various governments and healthcare organizations have formulated conflicting proposals for detection before tragedy strikes. The American Heart Association (AHA) guidelines combine medical and family history with a physical exam, but no ECG.[4]

The European Society of Cardiology, in contrast, has endorsed the use of a 12-lead ECG,[5] along with the AHA requirements. Italy mandates a physical exam along with a 12-lead ECG and a 3-minute exercise step test for all participants in organized competitive sports.[5] In the United States, sports leagues and school districts have various requirements. In Canada, there are no preparticipation screening requirements for SCD or any other injury.[6]

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....