The most important time to screen athletes is pre‐participation.9
Accordingly, potential medical problems that would preclude athletic activity or that need further evaluation can be identified before the individual starts participating in sporting activities. The American Heart Association recommends that high school and college athletes have a pre‐participation examination and that it be repeated every two years.1
A new medical history only is recommended in the intervening years. Many schools fully evaluate their athletes yearly, but this frequency of pre‐participation examinations was felt to be a potential hardship on less affluent schools. The American Heart Association recommends a 12 point screening procedure that is outlined in table 3. As can be seen, eight of the 12 points are related to the history and the remaining four are physical examination elements. These points should be viewed as minimal criteria and a complete physical examination should be encouraged when feasible. For example, palpation of the carotid pulses and precordium are not included in the 12 points, but they may provide important information. Also, a history of any medication or recreational drug use should be sought. Many physicians use the occasion of a pre‐participation evaluation to address adolescent health issues in general.
Table 3American Heart Association 12 point screening procedure
The American Heart Association did not recommend other testing on a routine basis, but rather that other testing be done on an individual basis when there are unexplained abnormal findings or suspicion of cardiovascular disease.1
The European Society of Cardiology has taken a different approach and specified that an ECG should be done with each evaluation.10
They believe that this will detect most cases of hypertrophic cardiomyopathy and the majority of cases of arrhythmogenic right ventricular cardiomyopathy. Although the American Heart Association did not disagree with this assertion, they believe that the cost of doing ECGs versus the yield is prohibitive and that the cost of evaluating false positives, both in terms of financial cost and psychological impairment, are too great to make this practice cost effective.1
Currently there are no comparative data using the two approaches and there are little data to support that either approach significantly reduces the risk of sudden athletic death. No matter what screening procedure is used it is impossible to achieve zero risk in sports.
If cardiovascular or other abnormalities are found when evaluating an individual, an estimation should be made of how much physical exercise can be safely tolerated. This requires knowledge of the type of exercise the individual will be doing; how much static and dynamic exertion is required; and how vigorous the training programme is. In some sports training is often more vigorous than the actual competition—for example, boxing. The 36th Bethesda Conference report has a chart of all major sporting activities and what level of dynamic and static exercise are generally required to participate in the sports.3
The report also discusses many cardiovascular diseases, including congenital heart diseases, and details what levels of exertion are acceptable at various severities of the disease. Combining this information will allow for a decision as to whether an individual patient can safely participate in a particular sport or not. For example, athletes with mild aortic stenosis can participate in all competitive sports, but moderate aortic stenosis would restrict an athlete to low to moderate static and dynamic sports such as diving or volleyball.
The primary obligation of a physician to the athlete is their best medical interest, but the physician must avoid unnecessary exclusion from sports. Thus, when abnormalities are detected that may disqualify a person from the sport they are interested in, it behoves the general physician to request specialty consultation or testing. Also, the athlete should be temporarily withdrawn from activities until the issue can be resolved. If the general physician and the specialist both agree that the patient's condition requires disqualification, then they should not hesitate to disqualify the individual from participation. Such decisions, if based on a reasonable pre‐participation evaluation following the usual and customary medical practices of the region, have generally been upheld in court cases. Also, there seems to be little liability risk if an asymptomatic condition is missed.8
The physician should resist pressure from competing interests such as the athlete, the family, the coach, the administrative officials of the educational institution, and the alumni. Such individuals may be interested in having the individual compete athletically for reasons that are not in the individual's best interest medically. Once a decision has been made, the physician should report only to the patient, or the patient's parents if the patient is a minor, the referring doctor, and in some cases the institutional officials when an institution is paying for the medical evaluation. It is unwise to make any public pronouncements or discuss cases with the press unless the above‐mentioned people all wish for this to be done.
Evaluating the older athlete who wants to embark on a fitness programme or participate in competitive master's level sports is a different challenge. Here one must weigh the health benefits of exercise versus the risk of triggering a cardiovascular event in those with unsuspected cardiovascular disease.11
Regular exercise decreases the overall risk of sudden death, but if sudden death occurs, it is more likely to occur during exercise. The focus in these athletes is coronary artery disease risk. They should be evaluated for coronary artery disease risk factors and if one risk factor beyond male sex is present an exercise test or some other screening procedure for coronary artery disease would seem warranted. Also an exercise test would determine the individual's overall fitness for athletic participation. If a patient has known coronary artery disease, even if they have been revascularised, high intensity competitive sports should not be permitted. Other contraindications to high intensity competitive sports are listed in table 4.
Table 4Contraindications to high intensity competitive sports