Screening for sudden cardiac death before participation in high school and collegiate sports.
General
Guideline Title
Screening for sudden cardiac death before participation in high school and collegiate sports.
Bibliographic Source(s)
- Mahmood S, Lim L, Akram Y, Alford-Morales S, Sherin K, ACPM Prevention Practice Committee. Screening for sudden cardiac death before participation in high school and collegiate sports: American College of Preventive Medicine position statement on preventive practice. Am J Prev Med. 2013 Jul;45(1):130-3. [23 references] PubMed
Guideline Status
This is the current release of the guideline.
Recommendations
Major Recommendations
The American College of Preventive Medicine (ACPM) supports an evaluation prior to participating in high school and collegiate sports using a standardized history and physical (H&P) (i.e., using standardized items as developed by the American Heart Association [AHA] to ensure uniformity and consistency in risk factor assessment [see the table below]). ACPM recommends against routine screening for potential sudden cardiac death (SCD) with electrocardiogram (ECG), echocardiography, and genetic testing in individuals without personal risk factors. The recommendations by ACPM address only mass screening approaches to detecting SCD and are not targeted toward individuals who may be identified by their healthcare provider as “above average” risk who may benefit from additional testing with the modalities mentioned above. ACPM supports the adoption of the National Heart, Lung, and Blood Institute (NHLBI) Working Group research agenda to evaluate the effectiveness of any screening program in reducing SCD, its cost–benefit ratio, and its impact on health outcomes (see Table 2 in the original guideline document).
Table: The 12-element AHA Recommendations for Pre-Participation Cardiovascular Screening of Competitive Athletes
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Medical History a Personal History
Family History
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Physical Examination
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a Parental verification is recommended for high school and middle school athletes.
b Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion.
c Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
Clinical Algorithm(s)
None provided
Scope
Disease/Condition(s)
Sudden cardiac death (SCD)
Guideline Category
- Prevention
- Risk Assessment
- Screening
Clinical Specialty
- Cardiology
- Family Practice
- Internal Medicine
- Pediatrics
- Preventive Medicine
- Sports Medicine
Intended Users
- Advanced Practice Nurses
- Nurses
- Physician Assistants
- Physicians
Guideline Objective(s)
To outline the American College of Preventive Medicine’s (ACPM) perspective on critical preventive medicine issues, in a timely fashion, in order to exert a positive influence on policy, practice, and research dealing with screening for sudden cardiac death (SCD) before participation in high school and collegiate sports
Target Population
Students playing high school and collegiate sports in the United States without personal risk factors
Note : This guideline does not include individuals who may be identified by their healthcare provider as “above average” risk.
Interventions and Practices Considered
Standardized history and physical (H&P):
- Personal history
- Family history
- Physical examination
Note : Electrocardiogram (ECG), echocardiography, and genetic testing were considered but not recommended.
Major Outcomes Considered
- Instances of sudden cardiac death (SCD)
- Detection of underlying cardiac conditions and disease progression
- Mortality rates
- Specificity and sensitivity of screening tests
- Cost-effectiveness of SCD screening
Methodology
Methods Used to Collect/Select the Evidence
- Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
PubMed, MEDLINE, and Google Scholar were the databases used for the qualitative literature search with a time frame of 1980 to 2013. No inclusion/exclusion criteria were used in the search.
The following search terms were used:
- Sudden cardiac death
- Screening for sudden cardiac death
- Sudden cardiac death in young athletes
- Pre-participation screening of sudden cardiac death
- Cost-effectiveness of pre-participation screening of sudden cardiac death
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
- Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
- Review
Description of the Methods Used to Analyze the Evidence
The American College of Preventive Medicine (ACPM) Prevention Practice Committee conducted a qualitative review of the literature on this topic to state the ACPM’s position on sudden cardiac death screening.
Methods Used to Formulate the Recommendations
- Expert Consensus
Description of Methods Used to Formulate the Recommendations
The American College of Preventive Medicine (ACPM) Prevention Practice Committee reached consensus on these recommendations after an extensive literature review and examination of recommendations from other organizations.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
- A limited number of studies suggest that combining history and physical (H&P) and electrocardiogram (ECG) screening for sudden cardiac death (SCD) may be cost effective. An Italian cost-effectiveness analysis of 33,735 athletes, using a more conservative approach (10% of affected athletes would live an additional 20 years), estimated the cost per year of life saved at approximately $20,000 for the Italian model (H&P and ECG) and about $53,350 for the U.S. model (H&P alone).
- The American Heart Association (AHA) estimates the cost of mass ECG screening, followed by echocardiogram and other indicated testing, to be $2.0 billion for 10 million middle and high school athletes. Pending further prospective studies involving U.S. participants, the cost effectiveness of routinely combining H&P and ECG in cardiovascular pre-participation screening in students cannot be conclusively determined.
Method of Guideline Validation
- Comparison with Guidelines from Other Groups
Description of Method of Guideline Validation
The guidelines from the following major professional and health organizations were used for comparison of recommendations on screening for sudden cardiac death before participation in high school and collegiate sports:
- American Heart Association
- European Society of Cardiologists
- International Olympic Committee
- American College of Sports Medicine
Evidence Supporting the Recommendations
Type of Evidence Supporting the Recommendations
The type of evidence supporting the recommendations is not specifically stated.
Benefits/Harms of Implementing the Guideline Recommendations
Potential Benefits
Reduction in mortality from sudden cardiac death (SCD)
Potential Harms
Although a history and physical (H&P) costs less, requires minimal resources, and is efficient to administer, it has low sensitivity in detecting hypertrophic cardiomyopathy and other asymptomatic cardiac diseases. Another limitation is the poor utilization of a standardized H&P for pre-participation sports evaluation.
Qualifying Statements
Qualifying Statements
The American College of Preventive Medicine (ACPM) acknowledges that studies addressing the efficacy of screening with clinical outcomes are lacking and that the utility of specific screening modalities remains unclear. However, at the present time, the history and physical (H&P) is the most widely used modality for pre-participation evaluation despite its limited sensitivity in detecting certain cardiac conditions. Promoting an H&P using standardized items as that developed by the American Heart Association (AHA) will ensure uniformity and consistency in risk factor assessment (see the table in the “Major Recommendations” field).
Implementation of the Guideline
Description of Implementation Strategy
An implementation strategy was not provided.
Institute of Medicine (IOM) National Healthcare Quality Report Categories
IOM Care Need
- Staying Healthy
IOM Domain
- Effectiveness
- Patient-centeredness
Identifying Information and Availability
Bibliographic Source(s)
- Mahmood S, Lim L, Akram Y, Alford-Morales S, Sherin K, ACPM Prevention Practice Committee. Screening for sudden cardiac death before participation in high school and collegiate sports: American College of Preventive Medicine position statement on preventive practice. Am J Prev Med. 2013 Jul;45(1):130-3. [23 references] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2013 Jul
Guideline Developer(s)
- American College of Preventive Medicine - Medical Specialty Society
Source(s) of Funding
American College of Preventive Medicine (ACPM)
Guideline Committee
American College of Preventive Medicine Prevention Practice Committee
Composition of Group That Authored the Guideline
Committee Members : Shamail Mahmood, MD, MPH; Lionel Lim, MD, MPH, FACPM; Yasir Akram, MD; Samantha Alford-Morales, MD, MPH, FACPM; Kevin Sherin, MD, MPH, MBA, FACPM
Financial Disclosures/Conflicts of Interest
No financial disclosures were reported by the authors of this paper.
Guideline Status
This is the current release of the guideline.
Guideline Availability
Print copies: Available from American College of Preventive Medicine, 1307 New York Ave, N.W., Suite 200, Washington, DC 20005-5603.
Availability of Companion Documents
None available
Patient Resources
None available
NGC Status
This NGC summary was completed by ECRI Institute on February 4, 2014. The information was verified by the guideline developer on March 13, 2014.
Copyright Statement
This NGC summary is based on the original guideline, which is subject to the guideline developer’s copyright restrictions.
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