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Special Communications

History and Application of the AHA 12 Points for Assessing Cardiovascular Risk in Athletes

Uberoi, Abhimanyu (Manu) MD, MS; Roberts, William O. MD, MS

Current Sports Medicine Reports: May/June 2015 - Volume 14 - Issue 3 - p 246-248
doi: 10.1097/01.CSMR.0000465133.17381.44
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The cardiovascular (CV) evaluation, one important part of the preparticipation physical examination (PPE), is the focus of this special communication. Cardiac events during sporting events, albeit rare, can be fatal, and these events are often very public (5,7,10). In the United States, most athlete PPE for ages 6 to 24 years are performed by family physicians and pediatricians (8), some with subspecialty training in sports medicine. Often, the PPE is the first encounter with the health care system for adolescents and serves as the sole opportunity for general screening, risk factor evaluation, and health education. This may be especially true for adolescents in lower income strata. The PPE is intended to reduce the risk of adverse outcomes without unduly restricting athlete participation. A thorough history examination can uncover a large portion of the athlete’s risk for injury or illness, and the physical examination unveils other abnormalities. There are very few proven screening methods that assure an athlete’s health, but the PPE provides a framework to assess and stratify sport participation risk. The intent of these evaluations is to deliver to health care providers pertinent information to educate athletes and parents and enable them to make an informed participation decision.

The first PPE monograph was published in 1992 by five organizations (American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine). The American College of Sports Medicine joined for the third edition in 2005, and the fourth edition was published in 2010 (1). The American Heart Association (AHA) developed CV preparticipation screening recommendations for young athletes in 1996 and updated the statement in 2007 (8). The AHA and the American College of Cardiology have reaffirmed their position regarding the CV PPE and electrocardiography (ECG) screening in healthy 12- to 25-year-old young people with a comprehensive review that endorses the 12-element history and physical examination in the 2014 Scientific Statement (9). This recent document added two elements regarding palpitations and previous evaluations similar to those in the fourth PPE. The question sets from the two examination recommendations are similar, and the fourth PPE monograph uses the same general questions, with some differences in syntax and depth of question content. The question wording of the third PPE monograph was based on input from parent and high school athlete focus group sessions to enhance the “understandability” of the questions for the end users. Of note, the question sets are based on expert opinion and have not been subjected to scientific study.

In the late 1990s, after surveys showed poor compliance with both the use of consensus-based forms and the AHA question set, some high schools and colleges across the country incorporated the elements of the PPE and the AHA questions (3,9) in their athlete evaluations. Despite progress, however, a 2013 Washington state survey showed that only 47% of physicians understood the AHA guidelines (4). This is unfortunate, given the evidence that supports the efficacy of adopting a standardized PPE form (10).

The 12-Step Questionnaire Recommendations for Health Care Providers for Preparticipation Cardiovascular Screening in Athletes (8)

Understanding and utilizing the AHA 12-point CV examination and its constellation of responses is essential to make logical, cost-effective decisions regarding additional evaluations, consultations, and sport participation recommendations (1,9). This document is intended to direct the use of diagnostic testing, including ECG, and reduce reflex use of consults and diagnostics along the lines of the American Medical Association “Choosing Wisely” campaign (6) and encourage the implementation of either the AHA 12-point or the PPE-4 CV screening tools as the minimal standard for athlete screening, not to endorse one questionnaire over the other.

The AHA 12-point question/examination set and the fourth-edition PPE monograph 13 history questions and five physical examination points are outlined as follows. Both emphasize the importance of personal and family history.

This Special Communication will provide the reader, and particularly primary care providers conducting the PPE, a framework to address positive responses to questions and findings reveled during the examination. This will help reduce the risk of adverse outcomes and allow athletes to participate in activities that best fit their risk profile. Positive responses to the CV questions require additional history and sometimes diagnostic investigations to rule out CV problems that put athletes at undo risk. Individual questions will be highlighted in a case presentation to illustrate the significance of each question. Informed analysis of the questions and judicious use of diagnostics will be the key to risk reduction, cost control, and unnecessary athlete restriction. The burden of these decisions rests on the shoulders of the physicians performing the PPE.

References

1. Bernhardt D, Roberts W. PPE Preparticipation Physical Evaluation. 4th ed. Elk Grove Village (IL): American Academy of Pediatrics; 2012.
2. Cassel CK, Guest JA. Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012; 307: 1801–2.
3. Glover DW, Maron BJ. Profile of preparticipation cardiovascular screening for high school athletes. JAMA. 1998; 279: 1817–9.
4. Gomez JE, Lantry BR, Saathoff KN. Current use of adequate preparticipation history forms for heart disease screening of high school athletes. Arch. Pediatr. Adolesc. Med. 1999; 153: 723–6.
5. Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of sudden cardiac death in National Collegiate Athletic Association athletes. Circulation. 2011; 123: 1594–600.
6. Madsen NL, Drezner JA, Salerno JC. Sudden cardiac death screening in adolescent athletes: an evaluation of compliance with national guidelines. Br. J. Sports Med. 2013; 47: 172–7.
7. Maron BJ, Haas TS, Ahluwalia A, Rutten-Ramos SC. Incidence of cardiovascular sudden deaths in Minnesota high school athletes. Heart Rhythm. 2013; 10: 374–7.
8. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007; 115: 1643–455.
9. Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12–25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology. Circulation. 2014; 130: 1303–34.
10. Roberts WO, Stovitz SD. Incidence of sudden cardiac death in Minnesota high school athletes 1993–2012 screened with a standardized pre-participation evaluation. J. Am. Coll. Cardiol. 2013; 62: 1298–301.
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