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Original Research

Cardiovascular Screening of Elite Athletes by Sporting Organizations in Australia: A Survey of Chief Medical Officers

Orchard, Jessica J. MPH*,†; Orchard, John W. MD, PhD; Toresdahl, Brett MD; Asif, Irfan M. MD§; Hughes, David BMed; La Gerche, Andre PhD; Semsarian, Christopher PhD**

Author Information
Clinical Journal of Sport Medicine: September 2021 - Volume 31 - Issue 5 - p 401-406
doi: 10.1097/JSM.0000000000000798

Abstract

Clinical Relevance

Most Australian sports that responded to the survey have a formal cardiac screening policy, with reasonable uniformity of methods, and almost all including electrocardiogram.

INTRODUCTION

Sudden cardiac death (SCD) in a young athlete occurs infrequently but is a tragic event for all involved.1 Risks vary according to age, sex, sport (and level), and ethnicity.2 Some heart diseases associated with SCD, such as hypertrophic cardiomyopathy (HCM), arrhythmogenic cardiomyopathy, and familial long QT syndrome, may be asymptomatic, and events may be triggered by competitive sport.

There are numerous expert bodies that now recommend screening elite athletes for conditions associated with SCD, but it remains a controversial area. The European of Society of Cardiology (ESC)3 and the Australasian College of Sport and Exercise Physicians (ACSEP)4 recommend cardiovascular screening of elite athletes with a medical history, physical examination, and resting 12-lead electrocardiogram (ECG). The American Medical Society for Sports Medicine (AMSSM) emphasizes physician autonomy in deciding whether to implement screening of athletes including an ECG, noting the gaps in current evidence.2 Specifically, the AMSSM suggests sports should assess the baseline risk of SCD in the relevant population and the availability of required cardiology resources and infrastructure before implementing a screening program.2 The inclusion of an echocardiogram in standard screening (especially at scale) is not recommended by the ESC3 or the American Heart Association (AHA)5 guidelines and is not discussed in the AMSSM2 or ACSEP4 position statements.

One area of divergence is whether to include an ECG in screening. Although the bodies listed above do recommend an ECG, the AHA recommends only a history and physical examination but not ECG.5 However, there have been numerous improvements in the sensitivity and specificity of athlete ECGs over the past decade with standardized interpretation criteria, most recently with the International Criteria.6 These refinements have improved the diagnostic yield of including an ECG in athlete screening and reduced the false-positive rate.7

At the elite level, many major sports governing bodies are now performing, requiring, or recommending cardiovascular screening. These sports include World Rugby,8 the UK Football Association (FA),9 Fédération Internationale de Football Association (FIFA),10 Cricket Australia (CA),11 the England and Wales Cricket Board (ECB),12 and the International Olympic Committee (IOC).13 These bodies generally recommend screening with a personal and family history, physical examination, and ECG, although there is some variation as to whether an ECG is required (vs recommended), and whether an echocardiogram is included as a standard part of screening and as to the frequency of each screening component. For example, the FA,9 ECB, FIFA,10 and Cardiac Risk in the Young14 (which performs a large number of elite athlete cardiac screenings in the United Kingdom) include echocardiograms as a standard part of screening (at least once per career), while the Union Cycliste Internationale (UCI) requires an echocardiogram and exercise (stress) ECG be performed on alternating years.15 In terms of frequency, the FA previously screened players only once per career at age 16,9 but now screens players at age 18, 20, and 25 years.16 This is a similar frequency of screening to CA11 and the ECB.

Although screening recommendations themselves vary, it is also likely that the real-world implementation varies as well. For example, a recent article surveying chief medical officers (CMOs) of countries participating the 2016 Rio Olympic games documented substantial variability in the screening components used, with wealthier countries more likely to include an ECG.17

The nature and uniformity of cardiovascular screening policies of elite sports in Australia has not been previously documented. The purpose of this study was to document and compare the cardiovascular screening policies and practices of elite sporting organizations in Australia.

METHODS

Chief medical officers of 31 elite sporting organizations were contacted and invited to complete an online survey (see Supplemental Digital Content 1, http://links.lww.com/JSM/A228) about cardiovascular screening of athletes in their sport. The survey was available from September 2018 to March 2019. Contact details were obtained through publicly available websites, and a link to the survey was forwarded to CMOs on 2 occasions by the convenor of an annual Australian CMO conference.

The survey included questions about which sport the CMO worked for and for how long, the CMO's medical specialty, and whether their sport had a formal cardiac screening policy. For sports with a formal policy, CMOs were asked to indicate which screening components were included and the frequency of these, whether screening was mandatory, and whether the policy applied to elite junior and/or adult players. For sports performing ECG screening, CMOs were also asked which criteria were used to interpret the ECGs.

Study data were collected and managed using REDCap electronic data capture tools hosted at the University of Sydney.18

The primary outcome was the implementation of formal cardiac screening programs for elite athletes. The secondary outcomes included the components of a screening program, the frequency of performing cardiac screening, and whether screening was mandatory or not.

Ethical Considerations

Ethical approval was obtained from the University of Sydney Human Research Ethics Committee (Protocol No.: 2018/649).

RESULTS

Cardiac Screening Programs

Chief medical officers for 22/31 (71%) major sporting organizations completed the survey, representing >5000 elite athletes. Of the CMOs who responded to the question regarding length of service with their sport, the median was 19 years. Of the respondent sports, 19/22 (86%) had a formal policy regarding regular cardiovascular screening of athletes. The most common CMO specialty of those who responded was sport and exercise physician (a standalone specialty in Australia) (73%), followed by general practitioner (primary care) (22%) and general surgeon (5%) (Figure 1). For sports with a CMO who was a sports physician, the rate of performing cardiovascular screening was 15/16 (94%).

Figure 1.
Figure 1.:
Chief medical officer specialty and cardiac screening program.

Of the 19 respondent sports with a formal cardiac screening policy, 100% included a personal history, family history, and physical examination (H&P) (Table 1). In addition, 89% conducted a resting 12-lead ECG for all athletes as part of screening, with the remainder performing an ECG for some athletes. No sports included an echocardiogram or exercise stress test as part of standard screening for all athletes, although cycling required an echocardiogram and exercise stress test for international athletes according to UCI requirements. Screening of both junior and adult elite athletes occurred in 68% of sports. Chief medical officers of these sports reported that screening policies mandated: components of screening (100%), frequency of screening (89%), and guidelines for ECG interpretation (26%). Most CMOs indicated they referred to a combination of sources for the policy, with almost half (47%) indicating that they referred to a generic policy (eg, ACSEP). There did not appear to be a strong association between the cardiac risk of a sport (Mitchell classification19,20) and whether the screening was mandatory. Screening was mandatory with enforcement for 26% (ie, players could not play unless they had been screened), mandatory without enforcement for 48%, and opt-out for 26% (written waiver).

TABLE 1. - Sporting Organizations With a Formal Cardiac Screening Policy, Level of Cardiac Risk, and Screening Components
Sport Mandatory or Opt-Out Mitchell Classification19,20 and Overall Cardiac Risk Athletes Covered by Screening Policy H&P 12 Lead ECG Echo/Exercise Stress Test
1. Athletics Australia Mandatory without enforcement IC, IIIA, IIB, and IIIC (medium) Adult elite
2. Australian Canoeing Mandatory without enforcement IIIC (high) Adult elite junior elite (≥16 years)
3. Australian Football League (AFL) Mandatory without enforcement IIB (medium) Adult elite junior elite (≥16 years)
4. Australian Institute of Sport (AIS) Opt-out with written waiver All Adult elite junior elite (≥16 years)
5. Australian Sailing Mandatory without enforcement IIIA (medium) Adult elite junior elite (≥15 years)
6. Basketball Australia Mandatory without enforcement IIC (high) Adult elite junior elite (≥16 years)
7. Biathlon Australia Opt-out with written waiver IA and IC (medium) Adult elite
8. Confederation of Australian Motor Sport Mandatory with enforcement IIA (low) Adult elite junior elite (≥16 years)
9. Cricket Australia Opt-out with written waiver IA (low) but should be IIB (medium)* Adult elite junior elite (≥16 years)
10. Cycling Australia Mandatory with enforcement IIIC (high) Adult elite Some athletes
11. Gymnastics Australia Mandatory without enforcement IIIA (medium) Adult elite junior elite (≥15 years)
12. National Rugby League (NRL) Opt-out with written waiver IIB (medium) Adult elite junior elite (≥16 years)
13. Netball Australia Mandatory without enforcement IIC (high) Adult elite
14. New South Wales Institute of Sport (NSWIS) Mandatory with enforcement All Adult elite junior elite (entry to sport ≥12 years)
15. Olympic Winter Institute Opt-out with written waiver IIIB (downhill skiing)/IIC (cross-country skiing) (high) Adult elite junior elite (entry to sport ≥14 years)
16. Racing Victoria Mandatory with enforcement IIA (low) Adult elite Some athletes
17. Rugby Australia Mandatory with enforcement IIB (medium) Adult elite junior elite (≥16 years) Some athletes
18. Tennis Australia Mandatory without enforcement IIC (high) Adult elite junior elite (≥16 years)
19. Water Polo Australia Mandatory without enforcement IIC (high) Adult elite
✓ indicates “all athletes.”
*We have previously published data arguing that cricket should be categorized as a medium-risk sport.30
International athletes only.
ECG, electrocardiogram; echo, echocardiogram; H&P, history and physical.

There were 3 respondents without a formal cardiac screening policy (or unknown). These sports were medium or high cardiac risk according to the Mitchell classification. In terms of reasons for not having a screening policy and/or for not performing ECG screening, CMOs indicated that athletes were either managed at a “lower” level than the head organization (eg, at the state level) and/or were screened precompetition only if required (eg, for the Olympic games). No sports screened nonelite players.

Frequency of Screening

Most sports performed screening components (especially the ECG) less often than annually (Table 2). However, almost half of respondents performed annual H&P components.

TABLE 2. - Cardiovascular Screening Frequency of Sports With a Formal Screening Policy for Elite Athletes
Screening Component Initial Only, n (%) More Frequently That Initial But Less Often Than Annual, n (%) Annual, n (%)
Personal history 0 (0) 10 (53) 9 (47)
Family history 1 (5) 10 (53) 8 (42)
Physical examination 0 (0) 11 (58) 8 (42)
ECG 2 (11) 15 (79) 2 (11)
Echocardiogram 0 (0) 0 (0) 0 (0)
Exercise stress test 0 (0) 0 (0) 0 (0)

Electrocardiogram Interpretation Criteria

In terms of the ECG interpretation criteria used, 74% noted that it was at the discretion of each ECG reporter. Several CMOs specifically mentioned that their screening ECGs were reviewed by specialist sports cardiologists. In addition, 33% of the CMOs explicitly stated that they used the most recently developed ECG interpretation criteria for athletes (International Criteria 20176).

Payment for Screening and Follow-up Tests

For most sports (58%), the cost of screening and follow-up tests (if required) was funded by the sport team or governing body and insurance. However, 42% of respondents indicated their sport required athletes to personally pay for screening tests and 63% required athletes to pay out-of-pocket costs for any follow-up tests required.

DISCUSSION

Although numerous guidelines recommend cardiac screening of elite athletes, the implementation of cardiac screening policies in Australian sports has not been previously documented. Most responding sports in Australia had a cardiac screening policy and regularly screened elite athletes. There was reasonable uniformity of screening methods, with all sports including H&P components, and almost all sports including an ECG for all athletes. No sports included an echocardiogram or exercise stress test as a standard part of screening, other than cycling where the athlete was in international competition. There was variation as to whether screening was compulsory or not, with 26% of respondents allowing athletes to opt-out (written waiver), and a further 48% stating that screening was mandatory but without enforcement (meaning players could still play if they had not been screened). Only 26% of respondents stated that screening was mandatory with enforcement (ie, no screen, no play). Most sports (68%) screened junior and adult elite athletes.

The use of ECG as a fundamental part of screening in most sports that responded was comparable with previous surveys of Olympic sports (in most Western countries where it was considered affordable),17,21 but in contrast to a similar survey of sports from the United States.22 Most sports in the United States perform regular screening but use H&P but not always ECG.22 Our survey shows that Australian sports sit very much in the position of routinely requiring ECG and H&P.

Only 33% of the CMOs explicitly stated that they used the most recently developed ECG interpretation criteria for athletes. For sports that use an ECG as part of screening, promoting the latest ECG interpretation criteria has potential to reduce false-positive rates and minimize costs associated with screening. Therefore, education in athlete ECG interpretation is particularly important. The Australasian College of Sport and Exercise Physicians (ACSEP) and the University of Washington (UW) have recently released a set of open-access training modules based on the International Criteria6 for clinicians to upskill in the interpretation of athlete ECGs.23 These modules were launched in January 2019, and many CMOs may not have had the opportunity to complete these before responding to the survey. The International Criteria provide clear guidance on which ECG findings are normal, abnormal, or borderline in athletes, which improves the efficiency, sensitivity, and specificity of screening.

Some sports specifically mentioned the use of a “sports cardiologist” to report on screening ECGs, although it should be noted that this term refers to individuals with self-described experience in the field of reading athlete ECGs. As the field matures, there will be a need to specifically define qualifications for a “sports cardiologist,” who would ideally be qualified to manage all aspects related to this field, including whether an athlete is fit to compete and whether specific treatment is required. The “sports cardiologist” qualification would therefore be superior to the basic qualification of demonstrated competency to read a screening ECG from having completed the ACSEP/UW modules.

Although some international sports include an echocardiogram as part of screening, no Australian CMOs who responded indicated that screening included an echocardiogram for all athletes. This is unsurprising because no guidelines expressly recommend including an echocardiogram as part of screening. Interestingly, the 2018 policy statement on echocardiography in screening of sports participants from the British Society of Echocardiography and Cardiac Risk in the Young does not make a recommendation either way about whether to include an echocardiogram as part of standard screening, stating that “the specific sporting/screening organisation will decide whether their athletes require a routine…echocardiogram.” 24 An echocardiogram provides additional information and may in a small number of cases identify pathology (eg, valve disorders, some cases of left ventricular hypertrophy, or HCM) that may be missed with H&P and ECG.25 However, the substantial extra time, costs, false-positives, and incidental findings must be carefully weighed against the potential benefits.

A substantial proportion of CMOs indicated athletes were required to personally contribute to the cost of screening and/or follow-up tests. It is noted that in Australia, Medicare (universal government insurance) will generally not cover screening, but would contribute to the cost of most follow-up tests required if an abnormality is discovered on screening. There are some exceptions, including new Medicare rebates for heart health assessments conducted in general practice announced subsequent to this study. These rebates commenced in April 2019 and provide for a comprehensive assessment of cardiovascular health, a physical examination, identification of any physical or lifestyle risks, and a preventive health care plan to improve cardiovascular health.26 However, the precise scope of who is eligible is not well defined, and it is unclear whether athletes could be covered.

In determining whether to implement a cardiac screening program, the AMSSM recommends an assessment of the risk of SCD in the relevant population.2 However, the risk of SCD in each of the respondent sports in Table 1 is not known. In Australia, the general incidence of SCD in young people aged 1 to 35 years is 1.3 per 100 000 people per year, with 15% occurring either during or immediately after exercise.27 The Mitchell classification provides some indication of the inherent cardiac risk of specific sports. In this study, there was no correlation between the Mitchell classification19,20 and whether the sport conducted screening, or whether it was mandatory or opt-out. The Mitchell classification itself, while valuable as a reference to risk rate various sports, could be updated with more emphasis on actual data (physiological requirements to play at elite level; rate of SCD in participants; rate of ECG abnormalities in participants, etc) rather than simply expert opinion. It is noted that the general rate of SCD in Australia in young people is low compared with some countries.27 It is likely therefore that there would be relatively lower yield in implementing a cardiac screening requirement for competing in amateur sport (which is required in countries such as Italy28 where the baseline risk of SCD in young people is higher).

The AMSSM also emphasizes the importance of developing a good “infrastructure” for screening.2 This includes developing “a close and collaborative relationship with local cardiology resources” as part of a team approach.2 Ideally, athletes should be screened in an environment where any abnormalities can be evaluated and communicated as quickly as possible. Future work should further explore the infrastructure needed to conduct a comprehensive cardiovascular screening program at the elite level in Australia, the cost of such an initiative, and long-term follow-up to understand potential outcomes.

No sports in Australia screened nonelite athletes, which differs from Italy28 and Israel29 which both have mandatory programs for all young athletes (broadly defined). In both the United Kingdom (through Cardiac Risk in the Young) and the United States (although high school and college systems), there appears to be more widespread screening of nonelite athletes.

Strengths and Limitations

This is the first time that cardiac screening policies of Australian sports have been documented. Respondents include CMOs for most of the major sports in Australia, although the response rate of 71% is a limitation. It is also possible that there is a bias of responses toward those sports that do have a cardiac screening program.

An important and related area is cardiac emergency preparedness, including cardiac emergency plans and access to automated external defibrillators, which was not assessed in this study. It is an area for future research, specifically at the elite level, which may have different needs and challenges from the community level.

CONCLUSIONS

Most sports have a screening policy, with reasonable uniformity of components. All included H&P, and almost all included ECG. Only one sport included an echocardiogram and exercise stress test as a standard part of screening (international players only). Promoting the latest ECG interpretation criteria may reduce false-positives and cost. Future work should explore cardiac emergency plans, infrastructure needed for screening, cost, and long-term follow-up.

ACKNOWLEDGMENTS

The authors thank all CMOs who responded to the survey.

References

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    Keywords:

    cardiac screening; athletes; electrocardiogram

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