Background Sudden cardiac arrest is the leading cause of death in competitive athletes during sport, and screening strategies for the prevention of sudden cardiac death are debated. The purpose of this study was to assess the incorporation of routine non-invasive cardiovascular screening (NICS), such as ECG or echocardiography, in Division I collegiate preparticipation examinations.
Methods Cross-sectional survey of current screening practices sent to the head athletic trainer of all National Collegiate Athletic Association (NCAA) Division I football programmes listed in the National Athletic Trainers’ Association directory.
Results Seventy-four of 116 (64%) programmes responded. Thirty-five of 74 (47%) of responding schools have incorporated routine NICS testing. ECG is the primary modality for NICS in 31 (42%) of schools, and 17 (49%) also utilise echocardiography. Sixty-four per cent of the programmes that do NICS routinely screen their athletes only once as incoming freshmen. Of institutions that do not conduct NICS, American Heart Association guidelines against routine NICS and cost were the most common reasons reported.
Conclusions While substantial debate exists regarding protocols for cardiovascular screening in athletes, nearly half of NCAA Division I football programmes in this study already incorporate NICS into their preparticipation screening programme. Additional research is needed to understand the impact of NICS in collegiate programmes.
- Cardiology prevention
- Cardiovascular epidemiology
- Injury Prevention
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Exceeding 300 000 cases annually, sudden cardiac death (SCD) is the leading cause of death in the USA.1–3 Defined as occurring within 1 h of participation in sport, exercise-related SCD occurs in 0.5–2.3 cases/100 000 young athletes per year.4 In young athletes (<35 years old), cardiomyopathies are the leading cause of sports-related SCD,5–7 with hypertrophic cardiomyopathy (HCM) representing approximately one-third of the cases.4 ,8–12
SCD prevention programmes that screen athletes through preparticipation history questionnaires and physical examinations have demonstrated a low sensitivity for the detection of cardiovascular disease.7 ,9 ,13–17 The additional use of non-invasive diagnostic tests, such as a resting12-lead ECG, currently included by the European Society of Cardiology and International Olympic Committees for screening, remains a topic of substantial debate in the USA.7 ,9 ,14–16 ,18 Italian data from a long-term study revealed an 89% reduction in SCD with the implementation of a nationalised preparticipation exam (PPE) inclusive of ECG.10 A recent study conducted at Harvard demonstrated the increased sensitivity of the PPE for detection of occult cardiac disease in college athletes when a screening ECG was added to the history and physical examination.19 Researchers at Stanford also estimated a significant increase in sensitivity and improved cost-effectiveness of the PPE with the addition of ECG screening.20
The purpose of this study was to investigate how NCAA Division I collegiate programmes are incorporating routine non-invasive cardiovascular screening (NICS) into their preparticipation examinations.
Certified athletic trainers and members of the National Athletic Trainers’ Association who were employed at NCAA Division I athletic departments with football programmes were asked to participate in the study. A 16-item survey was electronically mailed to each of the head athletic trainers associated with these schools that sponsored Division I level football.21 No incentives were provided. This study was approved by the University of South Florida's Institutional Review Board.
A total of 74 of 116 (64%) surveys were returned. Of the responding programmes, 35 of 74 (47%) incorporate routine NICS into their PPE's. Of the NICS performed, ECG was the most frequently ordered test in 31 of 35 (91%) of programmes. Seventeen of 35 (49%) programmes performed echocardiogram (table 1). Sixty-four per cent of the programmes that incorporate NICS only screen their athletes when they are freshmen (first collegiate year, typically 17–21 yearrs old).
Personnel qualifications of those involved in the screening programmes are delineated in table 2. The programmes that did conduct routine NICS were significantly more likely to order a greater number of cardiovascular tests, including stress tests (χ2=62.915, p<0.001), compared with programmes not performing NICS. There was no statistically significant difference between programmes that routinely use NICS compared to programmes that do not in the reported average number of athletes excluded from participation (χ2=2.068, p=0.36), reported costs of the exam (χ2=3.227, p=0.67), or in the insurance billing and reimbursement practices (χ2= 0.008, p=0.93).
Programmes that do not conduct NICS were significantly more likely to report cost issues and the American Heart Association guidelines as reasons for not using these tests (χ2=19.972, p<0.001; table 3. Only 3% of programmes reported a concern for false-positive rates as an obstacle to NICS. Interestingly, the majority (78%) of head athletic trainers reported no or minimal costs to their programme associated with the preparticipation screening exam. A relatively high number of responding head athletic trainers (23%) reported having had an SCD event at their institution. Programmes that routinely screen athletes with NICS were no more likely than programmes that do not report an SCD event at their institution (χ2=0.001, p=0.98). The vast majority of head athletic trainers (>96%) felt NICS for the preparticipation examination is helpful in identifying athletes at risk. Head athletic trainers of programmes that routinely screen athletes with NICS felt that their programmes were significantly better at increasing student-athlete safety than programmes that do not use NICS (χ2=12.487, p<0.01).
As tragedies from sudden cardiac arrest (SCA) continue to occur in competitive athletes, discussion surrounds best practices for preparticipation screening procedures in various athletic environments and levels of play.1–3 The goal in conducting this survey was to assess specifically how large Division I college football programmes are implementing NICS techniques into their preparticipation examination protocols.
Nearly half of responding programmes in this study are already incorporating routine ECG screening into their PPEs.This finding was unexpected, particularly in light of the recent American Heart Association (AHA) stand against routine mass preparticipation cardiac screening.19 Since the 2006 publication of a 25-year Italian experience incorporating ECG into the preparticipation exam,9 there has been a significant re-evaluation within the US sports medicine community of appropriate preparticipation testing for latent cardiovascular disease.15 ,16 ,18 ,20 ,22 The National Football League, Major League Baseball, National Basketball Association, the Federation International Football Association and the International Olympic Committee (IOC), have established protocols for preparticipation cardiovascular screenings inclusive of NICS.
This study reports the preparticipation cardiovascular screening procedures of NCAA Division I collegiate football programmes. A limitation of this study is the lack of a comparison to less high-profile collegiate programmes. Given cost was identified as a primary obstacle, it is likely that collegiate athletic programmes with less fiscal resources do not incorporate NICS to the same extent.
Identification of athletes with conditions at risk for SCA remains a major challenge. Provided most athletes who suffer SCD are asymptomatic until the time of their collapse, a screening strategy reliant primarily on a history questionnaire has inherent limitations. ECG screening increases the sensitivity to detect potentially lethal cardiac disorders, but concerns regarding ECG interpretation, false-positive results and cost remain.22 An additional research is needed to define the potential benefits and application of NICS within the collegiate setting.
A significant proportion of NCAA Division I football playing institutions conduct routine NICS. The cost associated with such screening, the presence of qualified personnel to perform the testing and existing screening guidelines all influence the specific screening procedures chosen by college programmes. An additional research is needed to explore the practice patterns of other collegiate programmes and investigate the impact of NICS in collegiate athletes.
Contributors Planning: EEC, FS, AC, SMW and MP; conduct: EEC, FS, AC, SMW, KKZ, MP, ER, JJ, DN and JGK; reporting:EEC, FS, AC, SMW, KKZ, MP, ER, JJ, DN, JGK and JAD and guarantor: EEC and JAD.
Competing interests None.
Ethics approval The study was approved by the IRB, USF College of Medicine, Tampa, Florida.
Provenance and peer review Not commissioned; externally peer reviewed.