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From guidelines to the sidelines: implementation of cardiovascular preparticipation evaluation in sports clubs is lagging
  1. Kristofer Hedman1,
  2. Sofia Sunnerud2,
  3. Anna Carlén1,
  4. Magnus Janzon2,
  5. Eva Nylander1
  1. 1 Department of Clinical Physiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
  2. 2 Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
  1. Correspondence to Dr Kristofer Hedman, Department of Clinical Physiology, Linköping University Hospital, Linköping 581 85, Sweden; kristofer.hedman{at}

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In the last years, European and American organisations have presented rigorous position statements for guidance of physicians engaged in the cardiovascular screening of athletes as part of a preparticipation evaluation (PPE).1 2 In addition, continuous improvements of criteria for ECG interpretation in athletes over the last decade have yielded comprehensive updated international guidelines.3 Thus, the stage should be set for an evidence-based, best-practice cardiovascular PPE for the benefit of all competitive athletes included under each country’s or sports governing body’s regulations and recommendations. However, as pointed out in last year’s position statement from the American Medical Society for Sports Medicine,2 the long-standing debate regarding the inclusion or not of ECG in cardiovascular screening may have halted or clouded other important discussions and progress in the field. We believe one issue that has received far too little attention is the question of actual implementation of the cardiovascular PPE in sports clubs.

Notably, several reports from the USA have found an inadequate implementation or awareness of PPE recommendations.4–6 For example, in 2013 in this journal, Madsen et al reported results from a survey directed to paediatricians, family physicians and athletic directors.4 They found a poor compliance to the American Heart Association PPE recommendations and also lack of awareness and knowledge regarding the recommendations. How well the cardiovascular PPE is implemented outside of the USA is largely unknown.

Cardiovascular PPE in Sweden

The PPE is non-mandatory for sports participation in Sweden, but recommendations from the Swedish Sports Confederation dictate that all elite athletes aged 16–35 years or athletes belonging to a sports high school should at least once every second year undergo cardiovascular screening, including a resting ECG. The concept of elite is to be defined by each specific sports federation (eg, Swedish Football Federation) and is in general associated with the level of competition at a national or international level. In Sweden, the PPE is performed outside the public healthcare system and the responsibility (and financing) of conducting PPE is divided between the sports club, the specific sports federation or the sports high school. Athletes with abnormal findings meriting for further investigation are referred to the public healthcare system.

We recently addressed an electronic survey to sports clubs with elite level athletes in one out of 21 geographical districts of the Swedish Sports Confederation. Our aims were (1) to investigate the adherence to current recommendations, (2) to find factors associated with committing to the recommendations and (3) inquire possible reasons for not performing a cardiovascular PPE. While our results are reported in detail elsewhere,7 in brief, only 4 out of 22 (18%) responding sports clubs with elite athletes followed the recommendations. These four clubs were all engaged in team sports, had a team physician and all had >10 elite athletes. The two most common reported reasons for not performing a cardiovascular screening were either a lack of knowledge in (1) the existence of recommendations or (2) how to actually conduct the PPE. A majority of either of these two responses came from sports clubs not having a team physician.

Important limitations in our survey were the unknown response frequency and broader representation across the country, which in turn highlights the lack of a regional or national Swedish registry of sports clubs that currently have elite-level athletes.

Future perspectives

Our results, and others, should not be taken as an argument for implementing universal or mandatory screening of athletes, which is another debate beyond the scope of this editorial.8 While it may be utopic to expect uniform cardiovascular PPE implementation, it is problematic when current recommendations are neglected, misinterpreted or simply unknown by those responsible for the initiation of the cardiovascular PPE of athletes.

Thus, a knowledge gap clearly needs to be overcome. This requires education of physicians (of different medical specialties) and the sports community including governing bodies and sports clubs. For the community of sports cardiology, the responsibility cannot end when new guidelines, position statements and updated recommendations are published, but should rather be seen as a starting point for the next part of the work—education and conveying the message. In this aspect, we believe that we can do better!

In summary, there is a need for positive examples of the successful implementation of the cardiovascular PPE. We hereby call out for more systematic evaluations of current adherence to recommendations and, optimally, evidence-based ways to increase the level of adherence. These should be used as inspiration to help transfer knowledge from the guidelines to the sidelines.



  • Contributors All authors contributed in drafting and revising the manuscript for intellectual content. The work was organised and led by the first author, KH.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.