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Many sporting teams, leagues and federations now mandate cardiac screening of athletes. The most common screening protocol in Australian sports involves a personal/family history and physical examination, together with a resting 12-lead ECG.1 Some bodies, such as the Union Cycliste Internationale, the England and Wales Cricket Board and the UK Football Association also mandate two-dimensional transthoracic echocardiography as part of the standard screen. While echocardiography is sometimes used as a screening tool, the variable use of this modality in cardiac screening programmes raises the issue of when this test should be used as a diagnostic tool for the follow-up evaluation of other screening abnormalities. There is a need for clear consensus guidance, which should take into account the additional costs, as well as the potential benefits of echocardiography and the potential harms of incidental findings.
We audited the national cardiac screening programme of elite men’s and women’s Australian cricket.2 The protocol consists of history, physical examination and ECG. Overall, 2.0% of ECGs were abnormal or had ≥2 borderline findings according to the international criteria for athlete ECG interpretation,3 although 5.5% of cases had an echocardiogram, which was the most common follow-up test performed. During the study, we observed substantial variation in the indications for players receiving follow-up echocardiograms.
While the international criteria provide a very useful objective guide for clinicians as to which players require follow-up based on ECG results, there is a lack of similarly clear and agreed on thresholds for the more subjective history and physical examination features. We note that there are a number of limitations with history and physical screening components, including: there is no consensus on wording of personal/family history questions; many questionnaires have not been scientifically validated; and clinician responses to positive questionnaires vary widely.4 In relation to physical screening examinations, we note that the accuracy of cardiac auscultation to determine which athletes require further evaluation for structural heart disease is also relatively imprecise.
Previous approaches
A review of the literature suggests there is substantial variation between approaches, with a need for more specific definitions of many features (table 1). We note that the Guideline from the British Society of Echocardiography and Cardiac Risk in the Young5 is the only guidance specifically provided for when diagnostic echocardiography is indicated (as a follow-up test) in athletes in the context of screening protocols using history, physical examination and ECG. However, this guideline is very broad, leaving ‘abnormal physical examination’ undefined. The Williams et al 4 study also included some very broad indications for diagnostic echocardiography, namely clinically relevant history that ‘could not confidently be classified as non-cardiac after physician review’.
Various approaches to defining indications for follow-up based on cardiac screening
Both the American Heart Association (AHA)6 7 and European Society of Cardiology8 approaches do not specify indications for a diagnostic echocardiogram. These guidelines provide a relatively detailed list of general indications for when further follow-up is required. It is also noted that the AHA recommendations do not include an ECG as a standard component of cardiac screening.
While there are some commonalities between these approaches, there is a substantial degree of variation between thresholds and many aspects that lack clear definition, leading to a lack of certainty for clinicians conducting athlete screening.
A suggested framework for discussion
Clinicians performing screening may benefit from a consensus list of indications for a diagnostic echocardiogram. It would be ideal to develop a clear standard for when an echocardiogram is indicated as a follow-up test in the context of cardiac screening involving a history, physical examination and ECG. We propose the following as a starting point, which could ideally be discussed and formalised into a more detailed consensus statement by some of the leading sports cardiology bodies.
Suggested indications for diagnostic echocardiogram: in the context of a screening programme for athletes comprising history, physical examination and 12-lead ECG, a diagnostic echocardiogram is indicated where the athlete has any of the following:
Personal history:
Unexplained syncope.
Unexplained exertional chest pain (not likely to be of musculoskeletal origin or injury).
Exertion-related excessive shortness of breath not explained by asthma.
Rapid, sustained palpitations.
Family history:
Family history of any first or second degree relative with sudden cardiac arrest <40 years unrelated to myocardial infarction.
Any first or second degree relative diagnosed with inherited conditions associated with sudden cardiac death (such as cardiomyopathies and aortopathies).
Physical examination:
Any diastolic murmur, any systolic murmur ≥3/6 and any murmur that is accentuated with Valsalva manoeuvre.
Stage 2 hypertension at rest.
Suspicion of Marfan syndrome.
ECG:
An ECG that is abnormal or has ≥2 borderline findings according to the international criteria.
We note that a short paper such as this cannot create a definitive set of recommendations and that the above list is intended as a starting point for discussion to try to work towards expert consensus.
We encourage sports medicine and sports cardiology experts and their associated societies to consider generating detailed consensus recommendations on diagnostic echocardiography in athletes. We believe that development of a consensus list with well-defined indications for diagnostic echocardiography would provide a useful guide for clinicians, standardise the approach and ultimately improve quality in the implementation of cardiac screening programmes in athletes to detect conditions with a risk of sudden death.
Acknowledgments
The authors would like to acknowledge the Cricket Australia Sport Cardiology Advisory Decisions Expert group, including Alex Kountouris, Mark Young, Hariharan Raju and Rajesh Puranik.
Footnotes
Twitter @jessicajorchard, @DrJohnOrchard, @CSHeartResearch
Contributors All authors contributed to drafting and finalising the Discussion piece.
Funding This study was funded by National Health and Medical Research Council (grant no: 1154992) and Australian Government Research Training Program.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.