Shalon Buchs | Skin Bones CME
By: Shalon Buchs, MHS, PA-C

Sport physical season is drawing near! Clearing young athletes for participation in sports is important work. Pre-participation or clearance forms will vary by the organization and state in which the athlete is planning to participate. Nearly all forms will have sections in the history requesting information about respiratory illness, dizziness, syncope, seizures, headaches, heat related illness, eyeglass use and of course, cardiac conditions of the athlete and their family. The physical exam section will include most of the components of a complete physical exam. Ultimately ensuring the athlete is healthy enough for the sport is up to the provider regardless of what is on the clearance form. What should catch the eye of the medical professional during the history or physical evaluation? Is there anything that should warrant further evaluation or referral?

What to watch out for:
While the entire clearance form is important, paying close attention to conditions that could place the athlete at serious risk is critical. Unfortunately, there have been sporadic reports of athletes dying suddenly on the field during a soccer game or track meet. How can those situations be avoided? The most common cause of sudden death in young athletes is hypertrophic cardiac myopathy (HCM), an inherited autosomal dominant trait. HCM increases the risk of ventricular arrhythmias that ultimately result in sudden death. HCM is the most common cause of sudden cardiac death in all people under age 30 and in athletes, accounts for approximately 36% of sudden deaths, making it the most common cause in this sub-population of young individuals. The condition is often undetected. (https://www.mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/in-depth/sudden-death/art-20047571

What the experts say:
The American College of Cardiology and the American Heart Association agree that a thorough history, to include family history, and an adequate physical exam are sufficient for pre-participation screening. Further testing is only recommended if history and/or physical exam prompts additional testing. Important clues in the history related to HCM may include a positive family history of sudden cardiac death before the age of 50. This question answered in the positive should minimally spur a series of additional questions given that HCM is an inherited condition. A positive personal history of a murmur, chest discomfort, dyspnea on exertion, easy fatigability, palpitations, elevated blood pressure, dizziness or syncope, history of restriction from sports or any prior heart testing should similarly initiate additional questioning and/or additional testing. The physical exam should include all components included on the clearance form, evaluation for stigmata of Marfan syndrome, femoral pulse evaluation, and evaluation for potential HCM. To properly evaluate for HCM, one should auscultation the precordium in all cardiac areas and perform special maneuvers such as Valsalva (increases the intensity of the murmur) to better evaluate for the presence of an HCM related murmur.

Additional tests:
ECG may be needed based on the findings of the history and physical examination.
Ambulatory ECG may be indicated for patients with syncope, especially if suspected cardiac origin.
Echocardiography is indicated if a pathologic murmur is detected.
Referral to cardiology may be necessary based on history, physical, and ECG/Echo results.

Clearance?
Clearance is not limited to what is referenced here. Clearance of the athlete will be dependent on the overall impression of the provider after obtaining a thorough history, completing a complete and proper physical exam, and obtaining any additional testing if necessary. No clearance should be provided if additional testing or referral is necessary. All results should be evaluated, and referral opinions considered before clearance consideration is made.

Summary:
Sudden cardiac death is a rare but devastating event that can be associated with athletic activity. According to the American College of Cardiology and the American Heart Association, a thorough history and proper physical exam is sufficient for screening athletes. Occasionally, additional tests such as an ECG or echo may be necessary to clear an athlete for participation in their chosen sport. It is imperative that providers take the time to perform an appropriate clearance exam in pre-participation physicals for athletes.

See Shalon Buchs, MHS, PA-C speak at a 2020 Skin, Bones, Hearts & Private Parts event in Destin • Myrtle Beach • San Antonio • Las Vegas