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Sudden Cardiac Death (SCD) is a prevalent topic and concern for all involved in the care of student-athletes. Associated with this issue is how to screen for SCD and potentially prevent these deaths. Some believe the 12-lead electrocardiogram (ECG) is necessary as part of the preparticipation physical exam (PPE), whereas others see it as an ineffective screening tool for SCD (Asif & Drezner, 2012; OConner & Knoblauch, 2010). Even though there are critics who are against the implementation of ECGs in PPEs for a variety of reasons, with proper implementation and education, the effectiveness of ECGs can be improved (Drezner, Asif, & Owens, 2012). Pre-Participation Physical Exams Main components of PPEs at the NCAA Division II level include a thorough medical history, including cardiovascular questions as outlined by the American Heart Association, and physical evaluation. Red flags on the PPE and medical history include, but are not limited to, heart murmur, diagnosed enlarged heart in a family member, unexplained chest pain, and complaints of skipped heartbeats. Electrocardiograms have become a routine part of PPEs at the collegiate level. The thought behind the use of ECGs is to screen for cardiac adaptations that may lead to sudden cardiac death. Even so, there are a number of reasons that ECGs have not become a requirement for PPEs. False-positive results are the main cause of criticism because most athletes with a positive ECG will have no actual cardiac abnormality.

Sudden Cardiac Death: How to Detect Abnormalities? An issue to discuss is which cardiac abnormalities are training induced and which are pathological. Endurance athletes often have abnormal ECG readings as a result of training induced abnormalities. Physicians need to be trained and up-to-date on reading ECGs. A possible solution to this problem would be to create guidelines on which adaptations are training induced, and which are abnormal. Macarie et al. (2009) and Drezner et al. (2012) have outlined guidelines of normal and abnormal ECG readings. With use of these modern ECG guidelines, false-positive rates have dropped from 7-15% to 2-3% (Drezner, Asif, & Owens, 2012) at the NCAA Division I collegiate level. Physicians should be required to be up-to-date on these guidelines. Also, it might be beneficial to specify which physicians should be allowed to read the athletes ECGs. For example, a cardiologist would be much better practiced at reading ECGs than an orthopedic physician. Costs In many instances the student must pick up the follow-up costs to determine if there is a cardiac risk or not. If an athlete is flagged as having a cardiac abnormality, needing further tests, this is a pre-existing injury and in most cases, not covered by the schools secondary insurance. Therefore, the student will be responsible for the testing costs. These costs average $371 according to the 2009 Medicare Physician Fee Schedule. This leaves a large majority of studentathletes spending money on follow-up costs.

Who is at Risk? One of the main arguments against routine ECGs for all athletes is the high number of false-positive results. According to research, data predicts that 16% of cardiac abnormalities would be read as positive for a cardiac abnormality; however, only 1.3% of that 16% would actually have the abnormality (OConner & Knoblauch, 2010). Research has also shown that black males are at the highest risk for cardiac abnormalities (OConner & Knoblauch, 2010). The American Heart Association (AHA) has developed guidelines consisting of 12 questions that will identify those individuals that may have a cardiac abnormality. Any athlete flagged because of one of the AHA questions or at risk because of ethic background should be screened with an ECG at PPEs (Maron et al., 2007). This would help to reduce costs stemming from false-positive results. Case Study At Tarleton State University, in Stephenville, TX, the Sports Medicine staff strives to be proactive in preventing cardiac emergencies. The staff performs an ECG on every incoming athlete in addition to compiling a thorough medical history and physical evaluation. The exercise physiologists on campus read the ECGs for abnormalities, which are then referred to the team physician. The athletic trainers review the medical history of each athlete, looking for red flags that may warrant a closer look at the ECG as well. Approximately 90 new Tarleton State University student-athletes were screened during the Fall 2012 pre-participation physical exams (PPEs). All athletes were questioned about past medical history on a medical history questionnaire, which included ten of the recommended 12

cardiovascular questions. Athletic trainers, a clinical exercise physiologist, and medical doctors reviewed the PPEs for red-flags. The athletic trainer for cross-country athletes performed the study and specifically chose to focus on just these athletes. There were 10 total incoming cross-country athletes that were screened during the required PPEs. After reviewing the medical history, four athletes were flagged by the athletic trainer for cardiac concerns due to distinguishing presentation features - 3 males (Cross Country) and 1 female (1 Cross Country). All of the athletes were in their first year of eligibility and the average age of the athletes was 18. A 12-lead electrocardiogram (ECG) was performed on each athlete. It is not uncommon for highly trained athletes, especially endurance athletes, to have cardiac adaptations classified as normal in an athlete compared to a sedentary individual. After reviewing the ECGs of each athlete, the clinical exercise physiologists recognized abnormalities from training induced cardiac adaptations in all ECGs. One of the four also showed right atrial enlargement, which would be typically classified as a non-training induced cardiac abnormality. However, the physician found only training induced abnormalities. The team physician cleared the athlete for competition, stating that the abnormality was training induced. Results The athletic trainer compared how many athletes were flagged from their medical history paper work and how many showed cardiac abnormalities from their ECG. In this study, 40% (4/10) of the incoming cross-country athletes were flagged as having cardiac concerns from their medical history paperwork. Of those 40%, one (25%) had a cardiac abnormality as determined by the exercise physiologist, even though the clearing physician found no such abnormality. The

results of the case study were similar to the data found in current research. Our numbers were a bit off, but we also had a very small sample size. Continuing research should be continued with a larger sample size to allow for more accurate results. In the study performed on the cross-country athletes at Tarleton State University, the abnormal ECG readings included left ventricular hypertrophy (LVH), incomplete right bundle branch block (IRBBB), sinus arrhythmia, and right atrial enlargement (RAE). LVH, IRBBB, and sinus arrhythmia were all found to be normal training induced adaptations, however RAE is typically a non-training induced cardiac abnormality. There were no follow-up costs for the athlete or the university since the team physician cleared the athlete at physicals. The athlete with RAE competed for the complete cross-country season without any issues or complaints related to his cardiac abnormality. In all other cases normal training induced abnormalities did not prevent athletic participation. Conclusion In conclusion, , it should be the responsibility of the athletic trainer at the university or high school level to provide the best care possible in preventing injuries. Included in this task is educating your physicians on updated PPE screening policies. The NCAA mandates that 10 of the 12 AHA guidelines are included on PPEs and that a qualified physician evaluates all athletes (Morse & Funk, 2012). Steps that could be most effective in providing effective cardiac screening are providing physicians with appropriate guidelines on the difference between training induced and abnormal cardiac adaptations. Also, only those physicians with up-to-date training on reading ECGs should be allowed to read the ECGs. To limit the number of falsepositive results, an option could be to only require ECGs for those athletes who are at risk for having a cardiac abnormality based on their medical history questionnaires.

References Asif IM, Drezner JA. Sudden Cardiac Death and Preparticipation Screening: The Debate Continues In Support of Electrocardiogram-Inclusive Preparticipation Screening. Progress in Cardiovascular Diseases. 2012; 54: 445-450. doi: 10.1016/j.pcad.2012.01.001 Drezner JA, Asif IM, Owens DS, et al. Accuracy of ECG interpretation in competitive athletes: the impact of using standardised ECG criteria. Br J Sports Med. 2012. doi: 10.1136/bjsports-2012-090612 Macarie C, Stoian I, Dermengiu D, et al. (2009) The electrocardiographic abnormalties in highly trained athletes compared to the genetic study related to cause of unexpected sudden cardiac death. Journal of Medicine and Life, 2(4), 361-72 Maron BJ, Thompson PD, Ackerman MJ, et al. (2007) Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athlets: 2007 Update: A Scientific Statement from the American Heart Association Council on Nutritions, Physical Activity, and Metabolism: Endorsed by the American College of Cardiology Foudation. Journal of the American Heart Association, 115, 164355 Morse E, Funk, M. Preparticipation screening and prevention of sudden cardiac death in athletes: Implications for primary care. Journal of the American Academy of Nurse Practitioners. 2012; 24: 63-69. doi: 10.1111/j.1745-7599.2011.00694.x O'Connor, D. P., & Knoblauch, M. A. (2010). Electrocardiogram Testing During Athletic Preparticipation Physical Examinations. Journal of Athletic Training, 45(3), 265-272.

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