Sports Exams and Young Athletes: Medicolegal Considerations

According to Mitten,(24) an attorney at the National Sports Law Institute, a physician can deviate from the guidelines when medical factors justify it, but he or she should document the reasons for this deviation. Courts generally will not enforce waivers of legal rights to release physicians from liability for negligent care. Such a waiver is legally unenforceable because it creates an incentive for physicians to avoid complying with their legal duty to adhere to accepted medical practice.

Both the Americans with Disabilities Act of 1990 and the Rehabilitation Act of 1973 prohibit unjustified discrimination against people who have physical deformities or impairments. These acts form the foundation of the legal argument against disallowing an athlete's participation on the basis of a doctor's evaluation. The legal framework in this area is still developing, but several decisions seem to support a physician's right to exclude athletes with conditions that expose them to an increased risk of significant harm (eg, Knapp v Northwestern, 1995).(25)

Avoiding Charges of Sexual Harassment
Because most preparticipation physical examinations will be done without an ongoing doctor- patient relationship, it is important that the physician inform the athlete beforehand that the exam will be thorough. Consistency with the examination and clothing is imperative. We suggest that male athletes be instructed to wear shorts and a T-shirt and that female athletes wear shorts and a jogging bra.

'Good Samaritan' Laws
Some states give physicians who do not charge fees for performing preparticipation physical examinations protection under this statute. However, the protection does not apply if the physician receives compensation.

Does Screening Prevent Cardiovascular Death?
There are no prospective studies of whether the preparticipation physical examination, if performed according to the two sets of recommendations, (2,3) effectively screens out cardiovascular conditions that predispose to sudden death. If the national guidelines were followed, perhaps the rate of sports-related cardiac sudden death would decline. However, there is not much reason to believe screening would be completely effective.

In fact, the AHA(3) states that screening by history-taking and physical examination alone (without noninvasive testing) is insufficient to guarantee detection of many critical cardiovascular abnormalities in large populations of young athletes.

They go on to say that detection of hypertrophic cardiomyopathy by standard screening is unreliable because 75% of patients have the nonobstructive form of the disease, which is characterized by a soft murmur or none at all. Furthermore, most athletes with hypertrophic cardiomyopathy do not experience syncope and do not have a family history of premature sudden death due to the disease.

The standard physical examination has a low specificity for detecting many cardiovascular abnormalities that lead to sudden cardiac death in young athletes, particularly those associated with symptoms such as chest pain or impaired consciousness. Across the broad disease spectrum of hypertrophic cardiomyopathy, the physical examination may not be a reliable method for clinical identification, given that most patients do not have left ventricular tract outflow obstruction and most of the well-documented physical findings (eg, loud systolic heart murmur, bifid arterial pulse) are limited to patients with outflow tract gradients.(26)

Neither is the history very sensitive. Maron et al(27) found that only 25% of athletes with hypertrophic cardiomyopathy who died of sudden cardiac death had a family history of one or more nontraumatic familial deaths at age 50 or younger.

In another study, Maron et al(28) retrospectively reviewed 158 sudden deaths in young athletes from 1985 through 1995. They found that 134 had a cardiac cause of death, 48 due to hypertrophic cardiomyopathy. In these 48 athletes, symptoms and history provided a clue to the ultimate diagnosis in only 20%. In the same study, 13 athletes died from an anomalous left main coronary artery; only 4 (31%) had symptoms (usually syncope or dizziness).

The ability to detect severe cardiac disease that might lead to death is only marginally improved by the addition of noninvasive testing. In one study in which electrocardiography did not detect more potentially fatal cardiac conditions, Fuller et al(29) added electrocardiography to the prospective screening of 5,615 high school athletes. Twenty-two athletes were determined to have serious conditions as defined by the 16th Bethesda Conference. A serious condition is one that requires further evaluation with testing, such as echocardiography; it does not necessarily mean that the condition leads to sudden cardiac death.

In the Fuller study,(29) taking a cardiac history led to detection of a serious condition in no athletes; 6 received a diagnosis after physical examination (one auscultation, five blood pressure measurements), and 16 were identified by electrocardiography (5 with premature ventricular beats, 6 with ventricular preexcitation, 4 with right bundle-branch block, and 1 with supraventricular tachycardia). The athlete with supraventricular tachycardia received ablation and was able to return to participation. The other 15 athletes identified with rhythms that needed further evaluation were not assessed further as part of the study. One athlete who was allowed to participate after normal history, physical examination, and electrocardiogram later had a ventricular fibrillation arrest due to an anomalous right coronary artery. Of the 22 athletes withheld, none had conditions that predisposed to sudden cardiac death during exercise. Thus, in this screening study, 22 athletes were withheld because of conditions not commonly associated with sudden cardiac death, and 1 athlete had an undetected condition that commonly is associated with sudden cardiac death in young athletes.

In a much larger study,(30) more extensive testing lead to a decrease in the death rate due to hypertrophic cardiomyopathy. Corrado et al30 screened 33,735 young athletes from 1979 to 1996 using history, physical examination, and electrocardiography. They documented 49 sudden deaths in athletes and 240 sudden deaths in a nonathletic control group during the same period. Hypertrophic cardiomyopathy was detected in 22 athletes (0.07%) during preparticipation physical examination screening and accounted for 3.5% of the cardiovascular reasons for disqualification. None of the disqualified athletes with hypertrophic cardiomyopathy died during the mean followup of 8.25 years. Hypertrophic cardiomyopathy caused one sudden cardiac death among the athletes (2%) but caused 16 cardiac deaths in the nonathletes (7.3%). Using extensive screening and vigorous follow-up, they were able to decrease the death rate from hypertrophic cardiomyopathy.

Interestingly, in the North American studies, the most common causes of death in athletes were hypertrophic cardiomyopathy (36%), coronary artery anomalies (19%), and idiopathic left ventricular hypertrophy (10%).(27) In the study by Corrado et al,(30) which took place in Italy, the most common causes of sudden death in athletes were arrhythmogenic right ventricular cardiomyopathy (22.4%), coronary atherosclerosis (18.4%), and anomalous origin of a coronary artery (12.2%). The reason for this regional variation is unclear.

Several objections are often made to using electrocardiography and echocardiography as screening tools. One objection is that electrocardiography is sensitive but not specific and thus may lead to false-positive results. Evidence of this can be found in a study by Pelliccia et al,31 who evaluated 1,005 world-class athletes (785 in routine yearly screening and 220 for suspected cardiovascular abnormalities) using history, physical examination, electrocardiography, and follow-up echocardiography when indicated. They found that 40% had abnormal electrocardiograms (14% had distinctly abnormal electrocardiograms and 26% had mildly abnormal ones) indicative of physiologic cardiac remodeling. Potentially lethal disorders were detected in only five athletes with abnormal electrocardiograms, and abnormalities of any level were documented in only 5% of those with abnormal electrocardiograms. Of note, females usually had normal or virtually normal electrocardiograms.

The investigators concluded that an important subset of their population without cardiac morphologic alterations had striking electrocardiographic abnormalities highly suggestive of cardiac disease that were likely an innocent consequence of athletic training and part of "athlete's heart syndrome." Such falsepositive results, the investigators concluded, may limit routine electrocardiographic testing as part of the preparticipation physical examination. However, normal electrocardiographic results were highly predictive of an absence of cardiovascular abnormalities.(31)

Maron et al(32) screened 591 Division 1 college athletes using histories, physical examinations, and electrocardiograms. They identified 90 athletes who required additional evaluation: 24 because of an abnormal physical examination, 13 because of abnormal history, and 65 because of an abnormal electrocardiogram. Upon examination, they found that none of the athletes had serious cardiac disease on echocardiography. The investigators found 15 cases of hemodynamically insignificant mitral valve prolapse and 3 cases of septal thickening without other features of hypertrophic cardiomyopathy.

Electrocardiography did not add diagnostic power and added only to false-positive results. In fact, none of the elements of the examination documented any potentially dangerous lesions.

Because they have low specificity, abnormal electrocardiograms would necessitate a large number of additional and even more expensive tests, such as echocardiography. By increasing the sensitivity of screening, more false-positive results would be anticipated, along with more testing and the associated expense. Such screening would be impractical and costly for schools, especially when considering that cardiovascular deaths occur among high school athletes at an estimated frequency of only 1 in 200,000.(26) If the occurrence of hypertrophic cardiomyopathy in a young athletic population is assumed to be 1 in 500, even at $500 per echocardiogram, it would theoretically cost $250,000 to detect even one previously undiagnosed case.(3)

Currently, the AHA does not recommend routine electrocardiography or echocardiography in preparticipation physical examination screening of athletes. While aware of its limitations, the association recommends the preparticipation physical examination as the most cost-effective strategy for screening athletes for cardiovascular disease.(3)

Death of Athletes is Rare
Van Camp et al(6) studied the frequency and causes of nontraumatic sports deaths in high school and college athletes in the United States through the National Center for Catastrophic Sports Injury Research. From 1983 to 1993, nontraumatic sports deaths were reported in 126 high school athletes and 34 college athletes. Estimated death rates were 7.47 per million male athletes and 1.33 per million female athletes.

Maron et al(33) found a similarly low rate when they examined sudden death due to cardiovascular disease in Minnesota high school athletes. From 1985 to 1997, there were 1,453,280 overall sports participations and 651,695 student participants. There were three sudden cardiac deaths in this group. The calculated risk for sudden cardiac death was 1 per 500,000 participants and 1 per 217,400 participants per academic year. Over the 3- year student athlete high school career, the estimated risk was 1 in 72,500.(33)