New Guidance Offers Hands-on, Big-Picture Approach to Preparticipation CV Screening

More than a year and a half after the National Collegiate Athletic Association (NCAA) convened a 29-person, multidisciplinary task force to establish guidance on preparticipation screening for cardiovascular disease in college athletes, the final document is seeing the light of day.  

The 13-page document comes less than 6 months after an exhaustive series of 15 scientific statements reviewing cardiovascular abnormalities in competitive athletes was released by the American College of Cardiology (ACC) and the American Heart Association (AHA), and less than a year after the Institute of Medicine (IOM) released its report Strategies to Improve Treatment of Cardiac Arrest: A Time to Act.

Described as an “interassocation consensus statement,” the new paper involved a wide range of professional medical associations, including the American College of Cardiology Sports and Exercise Leadership Council, the American Heart Association, the American Medical Society of Sports Medicine, the American College of Sports Medicine, and a range of others, including academic sports authorities.

“It was not an easy document to put together,” writing group leader Brian Hainline, MD (Sports Science Institute, NCAA, Indianapolis, IN), told TCTMD, citing, in particular, the disparate opinions on preparticipation ECG screening. “I would say it was a major bridge-building effort,” he commented.

The consensus document was published last week the Journal of the American College of Cardiology and will also be published in the British Journal of Sports Medicine and the April issue of the Journal of Athletic Training.

To Look Forward: A Giant Step Back

Unlike the ACC/AHA statements, which Hainline described as dealing with “high-level management concerns” across a range of cardiovascular diseases, he said the aim of the NCAA-led document “wasn’t really to produce a document to guide clinicians on management of the specific issues, but was really to take a giant step back and say, where are we right now to address the whole idea of cardiovascular care? We focus on college student-athletes, but I think there can be a downstream effect for other athletes.”

Sudden cardiac death is the most common nontraumatic cause of death among college students who play sports, with 75% of deaths occurring during sports and exercise, Hainline et al note. “And while the NCAA already mandates participation screening for college sports, there have not been strict definitions of what this should entail or how the information should be used. It is also not mandatory for team physicians to review results.

Preparticipation Evaluation and an Action Plan

There are two main thrusts to the new document, Hainline explained. The first is preparticipation evaluation. This section addresses the purpose of screening; the unknowns; a formal plan for conducting the screen; appropriate communication of finding and follow-up prior to athlete participation; qualifications of team physicians; a screening protocol; interpretation of findings; and management of any identified conditions associated with sudden cardiac death. Several pages of the statement are devoted to reviewing the14-element AHA recommendations for preparticipation screening, in addition to summarizing the evidence—and lack thereof—to support the 12-lead ECG for different underlying conditions and the lack of standardization.

“It is recognized that many member institutions utilize the ECG as part of preparticipation cardiac screening, even though there is no consensus as to the short-and long-term risk/benefit ratio of such an approach,” the document reads.

To TCTMD, Hainline said that the ECG discussions were some of the most contentious of the process. “We looked at why, for example, the NCAA cannot recommend widespread ECG screening for every college athlete in the country,” although some writing-group members are vocal proponents, he reported. Ultimately, the group reached consensus that “at this point of time in 2016, the knowledge base and the infrastructure are inadequate to do that, and so we don't know if there would be an upside or a downside.”

But the document also acknowledges that some institutions are routinely performing ECG screening. “So what we did, which was also an accomplishment, I think, is lay out a protocol to use if indeed you are going to screen using an ECG,” he noted. “So that also is consistent with the ACC/AHA guidelines in saying there may be pockets of places where screening is important and we acknowledge that in document and say, well, if you have the wherewithal and infrastructure, here's the way to do it.”

The second major thrust of the NCAA-convened document focuses on the need for emergency action plans following the appropriate recognition of an event. Hainline et al specify that action plans should be written (and reviewed annually); that appropriate training and communication procedures be in place; that access to defibrillation be swift and easy, with well-maintained devices; and that on-site responders and programs be integrated with the local emergency medical services.

Hainline identified the creation of an action plan as the “low-lying fruit” that every school in the country should have. These plans could also provide is the opportunity for preparticipation screening to “take a step back” and address overall risk factors for cardiovascular disease, beyond those for sudden cardiac death. “That's not uniformly done, and that may save more lives than screening,” he said, “because if you manage risk factors now, then 30 years from now you’re probably minimizing cardiovascular mortality.”

Part of the emergency-action-plan proposal is the creation of regional referral centers that could be used both for preparticipation screening and as resources should an event occur—and advice be required—midseason. It is “not realistic” to put infrastructure in place at every one of the NCAA’s 1,100 schools, some of which are located in very rural areas, Hainline said. Instead, he suggested, regional referral centers could be established that are capable of uploading and sharing data that could potentially offer remote solutions.

A Protracted Process, Impossible to Complete

Asked about the 18 months it took to pull the document together, Hainline noted that passing legislation within the NCAA typically takes longer, often closer to 3 years. Making this an “interassociation” document, he said, allows buy-in from all of the leading authorities to move the process along more swiftly.

That said, the writing group was set back by the need to include both the IOM document and the ACC/AHA recommendations. The IOM report actually came out “the day before I was ready to push the first send button on this published document,” Hainline said. “It was so important that I contacted everyone and said hey, can we rewrite this and put in the IOM report? You can keep doing that forever. There is always something new and emerging. But finally we said, we think we’ve got it and let’s settle with this.”

The number of college athletes dying of sudden cardiac death ranges from one in 43,000 to one in 83,000, the authors point out in the paper. For over 30 years, five to 10 NCAA student-athletes have died each year of sudden cardiac death, and the number of sudden death survivors is unknown.

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