Does cardiovascular preparticipation screening cause psychological distress in athletes? A systematic review

OBJECTIVE

To evaluate the psychological implications of cardiovascular preparticipation screening (PPS) in athletes.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, PubMed, CINAHL, SPORTDiscus, APA PsycInfo, Cochrane Library and grey literature sources.

STUDY ELIGIBILITY CRITERIA

Observational and experimental studies assessing a population of athletes who participated in a cardiovascular PPS protocol, where psychological outcomes before, during and/or after PPS were reported.

METHODS

Results of included studies were synthesised by consolidating similar study-reported measures for key psychological outcomes before, during and/or after screening. Summary measures (medians, ranges) were computed across studies for each psychological outcome.

RESULTS

A total of eight studies were included in this review (median sample size: 479). Study cohorts consisted of high school, collegiate, professional and recreational athletes (medians: 59% male, 20.5 years). Most athletes reported positive reactions to screening and would recommend it to others (range 88%-100%, five studies). Increased psychological distress was mainly reported among athletes detected with pathological cardiac conditions and true-positive screening results. In comparison, athletes with false-positive screening results still reported an increased feeling of safety while participating in sport and were satisfied with PPS. A universal conclusion across all studies was that most athletes did not experience psychological distress before, during or after PPS, regardless of the screening modality used or accuracy of results.

CONCLUSION

Psychological distress associated with PPS in athletes is rare and limited to athletes with true-positive findings. To mitigate downstream consequences in athletes who experience psychological distress, appropriate interventions and resources should be accessible prior to the screening procedure.

PROSPERO REGISTRATION NUMBER

CRD42021272887.

Masters Athlete Screening Study (MASS): Insights Into the Psychological Impact of Cardiovascular Preparticipation Screening

OBJECTIVE

To determine the psychological impact of a cardiovascular disease (CVD) diagnosis identified during preparticipation screening (PPS) of masters athletes.

DESIGN

Cross-sectional study.

SETTING

Masters athletes diagnosed with CVD through the Masters Athletes Screening Study.

PARTICIPANTS

Sixty-seven athletes (89.6% male, mean age at diagnosis 60.1 ± 7.1 years, range 40-76) with diagnoses of coronary artery disease (CAD) (73.1%), high premature ventricular contraction burden (9.0%), mitral valve prolapse (7.5%), atrial fibrillation (AF) (3.0%), bicuspid aortic valve (3.0%), aortic dilatation (1.5%), coronary anomaly (1.5%), and rheumatic heart disease (1.5%). Three participants had multiple diagnoses.

INTERVENTION

Online survey distributed to masters athletes identified with CVD.

MAIN OUTCOME MEASURES

Assessment of psychological distress [Impact of Event Scale-Revised (IES-R)], perceptions of screening, and preferred support by CVD type.

RESULTS

The median total IES-R and subscale scores were within the normal range {median [interquartile range (IQR)] total 2.0 [0-6.0]; intrusion 1.0 [0-3.0]; avoidance 0 [0-3.0]; hyperarousal 0 [0-1.0]}. Athletes with bicuspid aortic valve [20.5 (IQR, 4.0-37.0)], AF [7.0 (IQR, 0-14.0)], and severe CAD [5.5 (IQR, 1.0-12.0)] had the highest total IES-R scores. One individual with bicuspid aortic valve reported a significant stress reaction. Ten athletes (14.9%) had scores >12. Ninety-three percent of athletes were satisfied having undergone PPS. Preferred type of support varied by cardiovascular diagnosis.

CONCLUSIONS

The majority of masters athletes diagnosed with CVD through PPS do not experience significant levels of psychological distress. Athletes diagnosed with more severe types of CVD should be monitored for psychological distress. Support should be provided through a multidisciplinary and individualized approach.

Professional footballers have a limited understanding of the precompetition medical assessment and the possible outcomes including disqualification: a cross-sectional survey

Objectives

To determine professional footballers’ level of understanding of the purpose of the precompetition medical assessment (PCMA) and to evaluate their knowledge of potential outcomes following a PCMA, including disqualification.

Methods

Professional footballers from the Australasian A-League and Westfield W-League were asked to complete a 25-question survey. The relationship between dichotomised outcomes and explanatory variables was analysed with multivariate logistic regression; p<0.05 was considered statistically significant.

Results

A total of 212 players participated (response rate=48.8%). Most respondents selected ‘To detect medical conditions that may affect performance’ and ‘To detect current injuries’ (n=137, 64.6%; n=130, 61.3%) as the purpose of a PCMA. Approximately one-third (n=74, 38.1%) were neutral or believed that a normal PCMA prevented cardiac arrest. Receiving more PCMAs (p<0.0003) and receiving an explanation during their PCMA (p=0.0175) led to greater awareness of the assessment’s limitations. Most participants did not know the definitions of syncope (n=181, 93.3%) or Marfan syndrome (n=183, 94.3%). Fifty players (28.1%) did not know that disqualification was a possible outcome of a PCMA, and younger players were less aware of this possible outcome (p=0.0216).

Conclusion

Professional footballers appear to have a limited understanding of the purpose of a PCMA, emphasising the musculoskeletal system and performance. They also appear unfamiliar with the components of the PCMA and medical terms. Finally, many are unaware that disqualification can result from an abnormal PCMA. Player health knowledge must be improved; the informed consent process appears an ideal time to provide this education.

Impact of exercise addiction on attitude to preparticipation evaluation and adherence to medical prescription

AIMS

Identification of silent cardiovascular diseases by preparticipation evaluation (PPE) and disqualification from competitive sports have the potential to prevent sudden death but may induce adverse psychological consequences, particularly for exercise addicted athletes. We investigated the relationship between exercise addiction, attitude towards PPE and reaction to cardiovascular disease diagnosis.

METHODS

We invited Italian competitive athletes to participate in an online questionnaire investigating exercise addiction, opinion about mandatory PPE and potential reaction to both sports disqualification and hypothetical diagnosis of different cardiovascular diseases.

RESULTS

The survey was completed by 1011 athletes (75% men, median age 30 years) encompassing a wide range of sports disciplines and competition levels. According to the 'Exercise Dependence Scale-21', 6% were classified as exercise addicted. The vast majority of both exercise addicted and nonexercise addicted athletes agreed that PPE should be mandatory (92 and 96%, P = 0.17) and that the eligibility decision should be left to the sports medicine physician (82 and 89%, P = 0.08). In case a cardiovascular disease is identified, a higher proportion of exercise addicted athletes would undergo 'open-heart' surgery if this would allow resuming high-intensity sport (54 versus 31%, P < 0.001) and would continue exercising in case of diagnosis of a disease at risk of sudden death (57 versus 32%, P < 0.001).

CONCLUSION

Exercise addiction does not interfere with a general positive opinion about PPE, but is likely to impact on the adherence to medical prescription should a cardiovascular diagnosis be made. Exercise addiction should be taken into account when counselling athletes with newly diagnosed heart diseases.

Sudden cardiac death in football players: Towards a new pre-participation algorithm

Athletic pre-participation screening is essential for minimizing the risk for sudden cardiac death (SCD) in athletes participating in either competitive or leisure sporting activities. The primary causes of SCD in young athletes (<35 years of age) include hypertrophic cardiomyopathy, congenital anomalies of the coronary artery and arrhythmogenic right ventricular cardiomyopathy. Other abnormalities, such as malignant arrhythmia due to blunt trauma to the chest (commotio cordis), myocarditis, valvular disease, aortic rupture (in Marfan syndrome) and ion channelopathies (catecholaminergic polymorphic ventricular tachycardia, Brugada syndrome, long or short QT syndrome), also contribute to a lesser degree to SCD. Currently, clinical assessment, electrocardiogram (ECG) and echocardiography are the cornerstones of the pre-participation athletic evaluation. However, their low sensitivity raises queries as regards the need for the application of more sophisticated modalities, such as cardiovascular magnetic resonance (CMR). CMR offers precise biventricular assessment and is greatly reproducible without the inherent limitations of echocardiography; i.e., low quality of images due to the lack of appropriate acoustic window or operator's experience. Furthermore, myocardium replacement fibrosis, indicative of patients' increased risk for future cardiac events, can be effectively detected by late gadolinium enhanced (LGE) images, acquired 15 min post-contrast injection. Finally, diffuse myocardial fibrosis not identified by LGE, can also be detected by pre-contrast (native) T1, post-contrast T1 mapping and extracellular volume images, which provide detailed information about the underlying pathophysiologic background. Therefore, CMR is recommended in all football players with a positive family or personal history of syncope or SCD, abnormal/doubtful ECG or echocardiogram.

No psychological distress in sportsmen aged 45 years and older after cardiovascular screening, including cardiac CT: The Measuring Athlete's Risk of Cardiovascular events (MARC) study

Background

Psychological distress caused by cardiovascular pre-participation screening (PPS) may be a reason not to implement a PPS program. We assessed the psychological impact of PPS, including cardiac computed tomography (CT), in 318 asymptomatic sportsmen aged ≥45 years.

Methods

Coronary artery disease (CAD) was defined as a coronary artery calcium score ≥100 Agatson units and/or ≥50% luminal stenosis on contrast-enhanced cardiac CT. Psychological impact was measured with the Impact of Event Scale (IES) (seven items) on a six-point scale (grade 0–5). A sum score ≥19 indicates clinically relevant psychological distress. A Likert scale was used to assess overall experiences and impact on sports and lifestyle.

Results

A total of 275 participants (86.5% response rate, 95% CI 83–90%) with a mean age of 54.5 ± 6.4 years completed the questionnaires, 48 (17.5%, 95% CI 13–22%) of whom had CAD. The median IES score was 1 (IQR 0–2, [0–23]). IES was slightly higher in those with CAD (mean rank 175 vs. 130, p < 0.001). One participant (with CAD) experienced clinically relevant psychological distress (IES = 23). Participants reported numerous benefits, including feeling safer exercising (58.6%, 95% CI 53–65%) and positive lifestyle changes, especially in those with CAD (17.2 vs. 52.1%, p < 0.001). The majority were satisfied with their participation (93.8%, 95% CI 91–97%).

Conclusion

Cardiovascular PPS, including cardiac CT, causes no relevant psychological distress in older sportsmen. Psychological distress should not be a reason to forego screening in sportsmen.

Electronic supplementary material

The online version of this article (doi: 10.1007/s12471-017-0948-5) contains supplementary material, which is available to authorized users.

The Psychological Impact of Cardiovascular Screening in Young Athletes: Perspectives Across Age, Race, and Gender

OBJECTIVE

To determine the psychological impact of electrocardiogram (ECG) screening in young competitive athletes based on age, race, and gender.

DESIGN

Prospective multisite cross-sectional investigation.

SETTING

Young competitive athletes.

PATIENTS

One thousand five hundred six high school athletes (59.3% male with a mean age of 15.5 years, 56.2% white, 24.5% African American).

INDEPENDENT VARIABLES

Athletes underwent screening with a standardized American Heart Association-based history, physical examination, and ECG.

MAIN OUTCOME MEASURES

Prescreen and postscreen validated assessments for health attitudes, anxiety, and impact of screening on sport.

RESULTS

Of the athletes participated, 76.3% had normal screens, 22.7% false-positive (FP) results (12.9% history, 4.2% examination, 3.1% ECG), and 0.9% were diagnosed with serious cardiac disorders. There were no differences in anxiety levels among athletes screening normal versus FP (P = 0.69). There was no difference in anxiety based on the reason for a FP result (history, physical examination, or ECG) both during (P = 0.95) and after (P = 0.40) screening. Analysis by age, race, and gender demonstrated that before screening, females were more likely to prefer knowing about underlying cardiac conditions compared with males (P < 0.001), and males were less concerned about having cardiac disease (P < 0.001) compared with females. African Americans were less concerned about underlying disease (P < 0.001) and less interested (P < 0.001) in cardiac screening compared with whites. Athletes diagnosed with a cardiac disease described anxiety after screening, but still believe that all athletes should receive an ECG before competition.

CONCLUSIONS

Electrocardiogram screening does not cause excessive anxiety in US high school athletes across spectrums of age, race, and gender. Recognition of age, race, and gender-specific perspectives could improve physician-patient dialogue and support mechanisms for those diagnosed with potentially lethal cardiac disorders.

CLINICAL RELEVANCE

This article provides evidence that undue anxiety should not be used as an argument against the implementation of ECG screening during the preparticipation examinaton for young athletes. Although males and African Americans seem to be at highest risk for sudden cardiac death during exercise, they actually report being the least concerned and least worried about potentially harboring an underlying condition that might predispose them to such an event. Emotional support should readily be available for athletes who are diagnosed with cardiovascular conditions as these individuals report emotional distress after their diagnosis.

Family acceptability of school-based echocardiographic screening for rheumatic heart disease in a high-risk population in New Zealand

AIM

Echocardiographic screening for rheumatic heart disease has been piloted in high-risk areas in New Zealand and internationally, and fulfils most of the criteria for a targeted screening programme. The question of acceptability of rheumatic heart disease screening has not been assessed, and the aim of our study was to assess parental acceptability of a school-based echocardiographic screening programme in a high-risk population in New Zealand.

METHODS

A post-screening questionnaire was developed to survey parents of children who underwent echocardiographic screening. The families of 34 children with abnormal scan results and a sample of 80 children with normal scan results were surveyed by phone within 4 months of screening.

RESULTS

Positive results were seen in all survey questions in both normal and abnormal scan groups. All families were supportive of an ongoing screening programme. Of children with abnormal results, 62% of their parents reported that they would treat their child differently; however, all responses were positive health-promoting outcomes.

CONCLUSION

The study showed strong positive support for school-based echocardiographic screening by a community with high acute rheumatic fever incidence. The study did not detect any short-term negative effects in those with abnormal results. The survey result shows family and community support for the establishment of echocardiographic screening programmes in high acute rheumatic fever areas provided there is adequate infrastructural support.

Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review

Sudden cardiac death (SCD) in young competitive athletes (<35 years old) is a tragic event that has been brought to public attention in the past few decades. The incidence of SCD is reported to be 1-2/100,000 per year, with athletes at a 2.5 times higher risk. Soccer is the most popular sport in the world, played by people of all ages. However, unfortunately it is cardiovascular diseases such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy that have subtly missed screening and claimed the lives of soccer stars such as Marc Vivien Foe and Antonio Puerta during live action on the field and on an internationally televised stage. This paper covers the physiological demands of soccer and the relationship between soccer and SCD. It also reviews the most common causes of SCD in young athletes, discusses the current guidelines in place by The Fédération Internationale de Football Association (FIFA) for screening among professional soccer players, and the precautions that have been put in place to prevent SCD on the field in professional soccer.

Family-based associations in measures of psychological distress and quality of life in a cardiac screening clinic for inheritable cardiac diseases: a cross-sectional study

BACKGROUND

Family-based cardiac screening programmes for persons at risk for genetic cardiac diseases are now recommended. However, the psychological wellbeing and health related quality of life (QoL) of such screened patients is poorly understood, especially in younger patients. We sought to examine wellbeing and QoL in a representative group of adults aged 16 and over in a dedicated family cardiac screening clinic.

METHODS

Prospective survey of consecutive consenting patients attending a cardiac screening clinic, over a 12 month period. Data were collected using two health measurement tools: the Short Form 12 (version 2) and the Hospital Anxiety and Depression Scale (HADS), along with baseline demographic and screening visit-related data. The HADS and SF-12v.2 outcomes were compared by age group. Associations with a higher HADS score were examined using logistic regression, with multi-level modelling used to account for the family-based structure of the data.

RESULTS

There was a study response rate of 86.6%, with n=334 patients providing valid HADS data (valid response rate 79.5%), and data on n=316 retained for analysis. One-fifth of patients were aged under 25 (n=61). Younger patients were less likely than older to describe significant depression on their HADS scale (p<0.0001), although there were overall no difference between the prevalence of a significant HADS score between the younger and older age groups (18.0% vs 20.0%, p=0.73). Significant positive associates of a higher HADS score were having lower educational attainment, being single or separated, and being closely related to the family proband. Between-family variance in anxiety and depression scores was greater than within-family variance.

CONCLUSIONS

High levels of anxiety were seen amongst patients attending a family-based cardiac screening clinic.Younger patients also had high rates of clinically significant anxiety. Higher levels of anxiety and depression tends to run in families, and this has implications for family screening and intervention programmes.