Matthew J. Mitten

Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007 Update A Scientific Statement From the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: Endorsed by the American College of Cardiology Foundation

Sudden deaths of young competitive athletes are tragic events that continue to have a considerable impact on the lay and medical communities.1–17 These deaths are usually due to a variety of unsuspected cardiovascular diseases and have been reported with increasing frequency in both the United States and Europe.1,5 Such deaths often assume a high public profile because of the youth of the victims and the generally held perception that trained athletes constitute the healthiest segment of society, with the deaths of well-known elite athletes often exaggerating this visibility. These counterintuitive events strike to the core of our sensibilities, periodically galvanizing discussion and action, and in the process raise practical and ethical issues related to detection of the responsible cardiovascular conditions. Preparticipation cardiovascular screening is the systematic practice of medically evaluating large, general populations of athletes before participation in sports for the purpose of identifying (or raising suspicion of) abnormalities that could provoke disease progression or sudden death.13,16 Indeed, identification of the relevant diseases may well prevent some instances of sudden death after temporary or permanent withdrawal from sports or targeted treatment interventions.15,17–21 In addition, the increasing awareness that automated external defibrillators (AEDs) may not always prove successful in the secondary prevention of sudden death for athletes with cardiovascular disease22 underscores the importance of preparticipation screening for the prospective identification of at-risk athletes and the prophylactic prevention of cardiac events during sports by selective disqualification. Although some critics have questioned the effectiveness of cardiovascular screening,23,24 overwhelming support for the principle of this public health initiative exists in both the medical and lay communities.13–16,25 The efficacy of the various athlete screening strategies is not easily resolved in the context of evidence-based investigative medicine. Recently, recommendations of the European Society of Cardiology (ESC)16 and International …

Cardiovascular Preparticipation Screening of Competitive Athletes A Statement for Health Professionals From the Sudden Death Committee (Clinical Cardiology) and Congenital Cardiac Defects Committee (Cardiovascular Disease in the Young), American Heart Association

The sudden death of a competitive athlete is a personal tragedy with great impact on the lay and medical communities.1 Sudden deaths in athletes are usually caused by previously unsuspected cardiovascular disease.2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Such an event often assumes a high public profile because of the generally held perception that trained athletes constitute the healthiest segment of our society. The death of a well-known elite athlete often emphasizes this visibility.1 21 Athletic field catastrophes strike to the core of our sensibilities and often galvanize us. They also inevitably raise a number of practical and ethical issues. This statement is a response to these considerations and represents the consensus of a panel appointed by the American Heart Association Science Advisory and Coordinating Committee. The panel comprised cardiovascular specialists, other physicians with extensive clinical experience with athletes of all ages, and a legal expert. The panel (1) assessed the benefits and limitations of preparticipation screening for early detection of cardiovascular abnormalities in competitive athletes; (2) addressed cost-efficiency and feasibility issues as well as the medical and legal implications of screening; and (3) developed consensus recommendations and guidelines for the most prudent, practical, and effective screening procedures and strategies (the recommendations are listed at the end of this statement). This endeavor seems particularly relevant and timely, given the large number of competitive athletes in this country, recent public health initiatives on physical activity and exercise, and the staging of the 1996 Olympic Games in the United States. The competitive athlete has been described as one who participates in an organized team or individual sport requiring systematic training and regular competition against others while placing a high premium on athletic excellence and achievement.20 The …

Recommendations for Physical Activity and Recreational Sports Participation for Young Patients With Genetic Cardiovascular Diseases

A group of relatively uncommon but important genetic cardiovascular diseases (GCVDs) are associated with increased risk for sudden cardiac death during exercise, including hypertrophic cardiomyopathy, long-QT syndrome, Marfan syndrome, and arrhythmogenic right ventricular cardiomyopathy. These conditions, characterized by diverse phenotypic expression and genetic substrates, account for a substantial proportion of unexpected and usually arrhythmia-based fatal events during adolescence and young adulthood. Guidelines are in place governing eligibility and disqualification criteria for competitive athletes with these GCVDs (eg, Bethesda Conference No. 26 and its update as Bethesda Conference No. 36 in 2005). However, similar systematic recommendations for the much larger population of patients with GCVD who are not trained athletes, but nevertheless wish to participate in any of a variety of recreational physical activities and sports, have not been available. The practicing clinician is frequently confronted with the dilemma of designing noncompetitive exercise programs for athletes with GCVD after disqualification from competition, as well as for those patients with such conditions who do not aspire to organized sports. Indeed, many asymptomatic (or mildly symptomatic) patients with GCVD desire a physically active lifestyle with participation in recreational and leisure-time activities to take advantage of the many documented benefits of exercise. However, to date, no reference document has been available for ascertaining which types of physical activity could be regarded as either prudent or inadvisable in these subgroups of patients. Therefore, given this clear and present need, this American Heart Association consensus document was constituted, based largely on the experience and insights of the expert panel, to offer recommendations governing recreational exercise for patients with known GCVDs.

Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age) A Scientific Statement From the American Heart Association and the American College of Cardiology

TheAmericanCollegeof C follows:MaronBJ, Friedm BR,OkinPM, Saul JP, Salb GP, Bolling SF,MittenMJ, Clinical Cardiology, Advocacy Coordinating Committee, Council on Cardiovascular Disease in the Young, Council on Cardiovascular Surgery and Anesthesia, Council on Epidemiology and Prevention, Council on Functional Genomics and Translational Biology, Council on Quality of Care and Outcomes Research, and American College of Cardiology

Assessment of the 12-Lead Electrocardiogram as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12-25 Years of Age)

Sudden death (SD) of young people because of a variety of complex, predominantly genetic/congenital cardiovascular diseases is a riveting, devastating event and a public health and policy issue of increasing concern.1–6 The reliable identification of such individuals at risk for SD has become a major focus of the cardiovascular community for a number of reasons, including the opportunity to reduce SD events through selective disqualification from sports7 and the primary prevention of SD with the implantable cardioverter-defibrillator for some high-risk patients with genetic heart diseases.8–14 In addition, those SDs caused by underlying and unsuspected genetic or congenital cardiovascular diseases that occur in young trained athletes are a highly visible issue and have become a concern in both the public arena and the physician community.15–17 Consequently, the desire to screen populations theoretically at risk for cardiovascular disease to reduce morbidity and mortality is understandable in principle, and few would empirically argue against the potential benefit of this practice for some individuals. However, a debate has emerged regarding whether the conditions responsible for these tragic events can be detected effectively in populations of various sizes by the available testing and examination techniques, and specifically, there is debate concerning which strategies are potentially the most reliable to separate those individuals with disease from those who are probably unaffected.15–29 Most of this dialogue concerning SD prevention has been limited to the screening of young populations of competitive athletes, and the available data specifically related to cardiovascular screening efficacy (on which we largely and unavoidably rely) overwhelmingly come from such populations exclusively composed of trained athletes. Periodically, this has become a polarized controversy and public health debate, triggering a large and growing body of literature, including clinical studies… but notably also an …

Cardiovascular Preparticipation Screening of Competitive Athletes: Addendum An Addendum to a Statement for Health Professionals From the Sudden Death Committee (Council on Clinical Cardiology) and the Congenital Cardiac Defects Committee (Council on Cardiovascular Disease in the Young), American Heart Association

In 1996 the American Heart Association published a scientific statement on screening for cardiovascular abnormalities in young athletes participating in organized sports programs in US high schools and colleges. “Cardiovascular Preparticipation Screening of Competitive Athletes” ( Circulation. 1996;94:850–856) served as a critique of current and past screening practices and offered several specific recommendations for future screening endeavors, including the content of history and physical examination questionnaires, the nature and qualifications of designated examiners, and the timing of preparticipation examinations. This statement has become a well-known guideline endorsed by other medical and exercise science organizations. However, the recommendation for timing of preparticipation evaluations has become the source of some discussion. In the original statement, the writing group recommended that …

Return-to-Play Decisions: Are They the Team Physician's Responsibility?

Objective:Return-to-play (RTP) decisions are a central component of the Team Physicians clinical work, yet there is little more than anecdotal reference to these in the literature. We recently published a 3-step model for return-to-play medical decision making and, in the current paper, undertook a systematic review of the literature to determine the level of evidence in support of this model. Data Sources:PubMed, Web of Science, and CINAHL electronic databases. Any article specifically related to concussion, head injuries, neck injuries, illness, medical conditions (including cardiovascular and renal), and preparticipation in sport or that reported RTP as a clinical outcome was excluded. Any article that contained a discussion on one of the components of the 3-step decision-based RTP model was included. Results:We reviewed 148 articles that met the criteria for inclusion and found 98 review articles, 39 original articles, 6 case reports, and 5 editorials. Of these, 141 articles mentioned Step 1 of the medical decision-making process for RTP (Medical Factors), 26 mentioned Step 2 (Sport Risk Modifiers), and 20 mentioned Step 3 (Decision Modifiers). Of the 148 articles in total, only 13 focused on RTP as the main subject and the remaining 135 mentioned RTP anecdotally. Of these 13 articles, 5 were reviews, 4 were editorials, and 4 were original research. Conclusions:Although 148 articles we retrieved mention RTP in relation to a specific injury, medical condition, or specific topic, only 13 articles focused specifically on the RTP decision-making process, and 6 of 13 were restricted to Step 1 of the 3-step model (Medical Factors). Return-to-play is a fertile field for research and thought leadership beginning with a focus on the Team Physicians appropriate role in RTP decision making, particularly considering the factors identified in Step 3 (Decision Modification).

Criminal consequences of commotio cordis

A lthough first described over 120 years ago, 1 sudden cardiac death resulting from blunt, nonpenetrating chest blows to the anterior chest (precordium) unassociated with structural injury to the ribs, sternum, or heart, or preexisting cardiac disease (commotio cordis) has achieved a measure of public and medical recognition only within the past 5 years. These catastrophic events have been most prominently chronicled when occurring in organized or recreational sports settings, most commonly youth baseball. However, it is now evident that commotio cordis events occur as part of routine day-to-day living and arise in a variety of circumstances unrelated to sporting activities. Recently, several such cases of commotio cordis have entered the criminal justice system as the subject of prosecution for murder. It is our view that an analysis of those cases and their judicial outcomes relative to the evolving scientific knowledge of commotio cordis will be valuable in enhancing the understanding among the medical and legal communities (as well as the public at large) regarding sudden death resulting from blunt chest blows. It is possible that misconceptions within the criminal justice system have occasionally led to inappropriate legal consequences and results almost as tragic as the commotio cordis event itself. We believe that much of the responsibility to impart knowledge regarding commotio cordis into the justice system resides within the physician community. For all of these reasons, it is necessary to reexamine such cases so that commotio cordis is viewed in its proper context, thereby, possibly avoiding future unwarranted criminal homicide prosecutions.

‘Sports Law’: Implications for the Development of International, Comparative, and National Law and Global Dispute Resolution

In this Article, we observe that legal regulation of national and international sports competition has become extremely complex and has entered a new era, which provides fertile ground for the creation and evolution of broader legal jurisprudence with potentially widespread influence and application. Our principal aim is to draw these developments to the attention of legal scholars and attorneys not necessarily familiar with sports law. Specifically, the evolving law of sports is having a significant influence on the development of international and national laws, is establishing a body of substantive legal doctrine ripe for analysis from a comparative law perspective, and has important implications for global dispute resolution. For example, the global processes used to establish an international sports antidoping code and to resolve a broad range of Olympic and international sports disputes (which is rapidly creating a body of global private law) provide paradigms of international cooperation and global lawmaking. In addition, judicial resolution of sports-related cases may develop jurisprudence with new applications and influence. Our objective is to generate greater awareness of the importance of sports, not only as a worldwide cultural phenomenon and a significant part of the twenty-first-century global economy, but as a rich source of international and national public and private laws that provide models for establishing, implementing, and enforcing global legal norms.

Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 15: Legal Aspects of Medical Eligibility and Disqualification Recommendations A Scientific Statement From the American Heart Association and American College of Cardiology

From a legal perspective and medical perspective, protection of the health and safety of an athlete (as well as that of others potentially endangered by his or her participation) and avoidance of exposure to a significant risk of sudden cardiac death during competitive athletics should be the