Preparticipation Evaluation of the Athlete Heart:
Questionnaire and Resources

Introduction to Questionnaire and Videos for the Athlete


Why should you be concerned with answering these scary questions? Sure, heart problems and their complications including death are rare in young athletes. But what if the causes of these conditions and their complications were known and we knew their warning signs? Your parents, relatives and coaches would like you to be able to play sports safely. Modern medicine has made tools available for screening and treating heart conditions so why not take advantage of them? The first step in doing so is to watch these videos and answer these questions as best you can. Studies have shown us that they can be clues for recognizing the first signs of heart conditions. Your answers to these questions will be summarized for you to take to your annual screening for participation in organized sports with some suggestions for your doctor or organization to consider prior to sports participation. Even if you don’t have any of these symptoms now, you now know that if they ever occur they should be reported. Please share this resource with your teammates.



Athlete Cardiovascular Risk Video Questionnaire

Print out this form and watch the videos before entering your answer
Videos are courtesy of the University of Texas Southwestern Medical Center (Dr. Benjamin Levine).
Cardiovascular Risk Questionnaire [View, Download, Print PDF]

1.

Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?

Watch Video, then check appropriate response on printed questionnaire.



2.

Have you ever passed out or nearly passed out DURING exercise?

Watch Video, then check appropriate response on printed questionnaire.



3.

Do you ever get so out of breath that you can't continue to exercise even though your peers aren't tired yet?

Watch Video, then check appropriate response on printed questionnaire.



4.

Have you ever felt like your heart was racing, fluttering, or beating abnormally?

Watch Video, then check appropriate response on printed questionnaire.



5.

Have you ever seen a doctor for a heart problem before?

Check appropriate response on printed questionnaire.
6.

Has a doctor ever ordered testing for your heart, such as an EKG/ECG, x-ray, Echocardiogram, MRI or an exercise stress test?

Check appropriate response on printed questionnaire.
7.

Has a doctor ever told you not to play sports before?

Check appropriate response on printed questionnaire.
8.

Have you ever had an unexplained seizure?

Check appropriate response on printed questionnaire.
9.

Do you take any performance supplements or energy drinks?

Check appropriate response on printed questionnaire.

Suggestions for the Physician Performing the PPE

For the Physician [Can be Viewed, Downloaded, and Printed as a PDF]

Athlete COVID-19 Risk Questionnaire

Since we are in a Pandemic, your Pre Participation exam ( PPE) must include questions regarding whether you have had COVID-19 or been exposed. The SARS-Coronavirus-2 (COVID-19) infection can cause damage to your heart (myopericarditis) even if you’ve only had minor exposure and not had any complaints or symptoms. Screening for active or prior infection, with appropriate work up could prevent life threatening consequences during or after physical activity. Please complete this questionnaire and give it to your Doctor, coach or trainer.

Print out this form and enter your answer
Covid Questionnaire for Young Athletes [View, Download, Print PDF]

Pre Participation Exam (PPE) Screening

The PPE is widely advocated for all youth athletes engaged in competitive sports. This year, in order to screen for the possible consequences of COVID-19, all athletes should undergo a PPE that assesses current or past symptoms of the SARS-Coronavirus-2. Testing to exclude significant cardiopulmonary disease should be based on the algorithms provided below. Most organizations suggest individual screening by a qualified clinician ( or trainer ) who has an available cardiology ( or sports medicine ) consultant. Mass screenings would require extreme precautionary measures in order to maintain physical distancing. All screening should follow guidelines outlined by the California Department of Public Health, including cleaning of equipment (eg., ECG machines and wires to electrodes). Among athletes with definite or possible prior infection, the use of adjunctive testing including electrocardiography, cardiac biomarkers, non-invasive imaging, and exercise testing represent appropriate options for more definitive risk stratification as outlined in the presented algorithms. History of new cardiac symptoms is extremely important and may be difficult to distinguish from deconditioning which can be due to sheltering in place. Importantly, myopericarditis related to COVID-19 should be considered in athletes with a history of new onset chest pain/pressure (even in the absence of fever and respiratory symptoms), palpitations, exercise intolerance, and/or resting or exercise related excessive tachycardia. Comprehensive clinical evaluation, regardless of ECG findings, is indicated in athletes with new onset cardiovascular symptoms or exercise intolerance. COVID-19 affected myocardial tissue can promote cardiac arrhythmias, and a major aim of the PPE is to identify those at risk for cardiac arrhythmias. At Stanford, an inexpensive ECG patch that can be automatically interpreted for PVC burden in clinic is being evaluated for this purpose in athletes recuperating from COVID-19.

Current Recommendations for Cardiac Evaluation during the Covid-19 Pandemic

There is understandable concern regarding intensifying cardiac evaluation and revising exercise recommendations during this pandemic because of the cardiac complications noted in severe cases of Covid-19. This remains a concern even though severe cases of Covid-19 are rarely seen in younger individuals since cardiac complications can occur months after even mild or asymptomatic cases. Recommendations are empirical and must be dynamic as knowledge grows and testing techniques improve. The latest recommendation (October 2020) was commissioned by the ACC Council on Sports Cardiology who chose America’s most active and experienced Sports Cardiologists and Sports Medicine specialists with cardiology knowledge to develop the document. The recommendation has been published in a peer reviewed journal and is available as a ACC webex video. The recommendations are specific for High School athletes (Figure 1), College and Professional athletes (Adults, Figure 2) and Master athletes (Figure 3). The experts also recommended adapted criteria for Myocarditis (Table 1). They presented specific cautions regarding the use of Magnetic Resonance Imaging (MRI) until pathological changes can be differentiated from those due to exercise training. The risk level of symptoms is provided in Table 2.. As you will see, these experts have observed that cardiovascular consequences of Covid-19 are relatively mild and so when compared to initial recommendations at the beginning of the pandemic, they have lessened indications for cardiac testing prior to return to play.

It is assumed that the sport and exercise are performed consistent with current physical distancing, appropriate hygienic measures and face mask guidelines. Note that routine testing for the virus using a resting ECG looking for the repolarization changes associated with myopericarditis are not included at this time. Age and severity of illness have been emphasized and should be taken into account when considering cardiovascular diagnostics. Note also that at this time the benefits of exercise far outweigh the risk of exercise-induced cardio-pulmonary damage in the young. Our committee promulgates these recommendations with the caveat that they may be superseded by other guidelines as new knowledge comes available.

The pathology (fibrosis, inflammation and thrombosis) of damage to the heart and lungs has been demonstrated but their time course and severity are uncertain but appear to be mild in athletes. Also it is not certain to what degree exercise training can exacerbate the damage caused by the pathogen but the experience so far is that this appears to be minor as well.

Table 1. Adapted Criteria for Myocarditis

Myocarditis (Probable Acute Myocarditis With Both of the Following Criteria)

1. Clinical syndrome, including acute heart failure, angina-type chest pain, or known myopericarditis of less than 3 months’ duration.

2. Otherwise unexplained increase in serum troponin levels, ECG repolarization abnormalities, arrhythmias or high-grade atrioventricular block, abnormal ventricular wall motion, or pericardial effusion. Additional cardiac MRI findings that suggest myocarditis.

Sports Eligibility Myocarditis Recommendations

1. Before returning to sports, athletes diagnosed with a clinical syndrome consistent with myocarditis should undergo a resting echocardiogram, ambulatory ECG monitoring, and an exercise test no less than 3 to 6 mo after the illness.

2. It is reasonable that athletes can resume training and/or competition if all of the following criteria are met:

    A. Ventricular systolic function has normalized.
    B. Serum markers of myocardial injury, heart failure, and inflammation have returned to normal levels.
    C. Clinically relevant arrhythmias are absent.

Table 2. Risk levels of Symptoms

1. Mild Symptoms

include anosmia, ageusia, headache, mild fatigue, mild upper respiratory tract illness, and mild gastrointestinal illness;

2. Moderate Symptoms

include persistent fever, chills, myalgias, lethargy, dyspnea, and chest tightness;

3. Severe Symptoms

include dyspnea, exercise intolerance, chest tightness, dizziness, syncope, and palpitations which often require hospitalization.

Figure 1. Coronavirus Disease 2019 (COVID-19) Return-to-Play Algorithm for Athletes in Competitive High School Sports




Figure 1 used by permission.

Enlarge Figure 1
 

This is the currently recommended algorithm (Oct 2020) for high school athletes with confirmed COVID-19. Note that among the cardiovascular (CV) symptoms, syncope of unclear cause identifies individuals who definitely require advanced CV testing, including cardiac magnetic resonance (CMR) imaging, exercise testing, and ambulatory ECG monitoring. Typical initial testing is obtained via a nasopharyngeal swab and polymerase chain assay for conserved regions of severe acute respiratory syndrome coronavirus–2 RNA. Multisystem inflammatory syndrome in children (MIS-C) involves fever, rash, abdominal pain, vomiting, diarrhea, lethargy, and conjunctivitis, possibly developing weeks after infection. The guidelines for RTP after myocarditis is indicated in Table 1.
 

Legend:

CDC - US Centers for Disease Control and Prevention; ECG, 12-lead ECG/EKG; echo, echocardiogram; hs-cTn, high-sensitivity cardiac troponin-I; RTP, return to play.

Figure 2. Coronavirus Disease 2019 (COVID-19) Return-to-Play Algorithm for Collegiate and Professional Athletes in Competitive Sports




Figure 2 used by permission.

Enlarge Figure 2
 

This is the currently recommended algorithm (Oct 2020) for all college and professional athletes with confirmed COVID-19. Note that among the cardiovascular (CV) symptoms, syncope of unclear cause identifies individuals who definitely require advanced CV testing, including CMR imaging, exercise testing, and extended rhythm monitoring. (see comments and legend for Table 1).

Figure 3. Coronavirus Disease 2019 (COVID-19) Return-to-Play Algorithm for Recreational Masters Athletes




Figure 3 used by permission.

Enlarge Figure 3
 

This is the currently recommended algorithm (Oct 2020) for all athletes at the masters level with confirmed COVID-19. Cardiovascular disease (CVD) risk factors include hypertension, coronary artery disease, atrial fibrillation, and diabetes. (see comments and legend for Table 1).

Resumption of Institutional Sports

Multiple organizations have produced guidelines for the resumption of sport. During this time, we would like to emphasize the importance of trainers and coaches frequently communicating with athletes about symptoms and involving the medical staff when necessary. Additionally, preparedness with a rehearsed strategy, including an AED use, for potential cardiac events should be enacted even before training commences. Most of the information regarding the prevalence and severity of cardio-pulmonary sequelae in athletes who have survived COVID-19 is limited but our experience is growing rapidly.
 

References

 Additional Resources and References [View, Download, Print PDF]

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