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 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 are rarely seen in younger individuals. While most recommendations are empirical and must be dynamic as knowledge grows, testing techniques improve and the SARS-CoV-2 possibly mutates, expert groups have recommended the strategy shown in Figure 1. A similar guideline from the British Journal of Sportsmedicine includes ambulatory ECG monitoring in certain categories. 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 electrocardiography testing looking for repolarization changes associated with viral induced myopericarditis are not presently suggested in asymptomatic individuals. Note also that at this time the benefits of exercise far outweigh the risk of exercise-induced cardio-pulmonary damage in the young. These recommendations as to follow up testing may need to be adjusted for the setting which ranges from grade school to college and professional teams. The latter have the financial resources to do repeated viral swabs and cardiac testing and have the responsibility to do so since their athletes are accepting a higher risk than amateur athletes motivated by profits. Our committee promulgates these recommendations with the caveat that it be acknowledged that those individuals who need further testing and/or have limitations of activity who do not have medical insurance or adequate finances need to be subsidized.

Figure 1. Current Recommendations for Competitive Athletes and Highly Active People for Cardiac Testing and Exercise Limitations during the Covid-19 Pandemic


Figure 1 used by permission.

Enlarge Figure 1
 

Legend:

COVID-19 = coronavirus disease 2019
hsTn = high-sensitivity troponin I
RTP = return to play
a. Typical testing obtained via a nasopharyngeal swab. All athletes with positive testing should be isolated for 2 weeks regardless of symptoms.
b. If clinical and/or cardiac symptoms develop, follow appropriate clinical pathway.
c. The ACC/AHA athlete myocarditis guidelines are recommended. Some prefer the term “physical distancing” rather than “social distancing”.

Citations:

Dermot Phelan, MD, PhD1; Jonathan H. Kim, MD, MSc2; Eugene H. Chung, MD, MSc3 JAMA Cardiol.
Published online May 13, 2020. doi:10.1001/jamacardio.2020.2136

Resumption of Institutional Sports

Multiple organizations such as the National College Health Association 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. 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 anecdotal at this time (see links to two newspaper articles below). However, chest pain, fatigue and DOE appears to occur in 20% of non-athletes. The pathology (fibrosis, inflammation and thrombosis) of damage to the heart and lungs has been demonstrated but their time course and severity are uncertain. Also it is not known to what degree exercise training can exacerbate the damage caused by the pathogen. At this time recommendations are empirical and firm guidelines require more data.

We do not have good data from athletes yet but the following study in non-athletes raises concerns. It is known that pericarditis and myocarditis can occur long after SARS-CoV-2 infection. A cohort of 139 health-care workers with confirmed past COVID (103 diagnosed by RT-PCR and 36 by serology) were studied. Participants underwent PE, ECG, lab tests including immune cell profiling and cardiac MRI. At examination 10 1/2 weeks after symptoms, all participants were hemodynamically stable. Chest pain, dyspnea or palpitations were observed in 58 (42%) participants; EKG changes in 69 (50%); NT-pro-BNP was elevated in 11 (8%); troponin in 1 (1%); and cardiac MRI abnormalities in 104 (75%).The prevalence of pericarditis or myocarditis was high in both test groups 43% vs 31%. Pericarditis and myocarditis can occur months after COVID infection, even in presently asymptomatic, non-athletic subjects. Such studies need to be confirmed in athletes. https://www.medrxiv.org/content/10.1101/2020.07.12.20151316v1


These two articles from the lay press provide important balance to the current state of knowledge.

https://www.theatlantic.com/health/archive/2020/09/covid-19-heart-pandemic-coronavirus-myocarditis/616420/

https://www.latimes.com/opinion/story/2020-09-17/covid-wave-heart-disease

These are two news reports of young athletes who have died after recuperating from COVID-19:

https://www.cbsnews.com/news/michael-ojo-former-florida-state-center-dies-age-27/

https://sports.yahoo.com/cal-u-of-pa-player-jamain-stephens-jr-died-from-a-blood-clot-in-his-heart-after-contracting-covid-19-174117554.html
 

References

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

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2. To raise the awareness of Exercise Health to the Californians thereby reducing and preventing Cardiovascular related morbidity and mortality.

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