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
Barry J. Maron, MD, Chair; Paul D. Thompson, MD, FAHA, Co-Chair;
Michael J. Ackerman, MD, PhD; Gary Balady, MD, FAHA; Stuart Berger, MD; David Cohen, MD;
Robert Dimeff, MD; Pamela S. Douglas, MD, FAHA; David W. Glover, MD;
Adolph M. Hutter, Jr, MD, FAHA; Michael D. Krauss, MD; Martin S. Maron, MD;
Matthew J. Mitten, JD; William O. Roberts, MD; James C. Puffer, MD
lay and medical communities.1–17These 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.1,5Such 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 coun-
terintuitive 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.13,16Indeed,
identification of the relevant diseases may well prevent some
instances of sudden death after temporary or permanent
withdrawal from sports or targeted treatment interven-
tions.15,17–21In addition, the increasing awareness that auto-
mated external defibrillators (AEDs) may not always prove
successful in the secondary prevention of sudden death for
udden deaths of young competitive athletes are tragic
events that continue to have a considerable impact on the
athletes with cardiovascular disease22underscores the impor-
tance of preparticipation screening for the prospective iden-
tification 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,23,24overwhelming support for the
principle of this public health initiative exists in both the
medical and lay communities.13–16,25The 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)16and International Olympic Committee
(IOC)26,27have triggered a new debate regarding the most
appropriate strategy for screening trained athletes and other
sports participants. Indeed, issues related to the methodology
and justification for preparticipation screening, including use
of the 12-lead electrocardiogram (ECG), have become a
complex area of debate.
The present document is largely a response to these recent
considerations and developments and represents the consen-
sus of a number of cardiovascular and other specialists with
extensive clinical experience and expertise related to athletes
of all ages, as well as a sports medicine legal expert. The
panel addressed the benefits and limitations of the screening
process for early detection of cardiovascular abnormalities in
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside
relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required
to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.
This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on January 3, 2007. A single reprint
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© 2007 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.orgDOI: 10.1161/CIRCULATIONAHA.107.181423
AHA Scientific Statement
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competitive athletes, cost-effectiveness, feasibility issues, and
relevant medical-legal implications. The results of these
deliberations constitute the consensus recommendations and
guidelines presented here, which we believe outline the most
prudent, practical, and effective screening strategies for
competitive athletes in the United States. This update of the
1996 American Heart Association (AHA) preparticipation
screening scientific statement1310 years later seems particu-
larly relevant and timely given the large number of compet-
itive athletes in this country; the continuing (if not acceler-
ating) interest in the problem of athletic field deaths; recent
public health initiatives on physical activity, exercise, and
screening; and the rapidly approaching 2008 Beijing Olympic
Definitions and Background
The present discussion focuses on the competitive athlete,
defined as one who participates in an organized team or
individual sport that requires systematic training and regular
competition against others and places a high premium on
athletic excellence and achievement. This definition includes
organized and sanctioned sports (interscholastic: middle
school and high school), college sports (intercollegiate and
club sports, but exclusive of intramural competition), and
professional sports, which are examined separately.
The purpose of preparticipation screening (as described
here) is to provide potential participants with a determination
of medical eligibility for competitive sports that is based on
evaluations intended to identify (or raise suspicion of) clini-
cally relevant, preexisting abnormalities. Although this
screening process traditionally involves the evaluation of
many organ systems, the focus here is on cardiovascular
disease. The principal objective of screening is to reduce the
cardiovascular risks associated with organized sports and
enhance the safety of athletic participation; however, raising
the suspicion of a cardiac abnormality on a standard screen-
ing examination is only the first tier of recognition, after
which subspecialty referral for further diagnostic testing is
When a definitive diagnosis of heart disease is made, the
consensus panel guidelines of Bethesda Conference No.
3615,20,28may be used to formulate recommendations for
either continued participation or disqualification (temporary
or permanent) from competitive athletics. For those young
athletes with genetic heart disease who are disqualified from
competitive sports, recommendations for recreational athletic
activities and normal lifestyle are available.29
The guidelines advanced in the present document focus
primarily on the mass screening of high school and collegiate
student-athletes of all races and both genders. However, these
recommendations may also apply to athletes in youth (?12
years of age) or masters (?30 years of age) sports,30as well
as to clinical assessments in other venues, such as individuals
or small groups of athletes evaluated primarily in office
practice settings by personal or team physicians. Prepartici-
pation screening of a single athlete (or small groups) by
personal physicians also requires a standard history and
physical examination but may be much more likely to include
noninvasive testing. A limitation attached to medical evalu-
ations performed only for athlete screening purposes is the
lack of insurance carrier reimbursements for such examina-
tions. It is also understood that the standard preparticipation
screening examination extends beyond considerations for
cardiovascular disease and involves numerous other medical
issues and organ systems.
The present AHA recommendations and the importance
attributed to screening are predicated on the likelihood that
intense athletic training and competition act as a trigger to
increase the risk for sudden cardiac death or disease progres-
sion in susceptible athletes with underlying heart disease
(although quantification of that risk remains elusive).1,6,8,9,16
Indeed, the vast majority of young athletes who die suddenly
of cardiovascular disease do so during sports training or
competition, and a relationship has been drawn between
intense physical activity and arrhythmia-based sudden
death.1,6,8,16This risk of sudden death, however, appears to be
independent of the level of athletic competition (ie, high
school, college, or professional). Finally, early detection of
clinically significant cardiovascular disease through prepar-
ticipation screening13,16will, in some cases, permit timely
therapeutic interventions that may alter clinical course and
significantly prolong life.18,19For example, high-risk individ-
uals with genetic heart disease may be eligible for prophy-
lactic implantable cardioverter-defibrillators or other thera-
Causes of Sudden Death in Athletes
A variety of cardiovascular diseases represent the most
common causes of sudden death in young athletes.1,4,6,8The
vast majority of these deaths in US athletes ?35 years of age
are due to several congenital or acquired cardiac malforma-
(HCM)32is the single most common cause of athlete deaths
(responsible for approximately one third of the cases), fol-
lowed by congenital coronary artery anomalies, particularly
those of wrong aortic sinus origin.11Several other cardiovas-
cular diseases account for ?5% or less of these deaths in
athletes. In the United States, these deaths occur most
commonly in basketball and football, sports that have the
highest levels of participation and also involve particularly
intense levels of physical activity.1,4,6
The older athlete population (more than approximately 35
to 40 years of age) presents a different demographic profile,
with participation commonly in individual sports such as
long-distance and road racing (including the marathon).33,34
The vast majority of deaths in middle-aged athletes are due to
unsuspected atherosclerotic coronary artery disease.33,34
Because this document focuses on the cardiovascular
evaluation of athletes, other related medical problems that
may also cause sudden death in such individuals are not
considered here. These conditions include heat stroke, cere-
bral aneurysm, bronchial asthma, nonpenetrating blunt chest
blows (commotio cordis),35and sickle-cell trait, as well as
nutritional supplements and illicit drugs.
Prevalence and Scope of the Problem
Relevant to the design of any screening strategy is the fact
that sudden cardiac death in athletes is an infrequent event
March 27, 2007
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KEY WORDS: AHA Scientific Statement ? death, sudden ? exercise
?prevention ? automated external defibrillators ? electrocardiography ?
cardiomyopathy ? genetics
Maron et al Preparticipation CV Screening for Competitive Athletes
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Krauss, Martin S. Maron, Matthew J. Mitten, William O. Roberts and James C. Puffer
Cohen, Robert Dimeff, Pamela S. Douglas, David W. Glover, Adolph M. Hutter, Jr, Michael D.
Barry J. Maron, Paul D. Thompson, Michael J. Ackerman, Gary Balady, Stuart Berger, David
and Metabolism: Endorsed by the American College of Cardiology Foundation
Statement From the American Heart Association Council on Nutrition, Physical Activity,
Cardiovascular Abnormalities in Competitive Athletes: 2007 Update: A Scientific
Recommendations and Considerations Related to Preparticipation Screening for
Print ISSN: 0009-7322. Online ISSN: 1524-4539
Copyright © 2007 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
2007;115:1643-1655; originally published online March 12, 2007;
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