Preparticipation evaluation: an evidence-based review

To review available evidence establishing the validity of the preparticipation evaluation (PPE) as a method for screening health risk prior to participation in exercise and sport. Specific emphasis was placed on reviewing original research evaluating methods to screen participants for risk of sudden cardiovascular death. Literature on the current state of the PPE as a screening tool for athletic participation was examined.

Electronic databases were searched for articles relating to mass screening for sports participation and sudden cardiac death in athletes published up to January 2004. Databases searched included Medline (OVID Web, 1966-2004), PubMed (1966-2004), Sport Discuss (1975-2004), Current Contents, CISTI Source (1993-2004), Cochrane Database of Systematic Reviews, and EBM Reviews. Additional references from the bibliographies of retrieved articles were also reviewed.

All study designs were retrieved, but only those studying athletes and/or student-athletes under age 36 years were reviewed. Of the original research retrieved, the majority of the articles sought to establish incidence or prevalence of cardiovascular causes of sudden death in athletes or the validity of various screening tools. Original research articles seeking to establish the current use of the PPE in all its various forms were also reviewed. All of the articles selected for review consisted of type II, population-based data.

The initial literature search identified 639 papers. Of these, 310 articles that met the selection criteria were reviewed, and 25 articles were identified as original research directly relating to the PPE. All of these contained type II evidence-population-based clinical studies. The majority of the literature on the PPE consists of type III evidence-case-based opinion papers and position papers from respected authors and sports medicine societies and reports of expert committees. This literature was also reviewed, but only original research relevant to the PPE is reported in this article. The majority of these studies examined cardiovascular diseases and screening procedures.

The 5 studies that assessed the format or effectiveness of the PPE concluded that it was inadequate. The format of the PPE is not standardized and does not consistently address the American Heart Association recommendations for cardiovascular screening history and physical exams. A variety of health care professionals, some without proper training, administer the PPE. The 12 original studies that looked at specific cardiovascular screening techniques were divided on the effectiveness of history, physical examination, electrocardiogram, and echocardiography for detecting cardiovascular risks for sudden death in athletes.

A PPE is required by most sport organizations in America, but research as to its effectiveness is very limited. PPEs have been mandatory in Italy for many years, and we can draw on some the data recorded over this time. Otherwise, very few studies in America or elsewhere have been performed on the PPE process. The research available indicates that the PPE is not implemented adequately or uniformly. An opportunity exists to create a standardized, validated PPE that meets medical standards for quality and provides sensitive, specific screening of potential participants in sport and exercise.