Presentation on theme: "The Preparticipation Physical Exam Jennifer A. Southard, MD, MSc Saint Alphonsus Medical Group Family Medicine and Sports Medicine NP Idaho Fall Conference."— Presentation transcript:
The Preparticipation Physical Exam Jennifer A. Southard, MD, MSc Saint Alphonsus Medical Group Family Medicine and Sports Medicine NP Idaho Fall Conference August 24, 2013
Objectives Discuss purpose and timing of PPEs Give Overview of PPE Review 3 key areas: CV, Ortho, Neuro Identify conditions which warrant further investigation prior to allowing participation Discuss populations of athletes with special considerations Discuss clearing athletes for participation
Purposes of the PPE Objectives of the PPE Primary Objectives 1. Screen for conditions that may be life-threatening or disabling 2. Screen for conditions that may predispose to injury or illness Secondary Objectives 1. Determine general health 2. Serve as an entry point to the healthcare system for adolescents 3. Provide opportunity to initiate discussion on health- related topics
What the PPE is NOT: PPEs should NOT replace routine health care or comprehensive physicals –The PPE is a screening tool to determine fitness for athletic participation –The PPE often takes place in a format which does not allow adequate time for anticipatory guidance –The PPE often takes place in a format which does not provide adequate privacy to discuss confidential issues
Frequency and Timing of the PPE Ideally do PPEs 4-6 weeks before athlete’s season to allow for eval/treatment of problems NFHS: PPE necessary - but leaves to states to mandate & standardize NCAA recommends & most institutions require annual exams Youth / club sports - no formal requirements
Effectiveness of PPE Unknown as to: Effectiveness of PPE as a screening tool –Lack of efficacy data for PPE –Little effect on morbidity & mortality Ability of PPE to affect outcomes Detect risk for catastrophic events
Is the PPE a good screening tool? Significant burden of disease in population Preclinical stage is detectable and prevalent Early detection improves outcome (mortality) with acceptable morbidity Screening tests are acceptable to population, inexpensive, and relatively accurate Effective treatment available for detected disease
Approaches to the PPE Historically: the HHH exam –Hi, how are ya? –Heart –Hernia
Approaches to the PPE Office Based: maximizes privacy, allows single examiner to complete entire exam, but inefficient for large groups of people. Recommended method Locker-Room Approach: allows for one examiner to complete each part of the PPE but is also inefficient for large groups and does not allow for privacy Station-Based: requires multiple examiners, each doing a different part of the exam. Improves efficiency and privacy
The History and Physical AAFP AAP ACSM AMSSM AOSSM
PPE: The History History forms are very helpful –athletes and parents should jointly complete a history form prior to the PPE –Review form: 75% of issues detected through Hx alone Web based history forms may be more convenient for the athletes (ePPE) Preparticipation form recommended by the AAFP, AAP, AMSSM, and AOSSM is available in the Preparticipation Physical Evaluation, 4 th ed
The Cardiovascular History Screening for conditions that predispose to Sudden Cardiac Death Most common cause of SCD in US athletes <30 is HCM
AHA Guidelines Circulation, 2007 Personal History of: –Exertional chest pain –Syncope/near- syncope –Excessive fatigue –Prior murmur –Elevated BP Family history of: –Premature CV Death –CV disease <50yo –Specific conditions (ie Marfans, Long QT, HCM, etc) Maron BJ et al. Circulation 2007;115:
AHA Guidelines A positive finding on >=1 element on history is sufficient to warrant further CV investigation Might include ECG, ECHO, Stress test or referral to cardiology
The Neurologic History At each PPE, athletes should be asked about previous neurologic problems: –Prior concussions –Previous neck injuries –Previous history of stingers/burners –Seizure history –Current neurologic symptoms (numbness, tingling, weakness, etc.) –Current learning/emotional problems
Neurologic History Consider baseline neurocognitive studies in athletes who have a history of: –Multiple concussions –School performance problems –ImPACT testing available to all Boise Public HS students, free, or $15 via STARS
The Musculoskeletal History Complete history of musculoskeletal injuries is important –Operations –Time lost from play –Prior rehab Ongoing musculoskeletal complaints –Require a more complete history –Deserve detailed evaluation
Screening for the Female Athlete Triad All female athletes should be screened for the Female Athlete Triad WHAT MAKES UP THE FEMALE ATHLETE TRIAD???
Provider Knowledge 240 health care professionals (physicians, medical students, physical therapists, athletic trainers and coaches) were surveyed to determine their knowledge and comfort in treating the condition Results –48% of physicians, 43% of therapists, 38% of trainers, 32% of medical students and 8% of coaches could identify all 3 components –Only 9% of physicians felt comfortable treating the disorder Troy K, Hoch A, Stavrakos, J. Awareness and comfort in treating the female athlete triad: are we failing our athletes? Wisconsin Medical Journal. 2006;105(7):
Female Athlete Triad History Not a new entity – various components have been noted for years Not a new entity – various components have been noted for years Defined in 1992 by American College of Sports Medicine Defined in 1992 by American College of Sports Medicine ACSM developed a Position Statement in 1997 ACSM developed a Position Statement in 1997 revised statement in 2007 revised statement in 2007
1997 ACSM Position Statement Syndrome that can develop in physically active girls and women with three interrelated components: Disordered eating Amenorrhea Osteoporosis Otis CL, Drinkwater B, Johnson M, et al. American College of Sports Medicine Position Stand: The female athlete triad. Med Sci Sports Exerc 1997; 29(5): i-ix.
The Female Athlete Triad Today 2007 ACSM Definition (Renamed components) 2007 ACSM Definition (Renamed components) Disordered Eating Disordered Eating Menstrual Dysfunction Menstrual Dysfunction Low Bone Mineral Density (BMD) Low Bone Mineral Density (BMD) Greater emphasis on the full spectrum of behaviors and conditions within a given disorder. Greater emphasis on the full spectrum of behaviors and conditions within a given disorder. The original version focused more on the extreme end point of each disorder. The original version focused more on the extreme end point of each disorder. Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.
Who is at Risk? “Potentially all physically active girls and women could be at risk for developing 1 or more components of the Triad” “Potentially all physically active girls and women could be at risk for developing 1 or more components of the Triad” Sports that emphasize low body weight Sports that emphasize low body weight Subjective scoring of performance (figure skating) Subjective scoring of performance (figure skating) Endurance sports (distance running) Endurance sports (distance running) Body contour-revealing clothing (track, cheerleading, volleyball) Body contour-revealing clothing (track, cheerleading, volleyball) Weight categories (wrestling, horse racing) Weight categories (wrestling, horse racing) Emphasis on prepubertal body habitus (gymnastics) Emphasis on prepubertal body habitus (gymnastics) Male athletes are also at risk for disordered eating and anorexia nervosa Male athletes are also at risk for disordered eating and anorexia nervosa
Prevalence Disordered Eating: 8% - 62% depending on population studied. Disordered Eating: 8% - 62% depending on population studied. More prevalent in sports that emphasize lean physique BUT seen in all sports More prevalent in sports that emphasize lean physique BUT seen in all sports Athletes 2.6x more likely than non-athletes to manifest DE Sx Athletes 2.6x more likely than non-athletes to manifest DE Sx Burckes-Miller et al: Study 695 NCAA Div I athletes Burckes-Miller et al: Study 695 NCAA Div I athletes 3% met criteria for anorexia nervosa 3% met criteria for anorexia nervosa 21% bulemia 21% bulemia Burckes-Miller ME, Black DR. Male and female college athletes: prevalence of anorexia nervosa and bulimia nervosa. Athl Train J Natl Athl Train Assoc. 1988;23:
Prevalence Menstrual Dysfunction: 6% - 79% depending on definitions used in study Menstrual Dysfunction: 6% - 79% depending on definitions used in study Prevalence of secondary amenorrhea in adult female collegiate athletes reported at 14-66% compared to 2-5% of the general population Prevalence of secondary amenorrhea in adult female collegiate athletes reported at 14-66% compared to 2-5% of the general population Low Bone Mineral Density: 22% - 50% (mainly osteopenia) Low Bone Mineral Density: 22% - 50% (mainly osteopenia) Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad. The inter- relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994; 13:
Prevalence of the Triad Only 3 studies have examined all 3 disorders using direct measures of BMD in female athletes (DEXA) The prevalence of all three components simultaneously: 0.4% - 2.2%. Although prevalence small, presence of any of the three should warrant further provider investigation Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.
Etiology In the 1970’s low body weight or low body fat was thought to be the primary cause of amenorrhea Exercise-stress hypothesis Deficit in energy availability
Hypothalamic Dysfunction Disruption of hypothalamic-pituitary- ovarian axis –Decrease in pulsatile GnRH disrupts pituitary secretion of LH and FSH –Disruption of LH and FSH pulsatility shuts down stimulation to the ovary, ceasing production of estradiol
What causes hypothalamic dysfunction? Deficit in energy availability
Energy Availability Dietary energy intake minus exercise energy expenditure OR The amount of dietary energy remaining after exercise training to support physiological processes Loucks A & Nattiv A. The female athlete triad. Lancet 2005; 366:
Disordered Eating Includes a wide spectrum of unhealthy eating behaviors –Skipping meals or limiting calorie intake –Restricting certain foods such as those high in fat or protein –Binge eating or purging –Diet pills, laxatives, diuretics –Anorexia nervosa –Bulimia nervosa
Disordered Eating May be intentional or unintentional –Lose a few pounds before an event –“Inadvertently failing to balance energy expenditures with adequate energy intake”
2007 ACSM Definition: Menstrual Dysfunction Includes the full spectrum of menstrual irregularities. Luteal suppression Anovulation Oligomenorrhea Amenorrhea Primary – redefined by American Society of Reproductive Medicine as absence of menstruation by 15 years of age in girls with secondary sex characteristics Secondary – absence of 3 consecutive cycles Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.
Menstrual Dysfunction Prevalence studies Wide range (2-35%) of prevalence estimates can be explained by methodologic differences among studies differences in athletic populations studied failure to control for OCP use assessment and definition of menstrual dysfunction Despite differences, menstrual dysfunction is more prevalent in sports that emphasize leanness Menstrual dysfunction is NOT a normal part of training! Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.
2007 ACSM Definition: Low Bone Mineral Density Emphasis has been placed on the full spectrum of bone health. Low bone mass Stress fractures Osteoporosis Bone strength is characterized by bone mineral content and density as well as quality of bone Bone quality refers to the process of bone turnover Beals, K & Meyer, N. Female athlete triad update. Clin Sports Med, 2007;26:69-89.
Bone Health Estrogen suppresses osteoclast activity Female athletes have higher BMD than nonathletic counterparts UNLESS they have menstrual dysfunction Bone density declines in proportion to the number of menstrual cycles missed Myburgh and colleagues showed a direct correlation between time spent amenorrheic and number of stress fractures Low bone mineral density may be irreversible resulting in a lifetime lower bone density Multiple studies show irreplaceable bone loss after 3 years amenorrhea Risk of stress fractures is two-four fold higher in athletes with menstrual disturbances compared to those without
Bone Health Females gain more than 50% of skeletal mass during adolescence and reach peak bone mass between 18 and 25 years of age Young women menstrual dysfunction during these years are at risk for losing 2% of bone mass annually instead of gaining 2-4%
Bone Density Consider DEXA for the following: Amenorrheic > one year BMI < 19 Documented history of stress fracture Lo B, Hebert C, McClean A. The female athlete triad, no pain, no gain? Clinical Pediatrics 2003; 42(7)
How Should Athletes be evaluated for the Triad?
Evaluation Options History Questionnaire (easy and effective) All Blood Tests (measure ovarian steroid hormones) High Risk Dual Energy X-ray Absorptiometry (DEXA) High Risk
History Female Athlete Triad Coalition Screening Questionnaire (ACSM and IOC): –12 Questions –Sensitivity 91.5% –Specificity 74.2% –False Positive 25.8 % –False negative 38.5% Black DR, et al. Physiologic Screening Test for Eating Disorders/Disordered Eating Among Female Collegiate Athletes. Journal of Athletic Training. 2003:38; 4;
IHSAA PPE Questions (3/12 similar questions) When was your first menstrual period? When was your last menstrual period? What was the longest time between periods last year?
9 questions not on IHASS PPE Do you worry that you have lost control over how much you eat? Do you make yourself vomit, use diuretics or laxatives after you eat? Do you currently or have you ever suffered from an eating disorder? Do you ever eat in secret? Have you ever had a stress fracture?
9 questions not on IHASS PPE Are you unhappy with your weight? Are you trying to gain or lose weight? Has anyone recommended you change your weight or eating habits? Do you limit or carefully control what you eat?
Laboratory Evaluation CBC, CMP, ESR, Ferritin, VitB12, Folate, UA EKG and/or echocardiogram if abnormal cardiac exam TSH Pregnancy test for amennorhea LH, FSH to rule out premature ovarian failure Prolactin to rule out pituitary tumor Consider imaging If hirsutism, free testosterone, DHEA-S, 17- hydroxy-progesterone to screen for adrenal or ovarian tumors Progesterone Challenge Medroxyprogesterone 5-10 mg for 5-10 days Lo B, Hebert C, McClean A. The female athlete triad, no pain, no gain? Clinical Pediatrics 2003; 42(7)
Treatment Goal Restore reproductive and metabolic hormones by increasing energy availability Increase energy intake Reduce energy expenditure Weight gain of 1-2 kilograms (or 2- 3%) or 10% decrease in exercise load in either duration or intensity is often sufficient to reverse reproductive dysfunction! Loucks A & Nattiv A. The female athlete triad. Lancet 2005; 366:
Treatment Options Educate Correct energy deficit –Increase calories by 10% per week until target is reached. –Decrease activity levels to assist in correcting energy deficit. –Limit weight gain to 1-2 pounds per week
Treatment Options Add Calcium and Vit D supplement Treatment for osteoporosis with bisphosphonates and calcitonin has not been tested in younger patients, nor patients with female athletic triad
Hormone Therapy No published longitudinal studies available on long term benefits of HRT to slow or reverse loss of BMD –Longest studies currently available 60 months –Several good studies show irreplaceable bone loss occurs after three years of amenorrhea Minimal 4-11% BMD increases have been noted in women with hypothalamic amenorrhea on oral contraceptives –increases in BMD of 6-17% have been seen with spontaneous reversal of amenorrhea –Increases slow to 3% following year and plateau at BMD well below normal for age Goodman, L & Warren, M. The female athlete and menstrual function. Adolescent and Pediatric Gynecology. 2005;17(5):
Hormone Replacement Retrospective study of amenorrheic runners compared HRT with placebo over months Combined estrogen and progesterone Pt’s on HRT showed 3.7% increase in BMD Pt’s in control showed decrease of 2.4% BMD In women who have not responded to non- pharmacological treatment, initiate therapy with low-dose oral contraceptive to raise estrogen concentrations and prevent further bone loss Progesterone should be included in any tx regimen to prevent endometrial hyperplasia Cumming DC. Exercise-associated amenorrhea, low bone density, and estrogen replacement therapy. Arch Intern Med 1996; 156:
Treatment of Eating Disorder Depending on severity SSRI may be indicated Avoid bupropion because risk of sz TCAs and MAOIs cold be toxic in underweight pts Consider Cognitive Behavioral Therapy Consider psychiatric evaluation
Treatment of Eating Disorder –Recovery rates vary between 23% and 50%, and relapses range from 4% to 27%. –Even for those who recover, one study indicated that recovery took between four and nearly seven years. –Depending on the duration of the study, anorexic patients have reported death rates ranging from 4% to 25%.
PREVENTION! Educational programs targeting coaches, athletes, parents, athletic trainers, school administrators –Currently there is a lack of such programs Nutrition education –Emphasis should be placed on concept of food as energy for training and recovery rather than on body weight
Resources NCAA Handbook: “Managing the Female Athlete Triad” e4a146e2d0/handbook.pdf e4a146e2d0/handbook.pdf e4a146e2d0/handbook.pdf Academy for Eating Disorders: International Olympic Committee Position Stand on the Female Athlete Triad: Female Athlete Triad Coalition: National Osteoporosis Foundation: National Eating Disorders Association:
Other Important Historical Issues Respiratory- h/o asthma or allergic problems Infectious- h/o HBV, HCV, HIV, EBV Derm- Herpes gladiatorum, current rashes Hematologic- Sickle Cell, bleeding disorders Endo- diabetes Other- prior heat-related illness, sickle trait
The Physical Each PPE should include vitals, examination of HEENT, CV, RESP, ABD, GU (males only), MSK, DERM, and NEURO systems Forms, such as the one published in the Preparticipation Physical Evaluation, 4 th ed., 2010, may be helpful.
The Physical General: Attention for excessive height, Marfanoid appearance Vitals: especially important to check BP. Also Ht, Wt, BMI. Pediatric age and height percentile BP graphs HEENT: Visual acuity, pupils, conjunctivae, lenses, ear exam, oropharyngeal exam If unable to correct to better than or equal to 20/40 in each eye, need further evaluation and eye protection RESP: resp effort, wheezes, crackles, etc. ABD: masses, splenomegaly
The Physical CV: Auscultation, Femoral/Radial pulses, BP, provocative maneuvers for HCM –Systolic Murmur that increases in volume/intensity with Valsalva or with going from supine seated –Murmur of HCM will diminish with squatting or other maneuvers to increase venous return to the heart
Further Eval.: CV Findings Findings requiring further evaluation: –Systolic Murmur that is 3/6 or greater –ANY diastolic murmur –ANY murmur which increases in intensity with Valsalva –Any FH of SCD or predisposing condition (Long QT, Marfans, AVRD, HCM) or worrisome personal hx The Hypertrophic Cardiomyopathy Murmur: –Cres-Decres systolic murmur heard best at LLSB –Increases with maneuvers to decrease venous return (eg Valsalva, lying to standing) –Decreases with maneuvers to increase VR (ie squatting)
The Physical GU (males only): hernia, mass, undescended testicle. Instruction on TSE Derm: Rashes, lesions Neurologic: strength testing incorporated into MSK exam; more extensive evaluation required for pts with neurologic complaints Extremity: arachnodactyly
The Physical The Musculoskeletal Exam: –Asymptomatic pts: General Screening Exam only –Pts with specific complaints: Gen. Screening Exam PLUS a joint specific exam –Sport Specific Exam: consider doing a more complete joint exam for commonly injured joints (Shoulders in swimmers and throwers, Knees in athletes who do cutting maneuvers, etc.)
Beyond the Physical Are more tests necessary? JOHN RUSKIN ( ) “A thing is worth precisely what it can do for you not what you choose to pay for it”
Beyond the Physical: Screening Labs? Screening labs are NOT recommended at routine PPE’s Some sport governing bodies require lab tests for performance enhancing substances NCAA requires sickle trait screening Captive adolescents: should we screen for STIs? –Recent paper in J Adol Health found the following: Males 2.8% + for chlamydia, 0.7% + for gonorrhea Females 6.5% + for chlamydia, 2.0% + for gonorrhea 93.1% of all positives reported NO SYMPTOMS. Nsuami M et al. J Adolesc Health, 2003, p
Beyond the Physical: Screening CV Studies? The Italians: –Since 1982 Italy has screened ALL athletes with PPE, EKG, as well as Stress tests and ECHO’s for Elite/Olympic athletes –2.5% of all athletes screened were disqualified, 51% due to CV probs.
Beyond the Physical: Screening CV Studies? Baseline rate of SCD prior to initiation of screening protocol was 3.6/ After initiation of screening, rate of SCD fell to 0.4/ (89% reduction) Sounds really compelling for routine use of ECGs, right? Corrado D et al. JAMA 2006;296(13):
But Italy is not the USA…
Risk of SCD Now Equivalent in Italy and US Risk of SCD in US is 0.61/ In Italy, the EXCESS risk from SCD (3.6/100000) was related to ARVD By doing EKG/ECHO, the risk to Italian athletes is reduced to a comparable risk that exists in the US Maron BJ et al. Circulation, 2009;119:
Beyond the Physical: Screening CV Studies? Lausanne Recommendations of the European Society of Cardiology, 2006 –Similar screening questions to AHA –Similar physical screening exam to AHA –Adds 12-lead ECG after onset of puberty for all athletes Endorsed by IOC
Beyond the Physical: Screening CV Studies? AHA recommends against cardiovascular screening of asymptomatic athletes with ECG or Echo AHA recommends against cardiovascular screening of asymptomatic athletes with ECG or Echo Not practical for mass, universal screening – Size of athlete cohort (huge) – Prevalence of disease (low) – Limited resources ($$, personnel) –Absence of physician workforce to interpret ECG –Potential to create anxiety with False positive results (morbidity)
Beyond the Physical: Screening CV Studies? Feinstein et al. in 1993 did 1570 ECHOs on asymptomatic athletes, found no conditions which would preclude competition, at a cost of $500/test Epstein and Maron estimated in 1986 that ECHO alone would prevent 1 death per 200,000 athletes, at a total cost of $100,000,000 per life saved
Beyond the Physical: Screening Neurologic Studies? Currently, the NHL, NFL, many colleges, and increasing numbers of high schools require screening neuropsychological testing for athletes involved in contact/collision sports Preseason neuropsych testing allows each individual to provide his/her own control for comparison should a head injury occur during the season ImPACT testing for BPS athletes
Further Eval: Prior Head Trauma Prior concussion is an independent risk factor increasing risk for subsequent concussion Recurrent concussion increases risk for learning, emotional, and cognitive problems In pts with h/o concussion, consider baseline neuropsychological evaluation Consider neuropsych eval in kids with school performance problems (baseline study)
Further Eval: MSK Injuries Findings of new/recent injuries on PPE deserve appropriate evaluation and treatment Findings of inadequately rehabilitated injuries on exam should be followed up for several reasons: –Risk of re-injury or injury to others –Risk of long term complications (arthritis, etc)
Athletes with Special Considerations
Special Populations of Athletes Athletes with Down’s Syndrome Paralympics / Handicapped Athletes Athletes with one-organ or functionally one- organed Athletes s/p transplant Athletes with specific medical problems: bleeding disorders, infectious diseases, etc.
Athlete’s with Trisomy 21 Cardiovascular Abnormalities –50% of children with Down Syndrome have congenital heart disease Hypothyroidism –Occurs in 15% of kids with T-21 –Should be screened annually Atlantoaxial Instability –Should be screened for with flex/ext C-spine films at age 3 years –Required for participation in Special Olympics or contact sports
The Functionally One-Organed Athlete Concern is for damage to the “good” organ: –Ophtho: athletes with one eye or whose best corrected vision is worse than 20/40 Recommend appropriate protective equipment –Renal: athlete’s s/p nephrectomy Recommend appropriate protective equipment –GU: male’s s/p orchiectomy Recommend appropriate protective equipment Bottom Line- we are ALL one-organed athletes competing w/ 1 brain, liver, pancreas, etc.
We’ve Got Clearance, Clarence
Clearing Athletes for Participation 3.1% to 13.9% of athletes are initially not cleared pending further evaluation. Ultimately, 0.3% to 1.3% are denied clearance Options for Clearance: –Cleared without restriction –Cleared, pending evaluation or treatment of a specific problem –Disqualified Letter of clearance/DQ should be reviewed with athlete, athlete should sign release of information form, form should be passed on to coach/trainer
Conditions Which May Require Disqualification
Final Thoughts The PPE is an important skill for all providers to be comfortable with The PPE does not replace routine health care maintenance visits CV, neurologic, and orthopedic abnormalities may require further evaluation prior to clearance Vast majority of athletes screened will be permitted to participate without restriction
Selected References Kurowski K and S Chandran. The preparticipation athletic evaluation. American Family Physician,May p Lyznicki JM et al. Cardiovascular screening of student athletes. American Family Physician,Aug p Preparticipation Physical Evaluation, 4 th ed., 2010 Madden CC and M Putukian. The Preparticipation Physical Evaluation, Team Physician’s Handbook, 3 rd ed., 2002, pp Barrett JR et al. The Preparticipation Physical Evaluation, Care of The Young Athlete, pp Nsuami M et al. Screening for sexually transmitted diseases during preparticipation sports examination of high school adolescents. Journal of Adol Health May 2003, pp
Selected References Maron BJ et al. Cardiovascular Preparticipation Screening of Competitive Athletes. Circulation, Aug 1996, pp Fuller CM. Cost effectiveness analysis of screening of high school athletes for risk of sudden cardiac death. Medicine and Science in Sports and Exercise, 2000, pp Corrado D et al. Screening for hypertrophic cardiomyopathy in young athletes. NEJM 6 Aug 1998, pp Pelliccia A and BJ Maron. Preparticipation cardiovascular evaluation of the competitive athlete: perspectives from the 30 year Italian experience. Am J of Card. 15 April 95, pp
Selected References Maron BJ et al. Sudden Deaths in Young Competitive Athletes, Circulation, 2009:119: Corrado D et al. Trends in Sudden Cardiovascular Death in Young Competitive Athletes After Implementation of a Preparticipation Screening Program. JAMA 2006;296(13): Maron BJ et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes, 2007 Update. Circulation 2007;115: Bille K et al. Sudden cardiac death in athletes: the Lausanne recommendations. European Journal of Cardiovascular prevention and rehabilitation. 2006;13:
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