Does the School Physical prevent sudden death?

It is during this time of year that I see a lot of children and adolescents for pre-participation school physicals.  In the United States pre-participation physicals are mandated for most school athletes. This means that a lot of children are visiting their PCP or going to an urgent care to get a physical performed. 

One of the primary reasons for the pre-participation physical is to detect cardiovascular disease and thereby decrease the incidence of sudden cardiac death in athletes. But has the school physical actually been shown to decrease the incidence of sudden cardiac death?

It might surprise you that there is very little data and no randomized trials on the impact screening programs have on the incidence of sudden cardiac death (SCD) in athletes. Much of the rationale for these physicals is based on observational data or expert opinion. While the data does seem to demonstrate improved outcomes with screening, the absolute benefit (based on the overall low event rates) is small.

For example in one analysis of 134 cases of sudden cardiac death in high school and college athletes in the United States, cardiovascular abnormalities were suspected by standard history and physical examination in only 3 percent. This means that the vast majority of athletes that died suddenly had a normal physical exam.

In another series from a Italian co-hort who underwent routine pre-participation screening that included an ECG, the prevalence of markedly abnormal ECG patterns suggestive of significant structural heart disease was <5 percent.

There are little data that evaluate the efficacy of screening programs on outcomes. The only positive data come from an observational study from Italy (where athletic screening has been mandatory since 1982) in which all SCD in athletic and nonathletic populations between the years 1979 and 2004 was recorded, with the annual incidence of SCD in athletes decreasing from 3.6/100,000 person-years in 1979 to 1980 to 0.4/100,000 person-years in 2003 to 2004 (89 percent reduction). Notably, there was no change in the incidence of SCD among non-athletes over the same time period.

While I am not advocating that these screening programs be stopped or that you should not screen your child for cardiovascular disease it is important to realize that these exams will not decrease the risk of sudden cardiac death to zero. ​