International Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO


July 10, 2018

In This Article

Cardiac Screening in Young Patients

British Society of Echocardiography and Cardiac Risk in the Young

These guidelines are aimed at providing guidance for the use of echocardiography in screening young athletes (ages 14–35 years) for inherited and congenital cardiac disease.

Following a detailed questionnaire (including any symptoms or family history) and brief examination, the 12-lead electrocardiogram (ECG) should be the primary investigation. The ECG should be interpreted in accordance with international consensus guidelines. Those with 2 or more borderline ECG findings or any abnormal ECG findings require further investigation.

In the case of an ECG-only screening, transthoracic echocardiography (TTE) is recommended as a second-line investigation in those athletes with an abnormal ECG, cardiovascular symptoms, abnormal physical examination findings, or a family history of sudden death under the age of 40 years.

When screening patients for inherited cardiac disease due to a family history, the referring physician or echocardiographer should establish the patient’s level of physical activity. The total volume of training can be defined as (volume = intensity × duration) or Metabolic Equivalent Test (MET-h/week = METS × duration). Low-intensity exercise is defined as corresponding to 1.8–2.9 METS; moderate intensity is defined as corresponding to 3–6 METS; and high intensity is defined as >6 METS.

The aim of the TTE is to differentiate physiologic adaptation from pathologic abnormality where possible.

Sex: Cardiac chamber dimensions in female athletes rarely fall outside of the established normal range. If they do, further investigation is required. It is more common for male athletes to demonstrate a degree of eccentric remodeling of all cardiac chambers.

Age: Highly trained junior athletes still develop cardiac remodeling in response to physiologic conditioning, but this is often at a lower magnitude than in senior athletes.

Ethnicity: LV and RV cavity sizes are similar between African/Afro-Caribbean and white athletes; however, wall thicknesses and LA size are often larger in the African/Afro-Caribbean athlete. Any wall thickness measurement with a value greater than 13 mm in white male athletes (or greater than 11 mm in white female athletes) or greater than 15 mm in African/Afro-Caribbean male athletes (or 13 mm in African/Afro-Caribbean females) requires further investigation.

Body surface area: The relationship between body size and chamber dimensions is well established, and therefore all chamber dimensions should be indexed for body surface area. That aside, cardiac adaptation to exercise involves eccentric hypertrophy beyond what may be attributable to body composition alone. In the extremes of height and weight (body surface area [BSA] >2.3 m2), non-indexed LV wall thickness and diastolic diameter should not exceed 15 mm and 65 mm, respectively.

Symptoms: A positive history—including exertional chest pain, syncope or near-syncope, irregular heartbeat or palpitations, shortness of breath or fatigue, and in particular exertional symptoms—should direct the echocardiographer to closely assess for potential causes of sudden cardiac death (SCD). Symptoms are non-specific, and therefore it is important to ensure that all possible causes are excluded.

It is important to be aware that exertional chest pain may direct further evaluation for coronary anomalies, while syncope may be related to arrhythmogenic substrate such as arrhythmogenic right ventricular cardiomyopathy (ARVC) or hypertrophic cardiomyopathy (HCM) or to outflow obstruction.

ECG changes: The type of ECG changes that are present on an athlete’s ECG will further guide the focus of the examination. For example, T-wave inversion in leads V1–V3 is one of the hallmarks of ARVC and should lead to a more focused assessment of the right heart, whereas inferolateral T-wave inversion is more frequently present in HCM and should prompt a detailed LV assessment.

LV geometry should be determined using a combination of LV mass indexed to body surface area (left ventricular mass index; LVMI) and relative wall thickness (RWT). LVMI is calculated as per BSE guidelines, and RWT is calculated by summating septal and posterior wall thickness in diastole and dividing into the LV diastolic cavity dimension. LV geometry can be reported as normal (normal RWT and normal LVMI), concentric remodeling (increased RWT with normal LVMI), concentric hypertrophy (increased RWT and increased LVMI), or eccentric hypertrophy (normal RWT with increased LVMI) according to published criteria.


  • Oxborough D, Augustine D, Gati S, et al. A guideline update for the practice of echocardiography in the cardiac screening of sports participants: a joint policy statement from the British Society of Echocardiography and Cardiac Risk in the Young. Echo Res Pract. 2018 Mar;5(1):G1-G10.


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