Keywords: Collegiate athletes, preparticipation evaluation, cardiovascular screening, electrocardiogram (ECG), sudden cardiac death

Background

Preparticipation cardiovascular screening of athletes has long been a core tenet of the sports medicine physician’s role. While its importance is clear, the optimal approach remains debated—this blog summarizes our recent meta-analysis of NCAA athletes and explores why our findings may prompt a rethinking of the current screening paradigm (1).

Why is this study important?

Preparticipation cardiovascular screening is a cornerstone of athlete care, aimed at identifying conditions associated with sudden cardiac arrest and death (SCA/D). This is critical given sudden cardiac arrest is the most common cause of exercise-associated fatality in athletes (2). Historically, the history and physical exam (H&P) have been the foundation of the pre-participation screening process, largely due to its accessibility and low cost. However, research has repeatedly shown that H&P performs poorly in identifying conditions associated with SCA/D, particularly when compared to electrocardiogram (ECG) screening using athlete-specific interpretation criteria (3, 4). Despite this research there is a lack of consensus on the optimal preparticipation screening strategy for cardiovascular conditions predisposing athletes to SCA/D. 

To address this gap, our study comprehensively evaluated all studies existing in the literature that examined the outcomes of preparticipation cardiovascular screening of NCAA athletes. We also used a novel analysis to address the following important question: What additional value does the H&P provide when an ECG is already normal?

This question is highly relevant for clinicians balancing early detection, false positives, and downstream testing—all within time-pressured clinical environments.

How did the study go about this?

We performed a systematic review and meta-analysis of 27,891 NCAA athletes, comparing the diagnostic performance of ECG screening versus H&P alone for detecting cardiovascular conditions associated with SCA/D.

We specifically evaluated:

• Detection rates (true positives) 
• False-positive rates 
• Number needed to screen (NNS) 

Importantly, we also examined the added value of the H&P in detecting these conditions among athletes with a normal ECG.

What did the study find?

The results highlight a clear difference in performance between screening strategies.

First, ECG outperformed H&P alone:

• ECG screening resulted in a 3.5-fold higher detection rate of true positive cases 
• NNS: 475 (ECG) vs 1661 (H&P) 
• False positives: 5% (ECG) vs 17% (H&P) 

In other words, ECG was both more sensitive and more specific than H&P alone.

The most striking finding, however, emerged when focusing on athletes with a normal ECG.

In this group:

• The added diagnostic yield of the H&P was extremely low 
• The NNS to detect one true positive was 3,003 
• The false-positive rate remained high at 21–25% 

This means that in athletes with a normal ECG, the H&P generated substantial “noise” (false positives) with minimal “signal” (true disease detection).

What are the key take-home points?

1. ECG substantially improves screening performance
   Compared to H&P alone, ECG identifies more clinically relevant disease while producing fewer false positives.
2. The incremental value of H&P after a normal ECG is minimal
   In athletes with a normal ECG, the H&P rarely identifies additional true cases of disease associated with SCA/D.
3. False positives from H&P are not benign
   A 21–25% false-positive rate can lead to:

• Unnecessary downstream testing 
• Increased healthcare costs 
• Athlete anxiety and potential restriction from sport 

4. This challenges how we interpret symptoms in screening settings
   Clinicians frequently encounter vague or nonspecific cardiovascular symptoms (e.g., shortness of breath, palpitations). These findings suggest that when the ECG is normal, such symptoms identified during routine screening may have limited diagnostic value for detecting serious underlying disease.
5. Time to rethink screening strategies?
   This data support a more ECG centered approach to pre-participation screening and raise important questions about the role and weighting of the H&P, particularly in athletes with normal ECGs.

Conclusion

The H&P remains an important part of clinical care—but in the context of preparticipation cardiovascular screening of athletes, its role must be questioned.  

When the ECG is normal, clinicians should be aware that the H&P adds very little diagnostic yield while contributing a meaningful burden of false positives.

As screening strategies continue to evolve, the focus should remain on maximizing true detection while minimizing unnecessary downstream consequences—for both clinicians and the athletes we care for.

Image: Mass athlete cardiac screening event sponsored by the Nick of Time Foundation  (Courtesy of Ashwin Rao, MD)

References:

1. Conway JJ, Bennett D, Asif IM, et al. Pre-participation cardiovascular screening among NCAA athletes: a systematic review and meta-analysis of 27 891 athletes. Br J Sports Med 2026; 60:379-387.     
2. Petek BJ, Churchill TW, Moulson N, et al. Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A 20-Year Study. Circulation 2024;149:80–90.
3. Wilson MG, Basavarajaiah S, Whyte GP, et al. Efficacy of personal symptom and family history questionnaires when screening for inherited cardiac pathologies: the role of electrocardiography. Br J Sports Med 2008;42:207–11.
4. Fudge J, Harmon KG, Owens DS, et al. Cardiovascular screening in adolescents and young adults: a prospective study comparing the Pre-participation Physical Evaluation Monograph 4th Edition and ECG. Br J Sports Med 2014;48:1172–8.

GenAI was not used in the creation of this work. All content, interpretations, and conclusions are those of the authors

Corresponding Author: Justin J Conway [1,2]

Co-Authors: Dylan Bennett [3], Irfan M Asif [4]; Masaru Teramoto [5]; Brett G Toresdahl [5]

1. Department of Sports Medicine, Crystal Run Healthcare, Newburgh, New York, USA
2. Optum Center for Research and Innovation, Optum Health, Minnetonka, Minnesota, USA
3. Primary Sports Medicine Service, Hospital for Special Surgery, New York City, New York, USA
4. Department of Family and Community Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
5. Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA

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