Is Cardiac Auscultation the Achilles’ Heel of Sports Screening?

Recently one of the authors (M. W. Martinez) examined a 17-year-old lacrosse player who experienced an episode of syncope on the playing field. Physical examination revealed a systolic murmur that decreased on squatting. The athlete was diagnosed eventually with hypertrophic cardiomyopathy by 2-D echocardiography and restricted from competitive play. One month earlier, the athlete had been cleared for play by her primary care physician who did not document a heart murmur or any abnormalities on physical examination. The American Heart Association (AHA) recommends 12 elements of preparticipation cardiovascular screening for all competitive athletes. A key element of the screening process is cardiac auscultation. We wondered how effective screening for heart murmurs is in the real world of preparticipation screening. We suspect that episodes like the one mentioned happen far too frequently in the current system of preparticipation examinations. Of the 12 elements recommended by the AHA, 4 of these items refer to physical examination including auscultation for heart murmurs to exclude specifically dynamic left ventricular outflow murmurs such as hypertrophic cardiomyopathy. Given the recommendation that physical examination is a key one that gatekeepers use for keeping athletes safe, how good are primary care physicians at recognizing basic heart murmurs? A study by Roy et al. (5) revealed that family physicians are able to recognize less than half of abnormal heart murmurs. Even academic internists recognize only 40% of abnormal heart murmurs (4). One of the authors (F. O’Connor) found that sports medicine fellows demonstrated limited clinical agreement in simply trying to distinguish murmurs that needed further evaluation (3). Another study regarding who performs the bulk of preparticipation screenings in the United States revealed that many different practitioners are involved in clearing student-athletes for play, including family physicians, orthopedic surgeons, cardiologists, nurse practitioners, athletic trainers, and chiropractors (1). While there is clear epidemiologic evidence that highlights the difficulties with clinical auscultation, there is also evidence that this skill can be improved. One of the authors (M. J. Barrett) had the opportunity to test more than 800 primary care physicians on their ability to recognize heart murmurs. Primary care physicians attending a national meeting for internal medicine were examined on their ability to recognize five basic murmurs including aortic stenosis, mitral regurgitation, and innocent systolic murmurs among others. Murmurs were played in random order using a torso to show the location of the stethoscope. Participants were required to identify the heart sounds on a blank sheet of paper at the pretest. All subjects attended a 90-min workshop on cardiac auscultation where they listened to several hundred repetitions of these five basic murmurs. After the workshop, murmurs and heart sounds were tested again. This study revealed that primary care physicians only recognized 47% of abnormal heart murmurs (2). Following the workshop, they improved to 77% accuracy in recognizing these basic murmurs. Participants also could choose to learn the same material via a self-paced audio instruction program. The results were similar regardless of how the attendees chose to learn the material. Observations from other clinicians with similar training revealed that this proficiency lasts for up to 12 months in the absence of additional reinforcement. It appears from the given information that cardiac auscultation is, in part, a technical skill. With sufficient repetition in a fairly short time frame, most primary care physicians can readily recognize abnormal heart murmurs and maintain this skill for up to 1 year. As previously mentioned, other authors (5,6) have found similar low rates of proficiency in cardiac auscultation among family physicians and general internists. One practical effect of this low level of proficiency of cardiac auscultation in primary care physicians is that student athletes with heart murmurs potentially are being allowed to participate in sports, sometimes with fatal consequences. What do these results mean for preparticipation evaluation of student athletes for competitive play? At a time when there are suggestions that we begin to consider screening student athletes with an electrocardiogram and/or an echocardiogram, it is important to consider whether we are currently doing everything we can to safeguard young athletes at the time of the preparticipation examination. Before we embark on additional electrocardiogram (EKG) screening programs with its own set of false positives, false negatives, and limited clinical agreement, perhaps we should address first these known deficiencies in cardiac auscultation of young athletes. As mentioned, some experts have recommended the addition of electrocardiogram (EKG) screening for all student athletes. This approach we believe minimizes the challenges of EKG screening in this population, including normal variants such as elevated QRS and T-wave voltages, ST and J point elevations, and T-wave inversions particularly in the right precordial leads. In addition, the question of proficiency of primary care physicians in interpreting these normal variants in the electrocardiogram is relevant to any discussion of additional testing. Many computerized interpretation algorithms built into the current generation of EKG machines are known to have significant incidence of false-positive readings. Before we rush to add additional screening tools like the electrocardiogram with its own pitfalls, we should do a better job of assuring that those medical professionals who clear student athletes for play have the requisite skill to detect any abnormal heart murmurs. We strongly endorse the proper and effective implementation of the AHA guidelines for screening young athletes with careful attention to a well-performed history and physical examination. Most importantly, we feel it is critical that those asked to screen and clear young athletes have the demonstrated skill to perform properly cardiac auscultation. In summary, we believe that the available evidence suggests that primary care physicians do not have sufficient skill in detecting common heart murmurs to screen safely student athletes at the preparticipation screening. This skill can be mastered in a short time frame with a self-paced audio program. We think that, before embarking on an additional screening program using the EKG, medical personnel charged with assuring the safety of student-athletes to participate in competitive sports should demonstrate their proficiency in detecting basic heart murmurs. The authors declare no conflicts of interest and do not have any financial disclosures.