What is the most relevant aspect of a Physical Performance Evaluation (PPE)?

Cardiovascular Screening is the Most Relevant Aspect of the Physical Performance Evaluation (PPE)

The cardiovascular assessment, particularly focused on detecting conditions that may lead to sudden cardiac arrest (SCA) or sudden cardiac death (SCD), is the most relevant aspect of a Physical Performance Evaluation (PPE). 1

Rationale for Cardiovascular Focus

The American Heart Association and American College of Cardiology emphasize cardiovascular screening as the cornerstone of the PPE for several critical reasons:

• Sudden cardiac death is the leading cause of death in young athletes during sports participation
• The annual incidence of sudden cardiac death in competitive athletes is approximately 1:63,682, with higher risk in certain populations 1
• Cardiovascular conditions that increase risk of SCA/SCD can often be detected through proper screening

Key Components of Cardiovascular Assessment

1. Comprehensive Cardiovascular History

• Personal history of:

  • Exertional chest pain/discomfort
  • Unexplained syncope or near-syncope
  • Excessive/unexplained exertional dyspnea
  • Prior recognition of heart murmur
  • Elevated blood pressure

• Family history of:

  • Premature death before age 50
  • Heart disease in close relatives under 50
  • Specific cardiac conditions (cardiomyopathy, long QT syndrome, Marfan syndrome)
  • Family history of exercise-related death 1, 2

2. Physical Examination

• Blood pressure measurement
• Heart rate and rhythm assessment
• Cardiac auscultation (both supine and standing) for murmurs
• Assessment for physical stigmata of Marfan syndrome
• Femoral pulse examination 1, 2

3. ECG Consideration

• The inclusion of a resting 12-lead ECG is reasonable as it improves detection of underlying cardiac conditions in asymptomatic athletes compared with medical history and physical examination alone
• ECG screening increases sensitivity for detection of potentially fatal cardiac conditions to 94% 1
• Requires clinicians with adequate training in athlete-specific ECG interpretation criteria 1

Evidence Supporting Cardiovascular Priority

The 2025 scientific statement from the American Heart Association and American College of Cardiology explicitly states that cardiovascular medical history and physical examination should be performed as part of preparticipation screening as it can detect:

1. Symptomatic athletes with previously unrecognized disease
2. Those with family history suggestive of inherited cardiovascular disorders 1

Limitations and Considerations

• History and physical examination alone have relatively low sensitivity (10-20%) in detecting silent cardiac conditions 1
• ECG inclusion improves detection but requires proper interpretation and resources for follow-up
• No screening approach provides absolute protection against sudden cardiac arrest 1
• An emergency action plan with CPR training and AED access remains essential 1

Other Important PPE Components

While cardiovascular assessment is most critical, a comprehensive PPE should also include:

• Musculoskeletal assessment (particularly for previously injured areas) 2
• Female Athlete Triad screening in female athletes 2
• Concussion history and assessment 2
• Mental health screening 2

Common Pitfalls to Avoid

• Relying solely on history and physical without considering ECG when indicated
• Using non-qualified examiners to perform cardiovascular assessments 2
• Overlooking the Female Athlete Triad in female athletes 2
• Failing to establish an emergency action plan for sudden cardiac events 1

The evidence clearly demonstrates that while a PPE serves multiple purposes, the cardiovascular assessment remains paramount as it directly addresses the leading cause of mortality in athletes during sports participation.