This post is authored by Silvana M. Lawrence, MD, FACC, member of the ACC’s Sports and Exercise Section.

Although summer has come and gone, fall brings with it the excitement of the start of school and American-loving competitive sports like football. However, with the start of competitive sports also comes the fear of the unexpected event of a young athlete collapsing on the field.

Towards the beginning of fall, cardiologist’s offices become overwhelmed with young athletes needing sports clearance, and many questions surface that were not taught during training nor were considered in the daily practice of pediatric cardiology. Fortunately, parents pay more attention to complaints reported at the time of physical exams at the primary care physician’s office prior to sports participation. However, there is an undulating comfort level to clear young athletes with any positive answers to history questions or unusual findings on a cardiac exam.

To participate in sports in the US, a young athlete must first complete a screening, which includes a history and physical exam currently based on the AHA recommendations. However, those who undergo a screening at their cardiologist’s office will, undoubtedly, receive at least one test, i.e., an ECG, and not infrequently, additional testing that might include an echocardiogram, Holter and/or a stress exercise test.

Several screening programs exist in different parts of the country aiming at early detection of conditions associated with sudden cardiac death. Presently, an ongoing large screening program of high school athletes is occurring in the state of Texas: The Texas Adolescent Athlete Heart Screening Registry – TAAHSRTM. This program has screened over 6,000 athletes to date, ages 14-18 years and utilizing history, 12 lead ECG and limited echocardiogram. Initial analyses of data have demonstrated a referral rate of about 9 percent for abnormalities detected either by ECG or an echocardiogram. We are currently putting together a paper on our findings, which I think will be a good piece of information. I also want to follow these kids longitudinally and see what happens with their natural history.

There is also a multifaceted group of young adults with congenital heart disease, repaired and palliated, that poses challenges. The present Bethesda guidelines have provided guidance for many years. However, many in the field agree it might be time to revise our data and perhaps dare to cautiously, but yet firmly, expand the type of physical activities these patients can (and ought to) engage in.

Challenges are posed daily by the growing population of inactive children that in addition to underlying heart disease, have added risk factors such as obesity, hypertension and abnormal lipid levels. Our inability, to some extent, to better define the level of physical inactivity necessary in order to protect the diseased heart, is hurting us by not promoting physical activity perhaps in the most needed segment of our pediatric population.

Exciting times are ahead of us and I truly believe we are making a difference in kids’ lives. We may not have the perfect model and, in fact, I think we do need to improve our understanding of the process and results/data to reassess the best mode of screening. Regardless, the face of sports and exercise cardiology continues to reach new horizons and, undoubtedly, will contribute to change the world of athletes with a healthy or a diseased heart.