Table 2.

The 14-Element AHA Recommendations for Pre-Participation Cardiovascular Screening of Competitive Athletes Versus the PPE-4

AHA Recommendations (10)*	PPE-4 (21)
Medical History†
Personal History	Heart Health Questions About You
1. Chest pain/discomfort/tightness/pressure related to exertion	6. Have you ever had discomfort, pain, tightness, or pressure in your chest during exercise?
2. Unexplained syncope/near syncope‡	5. Have you ever passed out or nearly passed out during or after exercise?
3. Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise	12. Do you get more tired or short of breath more quickly than your friends during exercise?
	10. Do you get lightheaded or feel more short of breath than expected during exercise?
	7. Does your heart ever race or skip beats (irregular beats) during exercise?
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
6. Prior restriction from sports	8. Has a doctor ever told you that you have any heart problems? If so, check all that apply:
	□ High blood pressure
	□ A heart murmur
	□ High cholesterol
	□ A heart infection
	□ Kawasaki disease
	□ Other:________________
	1. Has a doctor ever denied or restricted your participation in sports for any reason?
7. Prior testing for heart disease, ordered by a physician	9. Has a doctor ever ordered a test for your heart? (For example, ECG/EKG, echocardiogram)
	11. Have you ever had an unexplained seizure?
Family History Heart	Heart Health Questions About Your Family
8. Premature death (sudden and unexpected or otherwise) before 50 years of age attributable to heart disease in ≥1 relative	13. Has any family member or relative died of heart problems or had an unexpected death before age 50 yrs (including drowning, unexplained car accident, or sudden infant death syndrome)?
9. Disability from heart disease in a close relative <50 yrs of age
10. Hypertrophic or dilated cardiomyopathy, long QT syndrome or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac condition in family member	14. Does anyone in your family have hypertrophic cardiomyopathy, Marfan syndrome, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, short QT syndrome, Brugada syndrome, or catecholaminergic polymorphic ventricular tachycardia?
	15. Does anyone in your family have a heart problem, pacemaker, or implanted defibrillator?
	16. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning?
Physical Examination	Physical Examination
11. Heart murmur§	a. Heart Murmurs (auscultation standing, supine, ± Valsalva)
	Location of point of maximal impulse
12. Femoral pulses to exclude coarctation	b. Pulses
	• Simultaneous femoral and radial pulses
13. Physical stigmata of Marfan syndrome	c. Appearance
	• Marfan stigmata (kyphoscoliosis, high-arched palate, pectus excavatum, arachnodactyly, arm span > height, hyperlaxity, myopia, MVP, aortic insufficiency)
14. Brachial artery blood pressure (sitting positional)‖	d. Blood pressure

Differences between AHA and PPE-4 recommendations are indicated in bold. *Reprinted with permission from Maron et al. (10). †Parental verification is recommended for high school and middle school athletes. ‡Judged not to be neurocardiogenic (vasovagal) in origin; of particular concern when occurring during or after physical exertion. §Refers to heart murmurs judged likely to be organic and unlikedly to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction. ‖Preferably taken in both arms.

AHA = American Heart Association; ECG/EKG = electrocardiogram; MVP = mitral valve prosthesis; PPE = pre-performance physical evaluation.