Open access Consensus statement

Preparticipation medical evaluation for

elite athletes: EFSMA recommendations
on standardised preparticipation
evaluation form in European countries
Anca Mirela Ionescu,1,2 Yannis P Pitsiladis ‍ ‍,1,3 Sandra Rozenstoka,1,4
Xavier Bigard,1,5 Herbert Löllgen,1,6 Norbert Bachl,1,7 Andre Debruyne,1
Fabio Pigozzi,1,8 Maurizio Casasco,1,9 Anna Jegier,1,10 Alina Maria Smaranda ‍ ‍,2
Adela Caramoci,2 Theodora Papadopoulou1,11

To cite: Ionescu AM, ABSTRACT

Pitsiladis YP, Rozenstoka S, Key points
Sports medicine is a medical specialty that supports the
et al. Preparticipation medical
performance of professional and amateur athletes while
evaluation for elite athletes: ►► Implementing a standardised preparticipation evalu-
EFSMA recommendations on maintaining their health. Sports medicine professionals
ation across Europe in order to provide the best care
standardised preparticipation need to ensure the safe participation of athletes in sports
to all elite athletes.
evaluation form in European activities achieved through a periodical preparticipation
►► Emphasising the importance of ECG screening
countries. BMJ Open evaluation (PPE) and a regular medical monitoring
Sport & Exercise Medicine
among athlete population.
of the athletes’ health in accordance with the latest
2021;7:e001178. doi:10.1136/ ►► Pointing out the necessity of training physicians into
recommendations regarding health condition and medical
bmjsem-2021-001178 interpretation of athletes’ ECG.
history, physical working capacity, training period and
►► Setting the basis for a future common, digital
►► Additional supplemental programme, recovery, nutrition, use of supplements,
database.
material is published online injuries prevention and safe return to play.
only. To view, please visit the In order to harmonise these national variations in the
journal online (http://​dx.​doi.​ content and application of the PPE, the EFSMA Scientific
org/​10.​1136/​bmjsem-​2021-​
monitoring of the athletes’ health for iden-
and Educational Commission proposes a ‘gold standard’
001178). tification of medical problems with possible
for elite athletes across Europe.
life-­threatening complications due to inher-
Important objectives of PPE are early detection and
prevention of severe complications during sports activities ited or acquired conditions. The goals of the
Accepted 2 October 2021
both in leisure time and competitive sports. The PPE should PPE also include fitness assessment, prescrip-
entail the following diagnostic components: health status, tion of recovery and nutritional strategies,
anthropometry, functional and exercise capacity. injuries prevention and safe return to play.
It is of utmost importance to develop and implement In 2018 Ron Golan (Israel) and Petra
preventive strategies such as the PPE. Besides monitoring Zuped (Slovenia) applied a questionnaire
the health status of athletes, the PPE plays an important to evaluate the current status of the PPE in
role in the selection process, bringing valuable information Europe. The overview of the results obtained
for coaches and supporting a personalised treatment from 30 European countries emphasised that
approach. Screening of athletes through a standardised
although PPE is widely accepted, its use and
digital PPE could be beneficial for a better understanding of
the impact of long-­term physical activity. Furthermore, PPE
content are not standardised and important
leads the scientific community to a way of working closer variations in terms of the different categories
together in the interest of the athletes. of athletes subjected to it (ie, professionals;
elite or junior athletes licensed by Sport
Federations or by the National Olympic
© Author(s) (or their Committee), legal aspects around it (eg, PPE
employer(s)) 2021. Re-­use compulsory or not), and the content and
permitted under CC BY-­NC. No BACKGROUND the cost of PPE. The results were presented
commercial re-­use. See rights
and permissions. Published by
Sports and Exercise Medicine (SEM) is a multi- through descriptive statistics. (11th EFSMA
BMJ. disciplinary, clinical and academic medical Congress of Sports Medicine, Portoroz,
For numbered affiliations see specialty that supports the performance of Slovenia, 2019, www.​efsma.​org.)
end of article. athletes while maintaining their health. SEM In most investigated European countries,
professionals need to ensure the safe partici- PPE is mandatory only for competitive sports
Correspondence to
pation of athletes in sports activities achieved (21/30=70%), and in nine countries, it is
Dr Alina Maria Smaranda; through a periodical medical preparticipa- strongly recommended. In 24 countries, SEM
​alina.​smaranda@​drd.​umfcd.​ro tion evaluation (PPE) and regular medical specialists are qualified to conduct the PPEs.

Ionescu AM, et al. BMJ Open Sp Ex Med 2021;7:e001178. doi:10.1136/bmjsem-2021-001178 1

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In other countries, the doctors conducting the PPEs are

certified SEM physicians or team physicians with rele- Box 1 Inherited diseases with life-­threatening risk of
vant certification and additional education in ECG and cardiac arrest2
cardiopulmonary exercise testing. Channelopathies or ‘electrical’ conduction diseases
To harmonise these national variations in the content ►► Long-­QT-­syndrome, short-­QT-­syndrome, Brugada-­syndrome.
and application of the PPE, the EFSMA Scientific and ►► Catecholaminergic polymorphic ventricular tachycardia (CPVT) car-
Educational Commission proposes a ‘gold standard’ for diac conduction diseases.
elite athletes across Europe. The proposed protocol is a ►► Pre-­excitation and conduction abnormalities (eg, WPW syndrome
basis for a comprehensive medical screening (https:// with atrial fibrillation).
www.​efsma.​org/​newsevents/​news-​events/​251-​efsma-​pre-​ Cardiac structural diseases
participation-​evaluations-​ppe- ​forms.​html).1 ►► Hypertrophic cardiomyopathy with or without outflow obstruction
The objectives of the current paper are to empha- dilated cardiomyopathy (familial).
►► Arrhythmogenic right ventricular dysplasia (or cardiomyopathy) left
sise the need for a standardised PPE among European
ventricular non-­compaction cardiomyopathy.
countries, to raise awareness of the importance of ECG
Others
screening during PPE, to recommend a comprehensive ►► Marfan-­syndrome (especially in tall athletes, eg, basketball, volley-
PPE form based on three diagnostic pillars and to create ball, rowing).
the framework for strategic planning and policy devel- ►► Coronary artery anomalies (eg, abnormal origin or bridging).
opment within Europe. The target group is represented
by elite athletes who could benefit from implementing
a homogenous medical screening protocol, such as the
EFSMA PPE form. There is a strong belief that if all coun- articles from 2013 published by Drezner et al).9–12 The
tries performed the PPE using the same template, SEM ECG at rest in PPE enhances the power of diagnostic
physicians would improve their standard of care, would value in athletes with genetic diseases such as cardio-
have a broader picture of the athletes’ health issues and myopathies, channelopathies which are predisposing
nonetheless would benefit from emerging prospective to sudden cardiac arrest or death.13 14 In a previous
studies. EFSMA statement on ECG for PPE15 Löllgen and
colleagues presented the pros and cons of having ECG
WHY IS PPE NEEDED? screening integrated in the PPE and concluded that
The main scope of the PPE is protecting the health of ECG is very sensitive in cardiac screening, and the spec-
the athletes. First and importantly PPE objectives are ificity is increasing constantly, as more studies emerge.
early detection and prevention of severe or threatening Cardiac complications comprise rhythm disorders,
complications during sports activities both in leisure structural cardiac diseases or other inherited diseases.
time and competitive sports.2–5 The PPE is a key tool Some of these demonstrate underlying genetic causes.
in the process of screening for conditions that may be Guidelines for detecting these diseases during PPE
life‐threatening, disabling or may predispose to injury are strongly improved by checklists, mostly based on
or illness. Secondary, PPE is useful to determine and family history and ECG findings with ECG interpreta-
improve the level of performance, to help the athlete’s tion supported by a special sports medicine software of
staff (coach, athletic trainer, strength and conditioning most ECG devices. The software-­based interpretation of
trainer, physiotherapist, etc) in the selection process and ECG is superior to visual analysis only.15 16 Furthermore,
further optimise the training according to the health the superior role of digital supported ECG interpreta-
status, to counsel the athlete regarding health issue and tion over visual approach for screening athletes and
nonetheless to establish a relationship between SEM physical active people has been demonstrated by two
physician and athlete. studies.17 Automatic evaluation of athletes ECG device
One of the longstanding debates is the question of based on current criteria, have made the interpretation
including ECG screening in the PPE for all competi- more reliable than visual alone.15 16
tive athletes. ECG at rest as a mandatory examination Potential cardiac disorders with life-­ threatening
in athletes is strongly recommended in most European arrhythmias or sudden cardiac arrest are listed in
countries. As such, there is long-­standing controversy box 1 (modified from Löllgen et al2). For most of
about whether ECG at rest should also be performed these diseases, checklists have been developed for a
in all athletes, whereas in the USA and Canada is not better and more reliable diagnosis. These lists can be
required for all. Main arguments against ECG are the downloaded from the EFSMA website together with
lack of large prospective studies with hard endpoints recommendations on genetic testing (​ www.​EFSMA.​
such as cardiac events or mortality. Some authors org). In all athletes, with even the slightest suspicion,
within former years emphasise the low sensitivity, spec- these checklists have to be worked off carefully and
ificity and predictive values of the ECG.6–8 However, mandatory in all tall athletes (eg, >190 cm height) such
current studies with newer criteria and interpretation as basketball or volleyball players and rowing athletes,
increased the validity of ECG, as false positive and nega- as these athletes often have abortive or manifest signs
tive findings decreased significantly (four scientific of Marfan-­syndrome.

2 Ionescu AM, et al. BMJ Open Sp Ex Med 2021;7:e001178. doi:10.1136/bmjsem-2021-001178

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WHAT SHOULD BE INCLUDED IN THE PPE? significance for soccer players and rugby or American
The PPE is a medical and legal document developed football to evaluate the risk of cerebral harms.
following a standardised periodic evaluation performed The musculoskeletal manual screening combines both
by SEM doctors. It is a complex assessment of the health history and physical examination, to be informed about
status, growth and development process and perfor- previous injuries in asymptomatic athletes. The clinician
mance level. The SEM doctor assumes responsibility for can detect more than 90% of significant musculoskel-
signing off the PPE, stating that the person can practise etal injuries. The physical screening examination is 51%
a sports activity with the maximal intensity and duration sensitive and 97% specific. So the physician can obtain
for himself without any contraindications and participate whether the player has had either a previous injury or
in competitions at the levels indicated. Other important even signs or symptoms of injury (eg, pain or tenderness;
objectives of PPE are to identify factors that may affect asymmetric muscle bulk, strength or range of motion;
performance and factors that increase the risk of future or any obvious deformity). This can be detected during
illness and ensure an appropriate medical treatment the examination or history, the relevant elements of a
following antidoping regulation.18 At the same time, PPE site-­specific examination should be performed.19 It is
has a great contribution to the scientific management of essential to identify current or past injuries and possible
sports activity to maintain the well-­being and health of sequelae to determine the athlete’s possible risk factors
the athletes. in the future and preventative programmes may be
The PPE should entail the following diagnostic compo- recommended.20
nents: Cardiac complications comprise rhythm and cardiac
►► Health status. structural abnormalities and inborn diseases such as
►► Anthropometry. Marfan-­syndrome (see above). A comprehensive medical
►► Functional and exercise capacity. history, a proper clinical examination alongside a resting
ECG can detect occult or congenital diseases that may be
Health status life-­threatening or disabling.
Health assessment is based on family medical history, ECG interpretation requires excellent education in and
personal medical history, training history, training infor- knowledge of the physiological adaptations of athlete’s
mation and medical complaints: symptoms and signs. heart and in deep knowledge of the abnormalities
Standardised history and clinical examination with suggestive of a disorder. Current international criteria for
digital or ‘e-­documentation’ are recommended, storing ECG interpretation expanded the legitimacy and validity
or paper documentation should be implicit avoided. of the results: the rate of false-­ positive and negative
Establishing the objective health status by physical discoveries declining significantly.3 International sports
examination includes the evaluation of dermatological medicine and cardiology societies endorsed the interna-
conditions, lymph nodes, musculoskeletal system, respi- tional criteria for ECG interpretation in athletes.21
ratory system, cardiovascular system and resting ECG The digitalised ECG recordings with software support
with 12 leads digital recording and software supported. based on the international criteria are highly sensitive
Abdominal, neurological, ophthalmological and ENT and specific, increasing ECG interpretation’s validity. The
examinations, blood and biochemical tests, urine European Association of Preventive Cardiology recently
samples should also be assessed. Important goals of PPE released a position paper concerning the preparticipa-
are early detection and prevention of severe complica- tion cardiovascular evaluation in athletes21 and several
tions during sports activities in both leisure time and consensus papers with recommendations for participa-
competitive sports.2–5 tion in competitive and leisure time sports in athletes
The athlete’s history forms have been listed above.1 with cardiac diseases.5 22 23
The needed information consists of the year when the While interpreting the ECG, physicians should look
athlete started with sports, current type of sports, and out for any rhythm or conduction abnormalities, QRS
results he obtained in competitions, and types of training morphology, abnormal axis deviation, alteration of the
the athlete performs. It is also important to hear the repolarisation and atrial enlargement. The international
athlete’s goals in sports to provide optimal opportunities criteria are very helpful when it comes to deciding which
and recommendations for achieving peak performance. alteration of the ECG is training-­related and does not
Further, particular, monitoring training effects of poten- require further investigation.
tial difficulties, injuries or overtraining should be asked For the athletes with cardiac abnormalities on the ECG,
for in order to get medical counselling or advice. a multidisciplinary team (cardiology, arrhythmology,
The physical examination of PPE is very important and cardiac surgery) is more than helpful to decide the most
it should be performed with a particular focus on cardio- appropriate case management.
vascular, pulmonary, musculoskeletal, neurological, Echocardiography allows the physician to sensitively
ophthalmological and otolaryngology screening. A thor- and specifically distinguish adaptive from maladap-
ough neurological assessment is necessary if the athlete tive remodelling. Admittedly, structural changes can
has a history of concussion, seizure disorder, cervical be missed on the ECG but can be diagnosed precisely
spine stenosis or spinal cord injury. This is of special through two-­ dimensional echocardiography including

Ionescu AM, et al. BMJ Open Sp Ex Med 2021;7:e001178. doi:10.1136/bmjsem-2021-001178 3

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►► Suspicion of active or past myocarditis.

►► Coronary artery disease and coronary anomalies.
►► Diagnostics of the bicuspid aortic valve.
►► Ventricular arrhythmia in athletes with normal TTE—
to identify spots of myocardial fibrosis.
CMRI has big potential for both clarifying difficult clin-
ical questions and better understanding of the structure
and function and diseases of the athlete’s heart.
Besides that, additional blood (haematological and
biochemical tests depending on the athlete’s age and
level of training) and urine samples are collected. Blood
analysis is a useful tool to optimise athlete’s health and
performance. Certain biomarkers such as vitamin D
and ferritin can directly impact athletic performance,
hyperthyroidism can also be detected by basal thyroid-­
Figure 1 Flow chart of preparticipation examination as stimulanting hormone (TSH), while others like cortisol
recommended by EFSMA.15 HRV, heart rate variability. and creatine kinase can provide insights into overtraining
and injuryprevention.28 Moreover, it would be important
speckle tracking, strain and stress measurement. Accord- for the healthcare professional to perform a compre-
ingly, an ECG followed by echocardiography would raise hensive nutritional assessment and recommend using
the sensitivity and specificity of detecting underlying supplements only when necessary. The most challenging
heart disease. part of using blood analysis is establishing the baseline
Transthoracic echocardiography (TTE) allows to level of certain markers for each athlete (hormone
evaluate and characterise cardiac morphology and profile, inflammation markers, muscle damage markers).
function—very important in assessment of cardiovas- The athlete blood test panel should include the complete
cular system/conditions.24 In the majority of cases, TTE blood cell count and a comprehensive metabolic panel
is a second- level examination, preceded by physical (glucose blood level, liver panel, kidney profile, lipid
examination and rest ECG as shown in the figure 1. Echo- profile, electrolytes, vitamin D). When the three diag-
cardiography is not mandatory for screening. It could be nostic components of the PPE are completed, the SEM
recommended for the first PPE for elite athletes when doctor can ask for more biomarkers to be tested to make
there is a justified clinical suspicion (eg, suspect ECG the right diagnosis (if there is a suspicion of nutritional
findings) with regard to the sports discipline with higher deficiencies, overtraining, relative energy deficiency
cardiac risk active (high static, high dynamic compo- in sport (RED-­ S), hormonal imbalances, inefficient
nents). recovery after injury, etc). Blood analysis is a dynamic
Echocardiography is performed in athletes: process that requires careful interpretation in a clinical
►► In search of pathologies that are a manifestation context considering the timing of the testing (off-­season,
of cardiovascular diseases that may cause a risk of preseason, competition), the workload of a training
sudden death. session and any other change reported by the athlete
►► In the assessment of the physiological adaptation of (menstrual cycle, injury). The goal is to have a wide view
the cardiovascular system to physical training and of the health and fitness status of the athletes so that the
exercises and to differentiate this from pathological SEM doctor can make a diagnosis and provide recom-
findings. mendations that are tailor-­made for the athlete.
Indication for performing a TTE examination are only
after information obtained from clinical history, physical Anthropometry
examination and ECG at rest and during exercise test.3 The next part of the PPE is the anthropometric examina-
Cardiac MRI (CMRI) is very useful tool for the assess- tion that includes the somatoscopy, the classic method
ment of cardiac structure, function, identify oedema, of assessing posture and body development by visual
inflammation and fibrosis in myocardium. This diagnostic observation of the athlete in the anthropometric frame-
tool is used in the case of abnormal history, clinical exam- work and biometrics (weight, height, sitting height, body
ination, ECG and usually after echocardiogram.3 Today, composition, girth measurements, diameters, mobility
the SARS-­CoV-­2 pandemic is more often an indication and strength measurements) to assess body shape,
for CMRI in athletes to detect asymptomatic myocarditis. posture, nutrition, body symmetry, harmony in develop-
The most common indication to CMRI in SEM praxis ment, compared with the somatic biotype of the sport.
are3 14 25–27: The somatic biotype represents the set of the most repre-
►► Differentiation of the athlete’s heart with hyper- sentative somatic qualities necessary for the practice of a
trophic cardiomyopathy, arrhythmogenic cardiomy- certain sport. Evaluating the somatic biotype in athletes
opathy, dilated cardiomyopathy and left ventricular is particularly important because there are correlations
non-­compaction cardiomyopathy. between the somatic biotype and sports performance.

4 Ionescu AM, et al. BMJ Open Sp Ex Med 2021;7:e001178. doi:10.1136/bmjsem-2021-001178

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Anthropometric indices assess the somatic biotype with training and personality traits). Mental health status is
predominantly genetic determination (stature, propor- vital to discover any obstacles to achieving performance.
tions of segments, diameters). Indices that change under SEM doctors alongside with sport psychologists can help
the influence of environmental factors (bodyweight), athletes develop a range of self-­management skills that
through their large variations, change the appearance they can use to manage psychological distress.
of the somatic biotype and therefore can only be inter- In competitive athletes, especially top-­ athletes, PPE
preted by correlation with body composition. From the without cardio-­pulmonary exercise test (CPET) is incom-
point of view of the somatic biotype, we have three cate- plete. Baseline evaluations can miss important signs and
gories of sports: symptoms, which only occur during specific exercise (such
►► Sports in which the somatic biotype is essential as fatigue, functional or non-­ functional over-­reaching
for obtaining performance: basketball, volleyball, and overtraining syndrome or arrhythmias). Managing
athletics, rowing, artistic gymnastics, extreme catego- the issues as mentioned above is very important, and a
ries in weightlifting sports. specialised and educated physician must monitor the
►► Sports in which the somatic biotype is important: interventions required. CPET is the golden standard to
handball, fencing, weightlifting, skiing, swimming, monitor the integrative response for exercise capacity,
rhythmic gymnastics. indirect lactate threshold determination, quantification
►► Sports in which the somatic biotype does not matter: of training management and evaluation via spiroergom-
bowling, shooting, chess. etry the cardio-­respiratory fitness.
Physicians can also focus on movement quality. This The evaluation by CPET allows a complex evalua-
involves identification and rating functional compen- tion of exercise capacity through measurement of gas
sations, asymmetries, impairments or efficiency of exchange, pulmonary ventilation response, in addi-
movement control through transitional or dynamic tion to blood pressure and heart rate measurement,
movement. Examination of the postural alignments of and exercise ECG (see table 1). This comprehen-
the athletes creates specific compensative or preventive sive method provides an amount of information with
training information to increase athletic performance regard to energy expenditure and the to many meta-
and prevent sports injuries.29 bolic processes.
Body composition is the main fitness component for The growing volume of evidence supports the use of
reaching an optimal body shape for the respective type
CPET in the PPE of athletes and diagnosis of possible
of sport. The body composition assessment is used as a
cardiovascular or pulmonary impairments in the presence
performance or selection criterion, so technique accu-
of early pathological fatigue and exercise intolerance. It
racy and reliability are of extreme importance. The body
can provide a baseline physical performance assessment
fat varies with age and sex, and the desired body fat of
before the initiation of a training regimen. It can help
athletes can vary depending on the kind of sport, training
establish the intensity of training, assess the performance
level and energy intake. Moreover, the somatic determi-
capacity and evaluate recovery. CPET is a vital tool in
nants should be correlated with the nutritional status of
SEM to determine which athletes may be presenting a
the athlete to achieve a proper energy intake.
pathology, diagnose latent cardiopulmonary diseases and
In the process of talent selection and orientation, the
assess fitness and endurance before or after specific exer-
anthropometric measurements and abilities of the athlete
are also important factors for performance estimation. cise regimens.
Further, evaluation of exercise capacity is an important
Functional and exercise capacity goal for reaching optimal performance in sports. It allows
The next component of PPE is evaluating functional and analysis of athletes' adaptation to the specific effort,
exercise capacity according to the predominant type of establishing the existing limits, the individual specific
effort of the sports discipline investigated. This includes target heart rates and unveiling how the athletes can
neuromuscular evaluation (determination of muscle push their boundaries. The information following these
fibre strength and driving speed, EMG, EEG and Sport tests is of great interest to support the work of coaches to
Concussion Assessment Tool in contact sports), psycho- achieve maximal performance at the desired time and
logical examination (testing aptitude, adaptation to preventing overtraining syndrome.

Table 1 Parameters to be measured during cardio-­pulmonary exercise test

VO2 max, VO2 max/kg Ventilator equivalents for O2 and carbon CO2, end-­tidal CO2
HR max, heart rate reserve, BP max Ventilators thresholds—VT1, VT2, VT3
O2 pulse, oxygen saturation Ventilatory efficiency
Breathing equivalent Respiratory exchange ratio
Dead space ventilation, breathing reserve Respiratory coefficient
BP, blood pressure; HR, heart rate.

Ionescu AM, et al. BMJ Open Sp Ex Med 2021;7:e001178. doi:10.1136/bmjsem-2021-001178 5

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As a result, after these evaluations, the athletes receive could be easily overcome by creating more continuous
oral or written recommendations related to their health education programmes on this topic.
status, anthropometric measurements, exercise capacity,
nutrition, recovery, medication. The athlete needs infor- FUTURE DIRECTIONS
mation, if additional investigations are required to clearly Nowadays, many healthcare policies focus on decreasing
establish a correct diagnosis or correct certain parame- the cost of patient hospitalisation for non-­communicable
ters outside the physiological limits. diseases. Therefore, it is imperative that healthcare
After the results of the PPE are analysed, athletes will providers involved in Sport and Exercise Medicine work
likely get one of the following conclusions: towards creating a standard of care for athletes of all
►► Medically eligible for sports performance without levels, a standardised digital PPE at among European countries.
restriction. In addition, there needs to be a focus on PPE educational
Medically eligible with recommendation for further programmes to have well trained medical personnel and
evaluation or treatment. create a well-­informed community of athletes. With a
►► Not medically eligible for sport performance. complete screening programme, the standardised PPE
In elite athletes, it is implicit recommended to discuss would promote sports-­related and health-­related fitness,
the result of the PPE with the athlete and, while bearing improve training efficacy, and provide insight into how
in mind the need to respect privacy, with the team staff athletes are responding to stresses occurred during and
(team doctor, coach, athletic trainer). The team in charge outside of training and competition. Other benefits of
of the athlete needs to create an individualised training using PPE include gathering scientific explanations
plan to achieve performance and anticipate barriers and for changes in performance or injury risk, enhancing
problems arising along the way. Efforts should be made coaches’ confidence when manipulating training loads,
to have more medical personnel trained to perform and improving athlete–coach–SEM physician relation-
a comprehensive PPE (ECG included) and formulate ship.
policies to enforce PPE as a key requirement for sports
participation. In this way, engaging and receiving input CONCLUSION
from all stakeholders involved in sports is mandatory. SEM plays an increasingly important role in supporting
athletic performance. By developing preventive strategies
POSSIBLE BARRIERS IN IMPLEMENTATION OF PPE IN EUROPE such as the PPE, we can identify potential health issues
Preparticipation clinical screening and examination at the earliest possible stage and take action accordingly.
before exercise and competition represents one of the The screening of athletes through a standardised digital
scopes of SEM. However, taking into consideration that PPE can be also beneficial for the selection process and
SEM is a multidisciplinary specialty there are countries a better understanding of the impact of long-­term phys-
within Europe where SEM does not stand as medical ical activity on athletes. Furthermore, a standardised PPE
specialty, but as an additional competence. As a result, helps the scientific community work closer together in
athletes’ screening programmes may differ due to a lack the interest of the athletes.
of common specific training for SEM professionals. An easy-­to-­use electronic PPE with a centralised data-
The main rationale for EFSMA working group was to base allows for international reporting and tracking,
create a uniform PPE for all EFSMA sports medicine with integrated research questions that can provide an
associations. The multidisciplinary approach of the SEM overview of athletes’ health correlated with their perfor-
team is to coordinate and planning of the athlete’s health. mance.31
Nevertheless, all the decision-­makers at the national and Once it is established as a European, comprehensive
European level should be involved in the process of and standardised tool for assessing athletes’ readiness to
implementing the EFSMA recommended PPE. There is play, it could also be used for conducting research and
a need to work alongside local health authorities and to creating policies for athletes’ preparticipation. There-
liaise with both public and private sector so as to put into fore, it would be a major step towards improving athletes’
practice the PPE among all European countries. health and performance in the medium and long term
Training in ECG interpretation in athletes as well and a significant contribution to the field.
as special ECG devices with programme dedicated to
athletes, are mandatory for correct ECG interpretation. Author affiliations
1
European Federation of Sports Medicine Associations, Lausanne, Switzerland
Even cardiologists have imperfect expertise in interpre- 2
Sports Medicine, Carol Davila University of Medicine and Pharmacy, Bucuresti,
tation of athlete’s ECG. Appropriate use of standardised Romania
criteria of physiological adaptation in bioelectrical func- 3
Collaborating Centre of Sports Medicine, University of Brighton, Eastbourne, UK
tion of athlete’s heart and knowledge about abnormal 4
Sports Medicine and Rehabilitation Centre, Riga Stradins University, Riga, Latvia
5
ECG findings in this group of people (requiring further Union Cycliste Internationale, Aigle, Switzerland
6
Practice for Cardiology, Sports Medicine, Remscheid, Germany
evaluation) are the basis of PPE.7 14 30 Therefore, training 7
Austrian Institute of Sports Medicine, Vienna, Austria
both SEM physicians and cardiologists in athletes’ ECG 8
Sports Medicine Unit, University of Rome Foro Italico, Rome, Italy
interpretations could represent a challenge for including 9
Italian Sports Medicine Federation, Rome, Italy
ECG screening in PPE as recommended by EFSMA. This 10
Sports Medicine, Medical University of Lodz, Lodz, Poland

6 Ionescu AM, et al. BMJ Open Sp Ex Med 2021;7:e001178. doi:10.1136/bmjsem-2021-001178

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11
Lower Limbs- ADMR Hip & Groin, Defence Medical Rehabilitation Centre Headley 12 Drezner JA, Ackerman MJ, Anderson J, et al. Electrocardiographic
Court, Loughborought, UK interpretation in athletes: the 'Seattle criteria'. Br J Sports Med
2013;47:122–4.
13 Harmon KG, Zigman M, Drezner JA. The effectiveness of screening
Contributors All listed authors have made substantial contributions to history, physical exam, and ECG to detect potentially lethal
the conception or design of the work, or the acquisition/analysis of data or cardiac disorders in athletes: a systematic review/meta-­analysis. J
interpretation of the current situation of Sports and Exercise Medicine in Europe. Electrocardiol 2015;48:329–38.
Also, all authors have been involved in drafting or revising the manuscript. 14 Mont L, Pelliccia A, Sharma S, et al. Pre-­participation cardiovascular
Nonetheless, they have approved the final version of the manuscript to be evaluation for athletic participants to prevent sudden death:
published. position paper from the EHRA and the EACPR, branches of the
ESC. endorsed by APHRS, HRS, and SOLAECE. Eur J Prev Cardiol
Funding The authors have not declared a specific grant for this research from any 2017;24:41–69.
funding agency in the public, commercial or not-­for-­profit sectors. 15 Löllgen H, Börjesson M, Cummiskey J, et al. The Pre-­Participation
examination in sports: EFSMA statement on ECG for Pre-­
Competing interests None declared. Participation examination. Dtsch Z Sportmed 2015;2015:151–5.
Patient consent for publication Not applicable. 16 Berge HM, Steine K, Andersen TE, et al. Visual or computer-­based
measurements: important for interpretation of athletes’ ECG. Br J
Provenance and peer review Not commissioned; externally peer reviewed. Sports Med 2014;48:761–7.
Data availability statement Data sharing not applicable as no datasets generated 17 Abächerli R, Schmid R, Richard K, et al. OC06_06 Automatic
Implementation of the Athlete’s Seattle Criteria Leads to Less than
and/or analysed for this study.
Ten Percent of Abnormal Electrocardiograms in General Young
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