Medical and Legal Issues in the Cardiovascular Evaluation of Competitive Athletes

Athletes are considered the healthiest members of our society, and an unexpected death during training or competition is a tragic event with widespread implications.^{1 - 2} Interest in athletic field deaths has intensified and has become a high-profile and compelling medical event.^{1 - 4} Such tragedies are always unexpected and counterintuitive, provoking several considerations including implementation of preparticipation screening^{5 - 6} and disqualification from competitive sports to reduce risk.^{7 - 8}

Liability issues in screening and management of competitive athletes are of increasing concern to the practicing medical community^{9 - 10} because some athletes’ deaths have triggered disputes in court, holding physicians accountable for alleged grievances. Consequently, a legal framework is evolving related to the alleged failure to properly diagnose, treat, or disqualify individuals from competitive athletics.

Sudden death in young athletes is largely due to a variety of clinically unsuspected congenital cardiac abnormalities.^{1 ,11 - 12} In the United States, genetic cardiovascular diseases including hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy, Marfan syndrome, and ion channelopathies (eg, long QT syndrome) account for approximately 40% of sudden deaths in young athletes,^{11 ,13} with HCM being the single most common cause and accounting for one third of the cases.^{11 ,14 - 15} Other less common causes include coronary artery anomalies, myocarditis, aortic valve stenosis, mitral valve prolapse, dilated cardiomyopathy, and premature atherosclerotic coronary artery disease.^{1 ,11 ,16 - 18} Available prevalence data for sudden death in young athletes are limited and may underestimate the magnitude of this public health problem.

Vigorous participation in competitive sports may predispose to sudden collapse by triggering ventricular tachyarrhythmias in the presence of underlying heart disease.^{1 ,11 ,19} Continued training and competition may expose vulnerable athletes to unacceptably high risk for sudden death or disease progression; disqualification from intense sports may be recommended to reduce that risk.^{7 - 8} Alternatively, overdiagnoses of cardiac disease may lead to unnecessary restrictions from sports, thereby depriving athletes of considerable psychological and often substantial economic benefits. Diagnostic distinctions between physiological (and benign) athlete's heart and heart disease can often be resolved with noninvasive testing.^{20 - 22}

Preparticipation screening is the systematic medical evaluation of large, general populations of athletes prior to training for the purpose of identifying (or raising suspicion) of cardiovascular abnormalities that could provoke disease progression or sudden death.^{4 - 6} Identification of these diseases may well prevent or delay some cases of sudden death because of physician-recommended temporary or permanent withdrawal from sports⁵ or treatment interventions.^{15 ,23} An impediment to implementing preparticipation screening is the large number of young athletes (an estimated 10 million-12 million per year) and the infrequency of sudden death.⁴ Furthermore, customary screening practice for US high school and college athletes consists only of performing a personal and family history and a physical examination. The efficacy of this practice has come under scrutiny.^{5 ,24 - 26}

The 1996 American Heart Association consensus panel⁶ stipulated that such preparticipation cardiovascular screening is a justifiable clinical practice, but routine noninvasive testing is not recommended due to the low-anticipated yield and associated cost-efficacy considerations. Specific screening recommendations were formulated to target those cardiovascular lesions known to cause youthful sudden death ( Article ).^{1 ,6 ,11}

Personal Medical History

Exertional chest pain/discomfort

Syncope/near syncope

Excessive exertional and otherwise unexplained dyspnea/fatigue associated with exercise

Prior recognition of heart murmur

Elevated blood pressure

Family Medical History

Premature death (sudden or otherwise) related to heart disease in relatives

Disability from heart disease in close relative younger than 50 years

Specific knowledge of hypertrophic or dilated cardiomyopathy, ion channelopathies such as long QT syndrome, Marfan syndrome, or clinically important arrhythmias

Physical Examination

Heart murmur†

Femoral pulses to exclude aortic coarctation

Physical stigmata of Marfan syndrome

Brachial artery blood pressure (sitting position)

*A statement for health professionals from the Sudden Death Committee and the Congenital Cardiac Defects Committee, American Heart Association.⁶
†Supine and standing to identify murmur of dynamic left ventricular outflow tract obstruction.

The relationship between sports medicine and the law is complex. It evolves from tenuous relationships between physicians, athlete-patients, teams, and institutions.

Athlete-Physician Relationship. Patient-athletes trust their physicians to advise them of the risk for untoward events during competitive sports. Indeed, physicians have a primary obligation to act in the athlete's best medical interest. The law relies on the collective judgment of the medical profession to establish the appropriate nature and scope of medical evaluations to identify cardiovascular abnormalities and other life-threatening conditions in athletes participating in organized sports.^{9 - 10 ,27 - 28}

Litigation in the sports arena appears to be increasing and physicians are frequently involved. Lawsuits for medical negligence and malpractice may arise when a breach of the physician's duty has occurred and medical conduct has failed to meet the standard of care, directly causing injury or death (Table).^{29 - 38} Lack of judicial resolution in some encounters due to settlement of claims represents an obstacle to establishing a comprehensive medical-legal framework. Nevertheless, measured inferences from such cases can create insights for practicing physicians in avoiding potential liability (Table and Article

Preparticipation Screening

Comply with the customary preparticipation screening practice by collecting a comprehensive personal and family medical history and conducting a physical examination in accordance with specific American Heart Association recommendations

Complete the screening examination and diagnostic assessment before signing the official medical clearance form or allowing formal training and competition to commence, thereby maintaining control over the medical process

Recognize that when a suspicion of cardiovascular disease is raised by screening, standard practice requires a specialty consultation with noninvasive testing

Perform preparticipation screening of college athletes in on-campus health care centers, when feasible

Recognize that the precise patient-physician relationship during standard athlete preparticipation screening is unresolved in legal terms

Physicians actively engaged in preparticipation screening can attempt to prospectively formulate the scope of their relationship with the patient-athlete to limit risk for medical malpractice, with the aid of legal counsel

Eligibility/Disqualification Decisions

It is mandatory to withdraw an athlete from training and competition when the possibility of heart disease surfaces and a specialty consultation with testing is being pursued

Rely on 2005 Bethesda Conference guidelines when determining whether a detected cardiovascular abnormality justifies temporary or permanent withdrawal from certain sports to reduce the risk of sudden death

Limit disqualification decisions for cardiovascular disease to athletes in whom the diagnosis is highly probable or definitive

Be aware of competing interests in volatile situations surrounding eligibility/disqualification decisions, which may insidiously impair a physician's medical judgment

Resist extrinsic pressures to retain athletic eligibility from the athlete, family members, coaching staff, administrators, alumni, and the public, which may impact the decision-making medical process

Avoid publicly announcing a medical diagnosis and recommendation in high-profile athletes

Recognize that disqualification decisions made by team physicians for college sports may be paramount as long as those judgments are consistent with good medical practice to avoid exposing the athlete to unacceptable risks during competition

Proceed with extreme caution when recommending treatment options for active athletes with established cardiac disease, particularly when alteration of that treatment could reduce its efficacy

Be aware that examining physicians who are not employees of a team or university (and are not a team physician) may be sued for breach of confidentiality should they disclose without authorization medical information about an athlete to the coach, team management, trainer, athletic director, or educational institution

Signed waivers do not immunize physicians and institutions from liability, and such agreements are generally unenforceable

Acting appropriately to disqualify an athlete with cardiovascular disease does not necessarily protect physicians against a lawsuit

Recognize that the medical-legal guidelines concerning cardiovascular disease in athletes largely concern high school and college participants and that there is little legal framework for preparticipation screening and disqualification criteria in professional athletes

Preparticipation Screening. Case law and statutes are limited in establishing the scope of the physician's role in preparticipation screening. One strategy by which physicians can limit potential liability is by strict adherence to the historical stance of the American Heart Association regarding physical screening guidelines.⁶ This principle is underscored by Izidor v Knight,³⁰ in which a community college basketball player sought a sports clearance examination using a form provided by his institution. A physician assistant noted a heart murmur and 2 prior syncopal episodes and referred the athlete for echocardiography, which led to a diagnosis of HCM. Unfortunately, the sports authorization clearance form was signed before echocardiography was performed. Six weeks later, after playing basketball, the athlete died suddenly. The treating physician testified that after the results of the echocardiogram were known, the athlete was notified to withdraw from competitive basketball, but refused to follow this recommendation. Prudent adherence to screening guidelines, taking into account diagnostic findings before providing official medical clearance, would have allowed the physician to control the evaluation process.

In Ivey v Providence Hospital,³⁵ the estate of a student-athlete who died from status asthmaticus after football practice sued Catholic University and a physician for negligence in failing to conduct a proper examination. The estate argued that the physician (unassociated with the university) failed to satisfactorily evaluate the potential consequences of vigorous exercise on his medically uncontrolled pulmonary condition and cardiovascular system. The case was settled by parties prior to judicial resolution.³⁵

In this case, it would appear that the physician performing the screening examination did not adequately adhere to customary American Heart Association guidelines and satisfactorily evaluate the athlete's fitness to withstand the stress of intercollegiate sports, thereby creating potential liability. Furthermore, it is possible to view Catholic University as negligent for abdicating responsibility for providing a screening process consistent with good medical practice. By requiring the athletes themselves to seek out and obtain medical clearance outside the college, the process became nonuniform and substandard as well as a circumstance in which obstacles were created for economically compromised student-athletes.

Malpractice liability may arise by improper use of diagnostic tests that would likely disclose a latent cardiac condition during screening. In Gardner v Holifield,³² the mother of a college basketball player alleged that a cardiologist who examined her son as part of preparticipation screening in the student health center misinterpreted the echocardiograms and failed to identify aortic root dilatation, which is a risk factor associated with Marfan syndrome. The athlete was not withdrawn from basketball and died of aortic dissection 6 months later. Resolution of the negligence claim was not reached because the court ruled that the health center’s physician was protected from liability for negligent medical care by Florida law (under sovereign immunity) afforded employees of public educational institutions. However, without such unique legal immunity the judgment could well have been physician negligence. In our opinion, the most prudent action would have been for the physician to recommend withdrawal from sports until a comprehensive medical evaluation was completed, and arrange for expert consultation to resolve diagnosis, risks, and treatment options if questions persist.

A lawsuit against a high school football coach, an athletic director, and the school district, Ramirez v Muroc Joint United School Districtet al,²⁹ also underscores the importance of proper preparticipation medical evaluations. The student-athlete was obese and deconditioned and had no prior experience in competitive sports. He had an abnormal electrocardiogram and a heart murmur that had been known since childhood. However, the required preparticipation examination was deferred and on the second day of practice he collapsed; the autopsy showed evidence of HCM. It is a reasonable expectation that preparticipation screening before formal athletic participation for this individual would have led to a diagnosis of HCM and disqualification from sports.

Two lawsuits cited with respect to screening involve individual athletes assessed largely in office practice settings with noninvasive testing.^{29 - 30} This represents a relationship in which physicians have a clear duty of care and primary medical obligation to act in the patient-athlete's best interest. In contrast, mass population-based preparticipation screening involves a much more limited patient-physician relationship (usually confined to performing a personal and family history and physical examination) in which typically a single physician evaluates a large number of athletes during a short period, often under suboptimal conditions. This circumstance could leave the physicians at uncertain risk for liability when an untimely death due to cardiovascular disease occurs in an athlete previously cleared for competitive sports. While at present there is insufficient legal precedent directed at the failure to diagnose potentially lethal abnormalities in a large population screening, physicians can try to formulate the scope of their relationship with the patient-athlete in such a way as to limit their liability. Hypothetically, this would require prospectively involving the institution or school district and legal counsel in the development of a proper consent form that addresses the limited scope of the physician's relationship with the patient-athlete.

Concern frequently arises among primary care nonspecialists (or nonphysician health care professionals), who predominantly perform screening of high school athletes, regarding the liability risks associated with such medical evaluations. Major considerations include (1) difficulty in differentiating innocent from pathological heart murmurs, (2) reliably raising clinical suspicion of potentially lethal cardiovascular lesions that may fall beyond the screening clinician's legitimate expertise, and (3) the dilemma of discerning which patient-athletes are most deserving of expensive noninvasive tests. While there may be no easy answers to these questions, it is clear (as in Izidor v Knight³⁰ ) that the recommendation of withdrawal from competition is mandatory when the possibility of heart disease has been raised and a specialty consultation has been pursued.

Alternative strategies, such as volunteer community-based initiatives, have emerged for large-scale screening of high school athletes with collection of a limited personal and family history and a physical examination combined with portable echocardiography to identify cardiac disease (particularly HCM).³⁹ Despite benevolent intentions and the potential benefit of such nonprofit initiatives, it would appear that these screening approaches do not fall within the usual scope of the patient-physician relationship, creating uncertain areas of liability.

In professional sports, preparticipation screening is customarily performed by physicians, often with noninvasive testing, and is generally more comprehensive than the screenings performed in high schools and colleges.⁴⁰ However, at present, there is no judicial precedent related to the screening of professional athletes. Professional team physicians are immune from claims of negligence under Worker's Compensation statutes unless intent to harm can be proven.⁴¹

Failure to Disqualify From Sports. Identification of cardiovascular abnormalities in athletes often leads to medical-legal controversies regarding eligibility/disqualification decisions.^{33 ,37} Such a medical decision-making process should be generally conservative and in accord with available guidelines, and should avoid disqualification of athletes without probable or definitive evidence of disease.

National high school and college organizations have not formulated independent standards for excluding participants with heart disease. However, over the past 20 years, the American College of Cardiology's Bethesda Conference expert consensus panels^{7 - 8 ,42} have advanced eligibility and disqualification recommendations for competitive athletes with established cardiovascular abnormalities. The recently updated guidelines⁸ from the 2005 Bethesda Conference will likely be accepted by physicians and the legal community as the most contemporary consensus in this area. Judicial precedent now provides a role for the Bethesda Conference in resolving legal disputes related to athlete participation.^{7 - 8} Such national association guidelines have generally been recognized by the courts as substantiation of good medical practice, although not conclusive evidence of the standard of care.

There have been several lawsuits alleging failure to diagnose, treat appropriately, and/or disqualify athletes from competitive sports, thereby providing insights into the potential pitfalls inherent in these medical decisions. In Gathers v Loyola-Marymount University,³⁷ it was alleged that the sudden death of an elite college basketball player (due to inflammatory cardiomyopathy) was caused by negligent reduction of cardioactive medication (ie, a β-blocker) administered for ventricular tachyarrhythmias to subtherapeutic doses as a means of continuing and advancing his athletic career.^{43 - 44} At that time, Hank Gathers was among the best college players in the country and likely to become a high professional draft selection. Shortly thereafter, he died suddenly during a nationally televised basketball game. Gathers' heirs filed a $32.5-million lawsuit⁴⁴ against his physician and the university alleging negligent interference with Gathers' medical care for cardiovascular disease and failure to remove him from college basketball in concert with Bethesda Conference recommendations.⁷

Although the Gathers case was settled prior to judicial resolution,⁴³ it is likely that a court would have regarded this scenario as malpractice by virtue of a breach of the customary patient-physician relationship and failure to comply with expert consensus recommendations. This case underscores several useful principles: (1) it is appropriate to temporarily disqualify trained athletes with certain cardiovascular abnormalities (eg, myocarditis) to assess reversibility; (2) be aware of competing interests and extrinsic pressures in volatile situations, which may insidiously impair a physician's medical judgment; and (3) avoid altering treatment strategies to enhance performance. A similar situation arose in Lillard v State of Oregon,³⁴ in which a college basketball player died of a massive stroke after his anticoagulant medication was reduced to a nontherapeutic dosage to enable his athletic career to continue.

Another high-visibility lawsuit involved professional basketball player Reggie Lewis, who fainted during a game.^{45 - 46} He underwent extensive testing and a panel of cardiologists diagnosed a life-threatening cardiac condition. However, Lewis left the hospital against medical advice and was diagnosed with a benign fainting disorder at a referral center, possibly allowing him to extend his basketball career. He collapsed and died while engaged in an informal basketball workout 11 weeks later. The autopsy revealed healed myocarditis (possibly due to adenovirus).

Lewis' widow brought suit against several physicians alleging failure to properly diagnose the heart condition that led to his death. The first trial ended in a hung jury and a second trial ended with a jury decision against negligence. Harris-Lewis v Mudge³³ suggests that physicians should proceed cautiously when confronted with athletes who seek medical clearance by soliciting multiple opinions in an effort to influence the final recommendation (ie, “shopping”). Also evident was the powerful resistance to disqualification on the part of some athletes, particularly in professional sports. This strong desire to remain competitive may exist despite knowledge of a life-threatening condition.

At present, there is no judicial precedent and little to guide disqualification decisions specifically in professional athletes. Furthermore, professional athletes differ from others by virtue of usually being adults (aged ≥21 years), employees of their teams, and involved in sports as a vocation potentially with substantial economic benefit. These factors potentially alter the medical-legal relationship with respect to eligibility when cardiac disease is present.

Resulting From Disqualification From Sports. Paradoxically, other lawsuits have been brought because physicians restricted individual athletes with heart disease. A unique lawsuit was brought by a college basketball player alleging physician negligence for withholding medical clearance to play because of a life-threatening heart condition (ie, HCM). In Penny v Sands,³⁸ the plaintiff claimed economic harm to his anticipated professional career by virtue of forced exclusion from intercollegiate basketball. The defendant-cardiologist who diagnosed Penny with HCM recommended against continuing in competitive sports, but Penny ultimately obtained medical clearance from 2 cardiologists in the United Kingdom. He subsequently collapsed and died while playing in a professional basketball game in England. Although the malpractice suit was voluntarily dismissed after his death, it is unlikely that a court would have awarded Penny's survivors compensation for economic loss after team officials accepted a physician's prudent recommendation that an athlete with established cardiac disease should be disqualified from competitive sports to reduce the risk of sudden death. Awareness of Penny v Sands³⁸ has periodically raised anxiety and confusion among clinicians by exposing the reality that no practitioner is immune from legal action, as well as conveying a chilling effect to some athlete-physician interactions.

The Americans with Disabilities Act⁴⁷ and the Rehabilitation Act⁴⁸ were designed to provide disabled people with the opportunity to participate in physical activities that they have the capabilities to perform. The scope of the Americans with Disabilities Act is broader because it covers entities that do not receive federal funding, including professional sports teams. These acts require careful balancing of an impaired athlete's right to participate in sports within his/her physical abilities, physician evaluation of medical risks, and the interest of teams or educational institutions in conducting safe athletic programs.^{7 - 9} Elements of a cause of action are if the plaintiff (1) has a medical disability that substantially limits a major life activity; (2) is otherwise qualified to participate in competitive sports; and (3) is excluded solely because of discrimination based on a medical disability.³¹ Colleges or universities are obligated to abide by these statutes in their relationship with student-athletes,⁴⁹ who have used these acts to resist disqualification from competitive sports.^{28 ,31 ,36}

In Larkin v Archdiocese of Cincinnati,³⁶ a federal court held that a high school could exclude an athlete with HCM from its athletic program because students do not have a compelling right to participate in extracurricular activities such as sports without medical clearance. Indeed, Larkin failed to satisfy an Ohio high school athletic association bylaw because cardiologists had judged him to be at an unacceptable risk of sudden death due to heart disease. The court held that the school's medical decision did not violate the Rehabilitation Act, and Larkin was not reinstated into the football program.

In this case, the athlete and his family were willing to waive future claims after complete disclosure of the medical risks of sports competition. However, the validity and power of such waivers (exculpatory agreements) is unsettled. Physicians and institutions must recognize that a signed waiver does not necessarily provide immunity from liability in the event of an athlete's death. Courts may view these waivers as unenforceable and a violation of public policy for high school⁵⁰ and college athletes.⁵¹ Physicians and institutions should seek expert legal advice when confronted by such issues.

In Knapp v Northwestern University, a student-athlete who survived a cardiac arrest due to unsuspected cardiovascular disease used the Rehabilitation Act to gain entry into Northwestern's intercollegiate basketball program.^{28 ,31} As a high school senior he collapsed with ventricular fibrillation during a basketball game, was resuscitated, and received an implantable defibrillator for sudden death prevention. Upon matriculation to Northwestern, the team physician declared Knapp ineligible for the basketball team based on the patient-athlete's medical history, consultation with other cardiology experts, and Bethesda Conference consensus guidelines,⁷ concluding that he would be exposed to unacceptable risks during competitive sports.

Knapp sued Northwestern in federal court for violating the Rehabilitation Act, alleging discrimination based on his physical impairment (ie, the defibrillator).³¹ The US District Court judge granted an injunction permitting Knapp full access to the basketball team, but an appellate court reversed that decision, in effect banning Knapp from the team. The appellate court held that Northwestern had a legal right to establish safe physical qualification standards for its intercollegiate athletes and that sports eligibility is not an inalienable, libertarian right of the athlete. Furthermore, playing college basketball was judged not to be a major life activity. Such medical decisions regarding eligibility are the proper domain of team physicians and schools as long as the process is based on reliable scientific evidence and expert consensus guidelines (ie, Bethesda Conference).^{7 - 8 ,42} Therefore, Knapp v Northwestern³¹ establishes the legal precedent that college athletes may be medically disqualified from competitive sports to avoid enhanced risk of serious injury or death that cannot otherwise be abolished by the use of medications, long-term monitoring, or the use of protective equipment. Deviations from expert consensus recommendations, which are nevertheless consistent with good medical practice, do not necessarily create physician liability, nor rigidly restrict individual clinical judgment. Alternatively, compliance with Bethesda Conference recommendations may carry substantial weight and form the basis for a successful defense against allegations of negligence and resolution of future eligibility disputes. In both the Larkin³⁶ and Knapp^{28 ,31} cases the plaintiffs attempted to extend application of the Rehabilitation Act beyond its initial intent, but failed because they would have placed themselves at enhanced risk for serious injury or death.

The law requires physicians to use customary skill and care consistent with good medical practice in evaluating an athlete's fitness to participate in sports. The physician's duty is to protect the patient-athlete's well-being while avoiding unnecessary exclusion from competition. The developing medical-legal construct holds that a high school or college may prudently withhold access to competitive sports programs from students with a cardiovascular abnormality to prevent exposure to medically unacceptable risks.

Physicians involved with eligibility decisions in athletes with cardiovascular disease and preparticipation screening may assume some risk of liability. Reducing this liability risk requires an understanding of the evolving judicial framework and compliance with the standard of care and available guidelines, including the American Heart Association's recommendations regarding preparticipation screening and the American College of Cardiology's Bethesda Conference disqualification recommendations.