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DOB:____________________________
Email:____________________________
..ever had discomfort, pain, or pressure in his/her chest during exercise or complained of his/her heart “racing or Y N
Heart of the Valley Pediatric Cardiology
..ever had a doctor identify high blood pressure, high cholesterol, a heart murmur, or a heart infection? Y N
(If “yes,” check which one[s]) _____________________________________
..had a sudden, unexpected death before age 50 (including from sudden infant death syndrome [SIDS], car accident, Y N
drowning, or others)?
This test is a screen for the underlying causes of sudden cardiac death in athletes. See the
accompanying tri-fold brochure for background and additional details of the screen. Screening of
athletes for causes of sudden cardiac death is routine if not mandatory in most European countries.
It is mostly unavailable and completely voluntary in the US. The screening offered by this practice
is adapted from the program that is used in Italy with great success. Please read the following
important points about the screening program.
1. The screen consists of the screening questionnaire and an ECG. The success of the screen depends on the accuracy
and completeness of the questionnaire and of follow-up answers to questions asked by the screening doctor. This
accuracy and completeness is the responsibility of the athlete and the parent.
2. As all screening tools, even under the best circumstances it is not perfect and it does not catch all causes. In Italy, the
screening program was able to reduce the incidence of sudden cardiac death to 1/6th of the rate without screening. This
means, in a typical population of 100,000 screened athletes, each year one athlete who passed the screen would still
be expected to die suddenly. However, this is an improvement compared to no screening where 6 athletes would be
expected to die suddenly each year.
3. Just as a screening tool does not catch all causes, sometimes it detects issues that appear to be of concern, but, with
further testing, are shown not to be of concern (These are called false positive screens). Thus, sometimes additional
costs are incurred for what ultimately turns out to be nothing serious. In Italy, 9% of athletes required additional
studies, usually an echocardiogram, before risk could be better assessed.
4. Insurance companies do not currently cover the cost of screening. They will cover the cost most of the time if
there are any positive responses on the screening questionnaire or the screening ECG and your doctor believes it is
important to have this further evaluated by a pediatric cardiologist.
5. It is very important to understand that, once a person is identified to be at increased risk of sudden cardiac death, the
risk is only reduced by some sort of intervention. Often this involves restriction from competitive sports. In Italy, 2%
of all those screened were restricted from sports even though it is estimated that only 1 in 10 of those restricted athletes
I am the legal guardian of this athlete and have read this important information about this test and
agree to this athlete being tested.