DanielTarditi, D.O.DanielTarditi, D.O.
andand
Steven Levi, M.D., FACCSteven Levi, M.D., FACC
 80-90% of SCD in young athletes occur during or
shortly after exercise
 Sex and sport related predilection
 Male to fe...
 Most common cause of sudden death in
young “healthy” individuals
 Characterized by thickened heart
muscle
 Inherited u...
 Clinical presentation varies depending on age of
onset (may be asymptomatic)
 Syncope
 Sudden death
 Heart failure
 ...
Arrhythmogenic Right Ventricular
Dysplasia (ARVD)
 Incidence unknown, but estimated to affect
1:1000.
 Mean age of diagn...
 30% of cases are familial (probably
underestimate)
 Diagnosis of ARVD is based on clinical findings
but this can be dif...
 Physical exam: The
conditions that cause
SCD may be subtle and
not apparent on routine
exam.
 History: Symptoms
may not...
 American Heart Association (AHA) recommends
health questionnaire and physical examination
onlyonly
 A mandatory careful, detailed history and
physical examination
 To identify abnormalities known to cause SCD
 Every TW...
 There is none
 Inconsistent forms: Only 3 states use ALL 12 AHA
elements
 Nonmedical evaluations account for about 35%...
 Prior occurrence of
exertional chest pain
 Syncope with exercise
 Shortness of breath or
fatigue with exercise
 Histo...
 Listen to heart in both
lying and standing
position to identify
murmurs associated
with outflow tract
obstruction (HCM, ...
 Recent analysis of high school pre-participation
screening - 2004
 80% of states ≥9 of AHA items
 2% of states ≤4 of A...
 General ProblemsGeneral Problems
 Some not doing them AT ALL
 Non-uniform approach, correct questions are not
asked
 ...
 Uniform comprehensive questionnaire – “a
national standard”
 Questionnaire and examination should be
administered by in...
Corrado, D. et al. J Am Coll Cardiol 2008;52:1981-1989
Flow Chart of the Italian Protocol of Cardiovascular Pre-
Participa...
(5-17%)(5-17%)
Conditions are rare enoughConditions are rare enough
NO DATANO DATA
YESYES
 Exertional chest pain/discomfort
 Unexplained syncope/near syncope – especially
when related to exertion
 Prior recogn...
 SCD is the leading cause of death in young
athletes
 Pre-participation screening strategies are of help
to identify ath...
Questions?
 Thank you.
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
Cardiac Arrhythmias and Screening in Athletes
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Cardiac Arrhythmias and Screening in Athletes

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A symposium sponsored by the Brad Wilby Memorial Foundation educating doctors and coaches on the need for cardiac screening in athletes.

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Transcript of "Cardiac Arrhythmias and Screening in Athletes"

  1. 1. DanielTarditi, D.O.DanielTarditi, D.O. andand Steven Levi, M.D., FACCSteven Levi, M.D., FACC
  2. 2.  80-90% of SCD in young athletes occur during or shortly after exercise  Sex and sport related predilection  Male to female ratio = 9:1  Mean age ranges from 17-23 years of age  Soccer and basketball = largest number
  3. 3.  Most common cause of sudden death in young “healthy” individuals  Characterized by thickened heart muscle  Inherited usually as autosomal dominant in older children and adults  Approximately 1 in 500 adults have HCM
  4. 4.  Clinical presentation varies depending on age of onset (may be asymptomatic)  Syncope  Sudden death  Heart failure  Sudden death risk similar in adolescents versus adults  EKG abnormal in 70-90% of patients  Should evaluate all 1st degree relatives for HCM
  5. 5. Arrhythmogenic Right Ventricular Dysplasia (ARVD)  Incidence unknown, but estimated to affect 1:1000.  Mean age of diagnosis is 30  Principle symptoms1  Palpitations – 67%  Syncope – 32%  Atypical chest pain – 27%  Short of breath – 11% Circulation 2004 Oct 5;110:1879-84.
  6. 6.  30% of cases are familial (probably underestimate)  Diagnosis of ARVD is based on clinical findings but this can be difficult and ambiguous, particularly in young family members  Genetic testing can be used to help clarify difficult diagnoses earlier in life  Important implications for both the patient and family members
  7. 7.  Physical exam: The conditions that cause SCD may be subtle and not apparent on routine exam.  History: Symptoms may not be present prior to SCD  The relative frequency of these conditions is low in the population  The impact is HIGH Sports Illustrated December 10 2007
  8. 8.  American Heart Association (AHA) recommends health questionnaire and physical examination onlyonly
  9. 9.  A mandatory careful, detailed history and physical examination  To identify abnormalities known to cause SCD  Every TWO years an interim history is recommended  By “qualified” care providers
  10. 10.  There is none  Inconsistent forms: Only 3 states use ALL 12 AHA elements  Nonmedical evaluations account for about 35%  Consensus of expert opinion  There are limitations to current system  More false positives and false negatives with pre- participation examination forms
  11. 11.  Prior occurrence of exertional chest pain  Syncope with exercise  Shortness of breath or fatigue with exercise  History of a heart murmur  History of hypertension  Family history of premature death, sudden or otherwise (age <50)  Specific knowledge of family history of HCM, LQTS, Marfan, DCM, arrhythmias  Disability from heart disease in close relative <50 years old  Parents need to be responsible for ensuring accuracy of historical data HCM – Hypertrophic cardiomyopathy; LQTS – long QT syndrome; DCM – dilated cardiomyopathy
  12. 12.  Listen to heart in both lying and standing position to identify murmurs associated with outflow tract obstruction (HCM, etc)  Assess femoral artery pulses (pulse in groin)  Recognize physical stigmata of Marfan syndrome  Blood pressure measurement while sitting
  13. 13.  Recent analysis of high school pre-participation screening - 2004  80% of states ≥9 of AHA items  2% of states ≤4 of AHA items  However, states in which non-physician examiners are permitted to perform screening examinations has increased from 22% to 35%
  14. 14.  General ProblemsGeneral Problems  Some not doing them AT ALL  Non-uniform approach, correct questions are not asked  Who administers or performs evaluations?  Questions not answered truthfully  AND not helpful if symptoms are not present, family history negative and examination “normal”
  15. 15.  Uniform comprehensive questionnaire – “a national standard”  Questionnaire and examination should be administered by individuals with knowledge and training  Parents need to be involved  Still will miss cases, but may find some too
  16. 16. Corrado, D. et al. J Am Coll Cardiol 2008;52:1981-1989 Flow Chart of the Italian Protocol of Cardiovascular Pre- Participation Screening
  17. 17. (5-17%)(5-17%)
  18. 18. Conditions are rare enoughConditions are rare enough NO DATANO DATA
  19. 19. YESYES
  20. 20.  Exertional chest pain/discomfort  Unexplained syncope/near syncope – especially when related to exertion  Prior recognition of heart murmur - should assess standing and sitting (outflow tract obstruction)  Elevated systemic blood pressure  Family history of sudden and unexpected premature death (<50 years old)  Family history of HCM, ARVD, long QT, Marfans or congenital arrhythmia disorders (Brugada syndrome, etc)
  21. 21.  SCD is the leading cause of death in young athletes  Pre-participation screening strategies are of help to identify athletes of risk for SCD  Parents, get involved when they go for pre- participation physical  Establishing emergency action plan at ALL athletic venues is needed
  22. 22. Questions?  Thank you.

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