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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.

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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    Cardiac Arrhythmias and Screening in Athletes Cardiac Arrhythmias and Screening in Athletes Presentation Transcript

    • Daniel Tarditi, D.O. and Steven Levi, M.D., FACC
      • 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
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      • 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
      • 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 1 st degree relatives for HCM
    • Arrhythmogenic Right Ventricular Dysplasia (ARVD)
      • Incidence unknown, but estimated to affect 1:1000.
      • Mean age of diagnosis is 30
      • Principle symptoms 1
        • Palpitations – 67%
        • Syncope – 32%
        • Atypical chest pain – 27%
        • Short of breath – 11%
      Circulation 2004 Oct 5;110:1879-84.
      • 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
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      • 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
      • American Heart Association (AHA) recommends health questionnaire and physical examination only
      • 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
      • 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
      • 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
      • 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
      • 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%
      • General 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”
      • 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
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    • Corrado, D. et al. J Am Coll Cardiol 2008;52:1981-1989 Flow Chart of the Italian Protocol of Cardiovascular Pre-Participation Screening
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    • (5-17%)
    • Conditions are rare enough NO DATA
      • YES
      • 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)
      • 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
    • Questions?
      • Thank you.