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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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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