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Athletes With Cardiac Problems
Almost all states in the United States require some type of preparticipation screening of participants in organized sports. The major reason for this screening is to help prevent sudden unexpected death. Most physicians encounter this issue in association with high school and college sports, and therefore physicians should have a general understanding of the eligibility guidelines and the participation eligibility for patients with specific CV conditions. Athletic competitions substantially increase the sympathetic drive. The resulting increase in catecholamine levels increases blood pressure (BP), heart rate (HR), and myocardial contractility and increases oxygen demand. The increase in sympathetic tone can cause arrhythmias and may aggravate existing myocardial ischemia.
The recommendations presented are mostly from American Heart Association (AHA) and American College of Cardiology (ACC) Scientific Statement (2015) and some are from the 36th Bethesda conference (2005). The following areas are presented.
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Causes of sudden unexpected death
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AHA/ACC) 14-element screening procedure (of 2014)
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Classification of sports according to the type and intensity to help physicians select allowable types of sports
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Overview of participation eligibility for athletes with different types of CV problems
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Guidelines for athletes with hypertension
I. Sudden Cardiac Death In Young Athletes
A. Statistics Of Sudden Unexpected Death
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Sudden cardiac death (SCD) occurs in about 1 per 200,000 high school sports participants per academic year. It is far more common in boys than in girls. In the United States, football and basketball are the sports most frequently associated with SCD.
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The two most important groups of heart disease that cause SCD are hypertrophic cardiomyopathy (HCM) and coronary artery anomalies or diseases, accounting for nearly 70% of the cases (see Table 25.1 ).
Table 25.1CARDIOVASCULAR CAUSES OF SUDDEN DEATH IN YOUNG ATHLETES (N = 690) aModified from Balady, G. J., & Ades PA. (2012). Exercise and sports cardiology. In O. Bonow, D. Mann, D. Zipes, & P. Libby (Eds.) Braunwald ’ s heart disease : A textbook of cardiovascular medicine (9th ed.). Philadelphia: Saunders.CAUSE PERCENT Hypertrophic cardiomyopathy 36 Coronary artery anomalies, congenital and acquired 23 Possible hypertrophic cardiomyopathy 8 Myocarditis 6 Arrhythmogenic right ventricular cardiomyopathy 4 Ion channel disease 4 Mitral valve prolapse 3 Aortic rupture 3 Aortic stenosis 2 Dilated cardiomyopathy 2 Wolff-Parkinson-White syndrome 2 Others 5 a Original data from Maron, B. J., Doerer, J. J., Haas, T. S., Tierney, D. M., & Mueller, F. E. (2009). Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation, 119 (8), 1085-1092.
B. Common Causes Of SCD
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HCM (up to 36%) and its variant (8%) account for nearly half of the unexpected SCD cases (see Table 25.1 ).
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Anomalies of the coronary arteries, both congenital and acquired (atherosclerotic or the result of Kawasaki disease), is the next important group of causes of SCD, accounting for 23%.
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Myocarditis and dilated cardiomyopathy are found in up to 8% of SCDs.
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Cardiac arrhythmias (caused by long QT syndrome, WPW syndrome, sinus node dysfunction, arrhythmogenic right ventricular dysplasia [ARVD]) account for 10% of SCD.
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Other rare causes of SCD in athletes include severe AS or PS, Marfan syndrome (from ruptured aortic aneurysm), MVP, dilated cardiomyopathy, primary pulmonary hypertension, “commotio cordis,” sarcoidosis, and sickle cell trait.
C. Preparticipation Screening
The most important reason for the screening is to detect “silent” CVD that can cause SCD. Detailed prospective CV screening of a large athletic population is impractical, because there are 8 to 10 million competitive athletes in the United States. Even with the use of specialized cardiologic tools, complete prevention of SCD is nearly impossible. Thus, medical clearance for sports does not necessarily imply the absence of CVD or complete protection from sudden death.
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Recommended screening
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Recommended screening for U.S. high school and college athletes is confined to history taking and physical examination, which is known to be limited in its power to consistently identify important CV abnormalities. In 2014, the AHA and ACC recommended using a 14-element screening procedure (formerly a 12-point screening) as shown in Box 25.1 . Ten of the 14 points are related to the history and the remaining 4 to physical examination.
Box 25.1The 14-Element Aha Recommendations For Preparticipation Cardiovascular Screening Of Competitive AthletesModified by American Heart Association with permission from Maron, B. J., Friedman, R. A., Kligfield, P., et al. (2014). Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American Collee of Cardiology. Circulation , 64 (14):1479-514.Medical History a
a Parental verification is recommended for high school and middle school athletes.
Personal History
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Chest pain/discomfort/tightness/pressure to exertion
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Unexplained syncope/near syncope b
b Judged not to be of neurocardiogenic (vasovagal) origin, of particular concern when occurring during or after physical exertion.
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Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
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Prior recognition of heart murmur
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Elevated systemic blood pressure
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Prior restriction from participation in sports
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Prior testing for the heart, ordered by a physician
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