2First year team physician’s dilemma This is your 1st yr as team physician for the local high school. All the talk in the community is about the school’s football team, which is expected to win the state championship this season. The coach of the football team “doesn’t like to lose” and was known to put pressure on the previous team physician to give medical clearance to player before games.
3Q1Which of the following is the most common cause of sudden death in an athlete younger than age 35 years?CADPremature CADMyocarditisHCMRupture of the aorta
4Q2Which of the following is a contraindication to participation in contact sports?Sickle cell traitHIVSolitary testicleFever of 102FConvulsive disorder, well controlled
5Q3Which of the following tests is recommended for routine screening of athletes during the preparticipatation evaluation (PPE)?EchoECGExercise stress testVision screenUA
6Can’t play any contact sports Can’t play until BP is under control During PPE, you note that the 17yo boy has a BP of 148/95mmHg. His past medical history is negative, and he has never been told that he had HTN. He is 6 ft2in tall and wt 175 lb. As the team physician, you tell himCan’t play any contact sportsCan’t play until BP is under controlHe is cleared to play, but must have his BP measured twice during next monthIf he begins BP med immediately, then he is clearedHe must lose 10lb before he will be cleared
7Q5The school’s wrestling team has had an unusually high amount of injuries this season. Which of the following conditions is reason to disqualify a wrestler from competition?Herpes simplexHep CInguinal herniaDiabetes mellitus
8Q6 Which of the following statement concerning PPE is true? About 10% of athletes are denied clearance during PPEThe PPE ideally should be performed 6 month prior to present practiceA primary objective of the PPE is to detect conditions that may predispose an athlete to injuryA complete hx will identify about 95% of problems affecting athletes.
9IntroductionEach yr , between 17 and 25 million adolescents engage in some type of sports activity.>6 million high school athletes at about 20,000 high schools.>2 million injuries occur each yr requiring 500,000 doctor visit and 30,000 hospitalization.Since 8/08, at least 12 high school football, 2 youthleague football and 2 soccer players have died during or as a result of athletic participation.
10N M A A S P O R T S M E D I C I N E A D V I S O R Y C O M M I T T E E 2009 Goal #1: Safe Participation Goal #2: Meeting Legal Requirements Goal #3: Preventative Healthcare
11To detect underlying CV abnormality that may predispose an athletes to sudden death
12To disclosure defects that may limit participation
13N M A A S P O R T S M E D I C I N E A D V I S O R Y C O M M I T T E E 2009 Facts A thorough medical history can reveal up to 75% of conditions that would limit or alter sports participation.In conjunction with basic musculoskeletaltesting highlights the fact that the majority of athletes are healthy.Only 3 to 13 percent require further evaluation
14CV causes of sudden death in young athletes HCMCoronary artery anomaliesCommontio cordis (i.e, blunt trauma to the chest causing VF)LVHMyocarditisMarfan syndromeArrythmogenic Right ventricular cardiomyopathyTunneled coronary arteryDilated CMASMyxomatous MV degenerationMVPDrug abuseLong QT syndromeCardiac sarcoidosisBrugada syndrome (genetic disorder of myocardial sodium ion channels)AAFP, The athletic PPE: cardiovascular assessment
15Table 2. Common Etiologies of Sudden Death in Young Athletes ConditionHistorical featuresPhysical examination findingsAortic stenosisPersonal history of exercise-induced chest pain, breathlessness, light-headedness, syncope, or dizzinessConstant apical ejection click; harsh systolic ejection murmur heard best at the upper right sternal border; crescendo-decrescendo murmur, normally grade 3 murmur or higherBrugada syndrome (a genetic disorder of myocardial sodium ion channels)Family history of premature sudden death, particularly in men of Southeast Asian descentUnremarkableCoronary artery diseases (congenital or acquired)Family history of early coronary artery disease, premature sudden death, or coronary anomaliesPersonal history of exercise-induced chest pain, syncope, or fatigueUsually normalHypertrophic cardiomyopathyFamily history of hypertrophic cardiomyopathy, premature sudden death, recurrent syncope, or lethal arrhythmias requiring urgent treatmentPersonal history of Exertional chest pain or syncopeWide range of ausculatory findings, from normal examination to a harsh midsystolic murmur that accentuates with standing or the Valsalva maneuverLong QT syndromeFamily history of premature sudden deathPersonal history of palpitations or recurrent syncopeMarfan syndromeFamily history of Marfan syndrome or premature sudden deathSee Table 5MyocarditisPersonal history of fatigue, Exertional dyspnea, syncope, palpitations, arrhythmias, or acute congestive heart failureMay be normalPalpable or auscultated extra systoles, third or fourth heart sound gallops, and other clinical signs of heart failure should be considered suspiciousArrhythmogenic right ventricular cardiomyopathyFamily history of premature sudden death; more common in persons of Mediterranean descent
16QuizThe most common abnormalities leading to disqualification are _____________The most common cause of sudden death in age older than 35?
17Major Questions to ask in Medical History Screening?
18Critical screening questions Exertional CP or discomfort, or SOB?Exertional syncope or near-syncope, or unexpected fatigue?Hx of cardiac murmur or systemic HTN?FH of HCM, long QT syndrome, Marfan syndrome, significant dysrhythmias?FH of premature death or known CAD in a first- or second-order relative younger than 50 years? (More concern if younger than 40 years.)
20Physical Findings of Marfan Syndrome Aortic insufficiency murmurArachnodactylyArm span that is greater than body heightHigh arched palateKyphosisLenticular dislocationMVPPectus excavatumMyopiaThumb signWrist sign
22Physical Finding in HCM Systolic murmurLouder with standing, decreases with squatting2nd RT ICS or Lt sternal borderLateral displacement of apical impulseHolosystolic murmur of mitral regurgitation at apex with radiation to axilla
23DiscussionEKG from a 33-year-old man with HCM. These are voltage criteria for left ventricular hypertrophy. Note the ST-segment elevation (short arrow) in the lateral leads and biphasic T-waves (long arrow) in V1 to V3.AAFP: The pre-participation Athletic evaluation 2000
24Discussion19 y.o. football player come for PPE, he was found to have II/VI systolic murmur at LLSB. He was referred for an Echo. Echo showed mild LVH, EF 60%, mild TR. Can he play football?
25Athletic Heart Syndrome The Merck Manual online library A constellation of structural and functional changes that occur in the heart of athlete. →Asymptomatic; →Signs include bradycardia, a systolic murmur, and extra heart sounds. →ECG abnormalities are common. →Diagnosis is clinical or by echocardiography. →No treatment is necessary. →It must be distinguished from serious cardiac disorders.
26Features Distinguishing Athletic Heart Syndrome From Cardiomyopathy Left ventricular hypertrophy*< 13 mm> 15 mmLeft ventricular end-diastolic diameter†< 60 mm> 70 mmDiastolic functionNormal (E:A ratio > 1)Abnormal (E:A ratio < 1)Septal hypertrophySymmetricAsymmetric (in hypertrophic cardiomyopathy)Family historyNoneMay be presentBP response to exerciseNormalNormal or reduced systolic BP responseDeconditioningLeft ventricular hypertrophy regressionNo left ventricular hypertrophy regression*A value of 13 to 15 mm is indeterminate.†A value of 60 to 70 mm is indeterminate.E:A ratio = ratio of early to late atrial transmitral flow velocity.The Merck Manual online library
27Athletic Heart Syndrome Prognosis and Treatment Although gross structural changes resemble those in some cardiac disorders, no adverse effects are apparent. In most cases, structural changes and bradycardia regress with detraining, although up to 20% of elite athletes have residual chamber enlargement, raising questions, in the absence of long-term data, about whether the athletic heart syndrome is truly benign.No treatment is required, although 3 mo of deconditioning may be needed to monitor LV regression as a way of distinguishing this syndrome from cardiomyopathy. Such deconditioning can greatly interfere with an athlete's life and may meet with resistance.
32Hypertension classification Definition* Follow-up Table 6. Recommended Follow-up for Hypertension in Children and AdolescentsHypertension classificationDefinition*Follow-upAthletic participationPrehypertensionBlood pressure is between the 90th and 95th percentilesRecheck blood pressure in six monthsFull participation is appropriateStage 1Blood pressure is between the 95th and 99th percentiles plus 5 mm HgRecheck blood pressure during two additional visits in one to two weeks, or sooner if patient is symptomaticParticipation is appropriate, although the patient should avoid power liftingStage 2Blood pressure is above the 99th percentile plus 5 mm HgRefer for immediate evaluation and treatmentParticipation restriction is needed until hypertension is controlledAAFP: The pre-participation Athletic evaluation 2000
33Benign Murmur Absence of associated symptoms Absence of family history Associated with normal, physiologic splitting of S2; absence of other abnormal heart sounds (e.g., clicks, gallops)Early to midsystolicCrescendo-decrescendo murmurMusical, vibratory, or buzzing qualityNormal blood pressure, pulse contour, electrocardiography, or precordial examinationOften heard best over pulmonic area or mid-left sternal borderSoft murmur (grade 1 or 2)AAFP: The pre-participation Athletic evaluation 2000
34Pathologic Murmur Associated arrhythmia Associated left ventricular apical or right ventricular parasternal heaveAssociated with abnormal jugular venous pulse; wide pulse pressure; or brisk, rapidly rising pulse or weak, slowly rising pulseChange in intensity with physiologic maneuvers (especially if murmur becomes louder with valsalva or squat-to-stand maneuvers)Diastolic murmurFamily history of sudden death or cardiac diseaseLong duration (mid- or late-peak or holosystolic murmur)Loud murmur (grade 3 or more)Other abnormal heart sounds (e.g., loud S1, fixed or paradoxically split S2, midsystolic click)Presence of associated symptoms (e.g., chest pain, dyspnea on exertion, syncope)Radiation to axilla or carotidsAAFP: The pre-participation Athletic evaluation 2000
35Contraindications for Sports Active myocarditis or pericarditisHCMSevere HTN until controlled by therapySuspected coronary artery disease until fully evaluated (patients with impaired resting left ventricular systolic function <50%, or exercise-induced ventricular dysrhythmias, or exercise-induced ischemia on exercise stress testing are at greatest risk of sudden death)Long QT interval syndromeHistory of recent concussion and symptoms of post concussion syndrome (no contact or collision sports)Poorly controlled convulsive disorderRecurrent episodes of burning upper-extremity pain or weakness, or episodes of transient quadriplegia until stability of cervical spine can be assured (no contact or collision sports)Sickle cell diseaseEating disorderAcute enlargement of spleen or liverInformation from Smith DM. Preparticipatation physical evaluation. 2d ed. Minneapolis: Physician and Sports medicine, 1997.
36Common Questions on PPE EyeFeverHeart murmurDiabetes mellitusDiarrheaEating disordersHIV infectionHTNConvulsive disorderAsthmaSickle cell diseaseSickle cell traitEnlarged spleenTesticleMVPEnlarge liverAbsence of one kidneyMolluscum contagiosumHSVImpetigoTinea corporisScabies
37Required stations on PPE Sign in, ht, wt, vital signs, visionHistory reviewPE (medical and orthopedic)Medical clearance
38ConclusionThe pre-participation physical exam is the single most effective method of addressing the health concerns of the adolescent student-athlete. ◊ Promotes safe participation ◊ Identifies areas of concern ◊ Helps satisfies legal requirements ◊ Addresses risk management issues ◊ Increasing the chance that the student athlete will have the best possible outcome
39References:“Primary care reports” The practical journal for primary care and family physician. Nov. 13, 2000“The athletic preparticipation evaluation: cardiovascular assessment” AFP April 1, 2007.“The preparticipation athletic evaluation” AFP May 1, 2000NMAA sports medicine advisory committee 2009The Merck Manual online library