Presentation on theme: "Cardiac Issues in Athletic Participation: To Screen or Not to Screen?"— Presentation transcript:
1 Cardiac Issues in Athletic Participation: To Screen or Not to Screen? George C. Phillips, MD, FAAP, CAQSMSeptember 18, 2008Sports Medicine Rounds
2 Cardiac Issues in Sports 12 million high school athletes in the U.S.Estimated 0.5% risk of sudden cardiac death in young athletes~60,000 athletes with a potentially life-threatening conditionEstimated 1/200,000 high school athletes suffer sudden cardiac death each year (60)Currently, routine screening includes a history and physical exam
3 Cardiac History Screening 1.0 Previous murmur or high BPFamily history of early MI or sudden deathExercise-related symptomsSurvey of PPE forms from 254 high schools, only 17% had all three questions
4 Cardiac History Screening 2.0 Unpublished data from Rausch and Phillips:Review of standard physical forms from 47 states85% (40/47) had all three elements for cardiac screening on their PPE form
5 Cardiac History Screening Preparticipation Physical Evaluation, 3rd Ed.Have you ever passed out or nearly passed out during exercise?Have you ever passed out or nearly passed out after exercise?Have you ever had discomfort, pain, or pressure in your chest during exercise?Does your heart race or skip beats during exercise?
6 Cardiac History Screening Has a doctor ever told you that you have high blood pressure, high cholesterol, a heart murmur, or a heart infection?Has a doctor ever ordered a test for your heart?Has anyone in your family ever died for no apparent reason?Does anyone in your family have a heart problem?Has any family member or relative died of heart problems or sudden death before age 50?Does anyone in your family have Marfan syndrome?
7 Cardiac History Screening Same 47 state forms reviewed17% (8/47) completely addressed all of the recommended screening questionsForms were generally better at questions addressing exercise related symptoms (79-100%) than past medical or family history (32-45%) with the exception of family history of early sudden/cardiac death (98%)
8 Sudden Death in Athletes Maron – , 158 sudden deaths among trained athletes134 were due to cardiovascular diseaseOnly 1 case had findings on PPE68% played basketball or football
10 Hypertrophic Cardiomyopathy Number one cause in athlete < 35 years oldAutosomal dominant, frequency ~ 1:500Only ~ 30% gene penetrance~ 5% lifetime risk with disorderNormal type histology, but with significant disarray
11 Hypertrophic Cardiomyopathy Asymmetric septal hypertrophy (>15 mm)Anterior motion of mitral valve in systoleFunctional LV outflow tract obstructionSyncope with exerciseSystolic ejection murmurIncreases with Valsalva, standing positionpreload exacerbates the functional obstruction
12 Hypertrophic Cardiomyopathy Cellular abnormalities in the heart cause other problems as wellElectrical conduction problems cause arrhythmiasVentricular tachyarrhythmiaCongestive heart failureMyocardial ischemia
13 Commotio Cordis Perfectly timed blow to the chest Many factors affect the transmission of force from impact into a disruption of the cardiac electrical cycleSize and compliance of the chest wallSpeed/force of impact (~40 mph)Localization of impactNo underlying cardiac history in victims
15 Reduced Risk of Sudden Death From Chest Wall Blows (Commotio Cordis) With Safety Baseballs Mark S. Link, MD*; Barry J. Maron, MD‡; Paul J. Wang, MD*; Natesa G. Pandian, MD*; Brian A. VanderBrink, BA*; and N. A. Mark Estes III, MD*(Pediatrics 2002)
16 ARVD Normal heart tissue is replaced by fibrofatty tissue Dilatation or formation of aneurysms in the right ventricular wallVery different experience from ItalyGenetics?Effect of their screening programUniversal EKGs
18 The QuestionShould young athletes in the U.S. be routinely screened beyond the preparticipation history and physical for cardiac abnormalities?
19 Demographics (78% male, 98% white) Cardiovascular evaluation, including resting and exercise electrocardiography, before participation in competitive sports: cross sectional study BMJ 2008~30,000 Italian athletesDemographics (78% male, 98% white)Sports (31.3% soccer, 17.7% volleyball)Resting EKG – 6% abnormalUpon further review, only 1.2% true positivesUnder age 30, only 0.65% true positivesExercise EKG – 4.9% abnormalUnder age 30, 4.1% abnormal159 athletes DQ’s = 0.46%
20 What if in the U.S.? 12 million high school athletes Resting EKGs – 720,000 initially abnormalOnly 78,000 true positivesExercise EKGs – 492,000 abnormalDQs – 55,200 athletes (13,800 annually thereafter)Cost: $600 million in year one, then $150 million annually thereafter if only one screening for entry into high school sports
21 What if in the U.S.? ~$11,000 per athlete DQ’d Hypertrophic CardiomyopathyPrevent 16 deaths annually$2.475 million per death preventedCommotio CordisPrevent 8 of 12 deaths annuallySafety 10 dozen per team, $3 per baseball, and 15,500 HS teams~$700,000 per death prevented