2. Cardiac Pre-Participation Exam and Abnormalities Jamie B. Varney, M.D. CAQ Sports Medicine Pikeville Medical Center Orthopedics and Sports Medicine

3. Guidelines AAFP,AAP,AMSSM,AOSSM,AOASM publish guidelines to follow 1 AHA has specific recommendations 2AHA has specific recommendations 2 36 th Bethesda Recommendations 336 th Bethesda Recommendations 3 Seattle Criteria EKG Interpretation 4

4. AHA Recommendations 2 Medical history * ▫Personal history  Exertional chest pain/discomfort  Unexplained syncope/near-syncope†  Excessive exertional and unexplained dyspnea/fatigue, associated with exercise  Prior recognition of a heart murmur  Elevated systemic blood pressure *Parental verification is recommended for high school and middle school athletes †Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion

5. AHA Recommendations 2 Family history Premature death (sudden and unexpected, or otherwise) before age 50 years due to heart disease, in 1 relative Disability from heart disease in a close relative <50 years of age Specific knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy long-QT syndrome or other ion channelopathies, Marfan syndrome clinically important arrhythmias

6. AHA Recommendations 2 ▫Physical examination  Heart murmur ††  Femoral pulses to exclude aortic coarctation  Physical stigmata of Marfan syndrome  Brachial artery blood pressure (sitting position) ††† †† Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction †††Preferably taken in both arms

7. Cardiac Exam Vital signs ▫Resting pulse ▫Resting BP, preferably both arms Auscultation ▫Rate and Rhythm ▫Murmurs  Supine and standing or with valsalva Palpation of Apical Impulse Pulses ▫Femoral ▫Radial ▫Assess for delay (Coarctation)

8. Vital Signs Bradycardia may be normal Low BP not uncommon If asymptomatic with appropriate response to exercise likely no further evaluation needed Keep in mind that children/adolescents have different normal values for elevated BP ▫Age and height percentile tables 5

9. Murmurs 1Barely audible 2 Soft but easily heard 3 Loud but not accompanied by a thrill 4 Loud and associated with a palpable thrill 5 Associated with a thrill and heard with the stethoscope partially off the chest 6 Audible without a stethoscope Grade

10. Cardiac Timing 6

11. Murmurs 7 Innocent/Functional Pathologic Less than Grade 3 Systolic Decrease from supine to standing Grade 3 or greater Any diastolic component Increases with standing or valsalva Decreases with squatting

12. Murmur of HCM Systolic heard best at lower left sternal border Increases with standing or valsalva Decreases with squatting NO PARTICIPATION including lifting until full cardiac workup

13. Murmur of Aortic Stenosis Systolic ejection murmur Crescendo/Decrescendo Radiates to Carotids NO PARTICIPATION including lifting until full cardiac workup and see Bethesda recommendations 3

14. Mitral Valve Prolapse Mid-systolic click Late systolic murmur

15. 36 th Bethesda Recommendation 3 Whatever cardiac condition you discover these recommendations are extremely helpful in evaluation and recommendations

16. Need for EKG/Echo/EST AHA - Only if identified risk or suspicious finding 2 Cost inefficient to screen everyone European Society of Cardiology recommends EKG (high rate AVRD in Italy) Seattle EKG Criteria group investigating Special consideration for athletes > 35 “masters athletes” with CAD as primary cause of SCD EKG/Echo first is suspect cardiac abnormality (before stress)

17. Sudden Cardiac Death (SCD) Estimated prevalence 1:200,000 2 Most athletes who die suddenly have no symptoms Difficult to detect risk prior to event Any athlete with any suspected risk can not participate until evaluated properly

18. Causes of SCD 8 Hypertrophic Cardiomyopathy (HCM) 36% another % possible HCM Coronary Artery Anomalies 17% Myocarditis 6% Arrhythmogenic right ventricular dysplasia 4% Mitral valve prolapse 4% Aortic Stenosis 3% Coronary Atherosclerosis 3% Ion Channelopathies 3% Ideopathic Dilated Cardiomyopathy 2% Aortic rupture (Marfan syndrome) 2% Other 2%

19. Causes in Absence of Structural Disease Commotio Cordis Long QT Syndrome Brugada Syndrome Catecholaminergic polymorphic VT

20. Challenges in Screening Large population Low prevalence 2 ▫Estimated 0.3% underlying congenital heart disease

21. EKG Interpretation: Seatle Criteria 4 Online Training Module 9 Committee to establish normal and abnormal findings on EKG for Athletes

22. Normal EKG Findings in Athletes 4 Sinus Bradycardia >30 bpm Sinus Arrhythmia Ectopic Atrial Rhythm Junctional Escape Rhythm 1 st Degree AV block (PR>200ms) Mobitz Type I (Wenckebach) 2 nd Degree AV block Incomplete RBBB Isolated QRS voltage criteria for LVH ▫Unless also non voltage criteria present  Left atrial enlargement, Left axis deviation, ST depression, T- wave inversion, pathological Q waves Early Repolarisation (ST elevation, J-point elevation) Convex ST segment elevation with T wave inversion in V1- V4 in African Americans

23. Abnormal EKG Findings in Athletes 4 T-Wave Inversion ▫>1mm in 2 or more leads excluding III, aVR, V1 ST Depression ▫≥0.5mm in 2 or more leads Pathologic Q waves ▫>3mm or >40 ms in 2 or more leads except III and aVR Complete LBBB ▫QRS ≥120 ms, predominantly negative QRS in V1 and upright R wave in leads I and V6 IVCD ▫QRS ≥ 140 ms Left Axis Deviation ▫(-30 to -90 degrees)

24. Abnormal EKG Findings in Athletes 4 Left Atrial Enlargement ▫Prolonged P wave > 120 ms in lead I, II with depth ≥1mm and ≥40 ms duration in V1 Right Ventricular Hypertrophy ▫R in V1 and S in V5 >10.5 mm AND right axis deviation > 120 degrees Ventricular Pre Excitation ▫PR 120 ms Long QTc ▫Male ≥ 470 ms Female ≥ 480 ms Short QTc ≤320 ms

25. Abnormal EKG Findings in Athletes 4 Brugada-Like Pattern ▫High take off and downsloping ST segment elevation followed by negative T wave in 2 or more leads V1-V3 Profound Bradycardia < 30BPM or pauses ≥ 3sec Atrial tachyarrhythmias ▫SVT, Afib, Aflutter PVC’s ≥ 2 per 10 sec Ventricular Arrhythmias ▫Couplets, Triplets, Non-sustained V-Tach

27. Hypertrophic Cardiomyopathy 0.2% of general population 2, 3 Family history in 30 % 10 90% of those with HCM have abnormal EKG 10 Typically asymmetric hypertrophy with LV wall thickness > 16mm 3 Athlete’s Heart has symmetric hypertrophy and thickness generally < 12mm 3 HCM Phenotype can develop over 3-4 yrs 3

28. Diagnosis of HCM Characteristic murmur EKG ▫Dramatically increased voltage ▫Prominent Q waves ▫Deep T-wave inversion Echo Exercise testing or Stress Echo

29. HCM 11

30. HCM 12

31. HCM Recommendations 3 Athletes with definite or probable HCM should not compete in athletics except possibly Low Intensity Independent of symptoms, age, or treatment

32. Coronary Artery Anomalies May present with angina or syncope Typically diagnosed with angiography or possibly Cardiac CT/MR Exclude from sports unless corrected 3 ▫3 months after correction may participate unless  Previous MI  Or abnormal maximal exercise test

33. Myocarditis Be suspicious in athletes with febrile illnesses Diffuse EKG repolarization abnormalities Pericardial friction rub Those with probable or definite myocarditis should be removed from sports for minimum of 6 months 3 Must have complete evaluation prior to return ▫Normal EKG, Echo, no arrhythmias on Holter or EST, normalization of inflammatory markers 3

34. Myocarditis 13

35. Arrhythmogenic right ventricular dysplasia (ARVD) Fatty infiltration of right ventricular myocardium Mortality at 10 yrs 20% 7 More common in Italy (most common cause of SCD) Exercise induced palpitations, syncope EKG ▫QRS duration in V1 > 110 msec ▫Epsilon wave in V1 or V2 ▫T-wave inversion in right precordial leads

36. ARVD 14

37. Epsilon Wave 15

38. ARVD Recommendations 3 No participation except perhaps low intensity Cautious with activities due to risk of syncope ▫Freeweights, swimming, scuba

39. Mitral Valve Prolapse Can participate in all sports unless the following exist 3 (may participate in low intensity) ▫History of syncope documented to be arrythmogenic ▫Family history of SCD caused by MVP ▫SVT and VT worsened by exercise ▫Moderate/severe mitral regurgitation ▫Prior embolic event Also is minor criterion for Marfans

40. Commotio Cordis 10 Cardiac contusion Arrhythmia precipitated to external blow to heart At least 70 deaths (40 in baseball) Survival rate 10%

41. Long QT Syndrome Be aware that some meds may cause or worsen ▫Antibiotics, albuterol, antidepressants, stimulants, etc. Genetic testing (Type 1,2,3) Limit to low-intensity 3 ▫suspected LQTS associated syncope ▫Asymptomatic with QTc ≥ 470 in men and 480 in women ▫Restrict from swimming and diving if Type 1 ▫LQTS Type 3 who are asymptomatic may do more

42. Long QT 16

43. Brugada Syndrome RBBB and ST elevation V1-V3 Type 1 (coved) more concerning or if type 2/3 can be converted to coved with sodium channel blocker Bethesda (2005): Restrict to low intensity 3 No clear exercise relation 7 and AHA has looser guidelines published in 2004 that suggest avoiding high intensity and risk of loss of consciousness

44. 17

45. Brugada 18

46. Brugada 19

47. Marfans See Bethesda Recs Mostly Low intensity only unless Echo abnormal or family Hx SCD 3

49. 1 st degree AV Block 20 PR > 200 msec If asymptomatic no further workup/restriction unless excessive (>300 msec) 3

50. 2 nd Degree Type I (Wenckebach) Progressive prolonged PR then dropped QRS complex Should be evaluated with Echo/Stress If has coexisting bundle branch block may consider EPS If no worsening of EKG or symptoms may participate 3

51. 2 nd Degree Type II (Mobitz) Random drop of QRS complex without associated PR prolongation Require pacemaker No contact sports with pacemaker 3

52. 21

53. 3 rd Degree AV Block 20 AV dissociation Require pacemaker 3

54. Bundle Branch Blocks Recommend Echo / Stress Consider EPS for LBBB in children May compete if do not develop heart block or ventricular arrhythmia 3

55. 22

56. Tachycardias Afib ▫Echo/Stress/Holter ▫Appropriate increase/decrease in HR may participate 3 Aflutter ▫Echo/Stress/Holter ▫If no structural disease and appropriate increase/decrease in HR may participate 3 Anticoagulation is contraindication to contact sports

57. Tachycardias SVT ▫Echo/Stress/Holter ▫If treated may compete 3 ▫May need stress with treatment to determine if adequate exercise control WPW 3 ▫Echo/Stress/Holter ▫Consider EPS (especially <20 y/o or symptomatic) ▫If no tachycardia or structural disease may compete ▫If has tachycardia and treated may compete ▫Remember this is not treated with B-blockers, Ca Channel blockers or Digoxin. ▫May need repeat stress to document treatment

58. Vtach 3 Without structural disease ▫May compete if ablated and documented improvement by EPS/Stress/Holter ▫If treated with medication no competition for at least two to three months after the last VT episode  If no recurrences, and the VT is not inducible by EPS/Stress/Holter may compete. ▫Asymptomatic athlete with less than 8 to 10 consecutive ventricular beats of nonsustained monomorphic VT, rates generally less than 150 beats/min without worsening with stress/Holter may compete With structural heart disease and VT, moderate- and high-intensity competition is contraindicated regardless of whether the VT is suppressed or ablated

59. Summary Asking appropriate history is best resource for finding potential abnormalities If there is any concern hold player and work up/refer Bethesda Recommendations General starting point is EKG/Echo Stress/Stress Echo if needed Add Holter if arrhythmia is suspected and EPS if indicated If persistent symptoms may consider angiogram or Cardiac CT/MR to evaluate anatomy Evaluate for other sources if work up negative ▫Respiratory/GI/ Musculoskeletal

60. References 1.American Academy of Family Physicians, American Academy of Pediatrics, American College of Sports Medicine. Preparticipation Physical Evaluation, 4th Ed., Bernhardt D, Roberts W (Eds), American Academy of Pediatrics, 2010 2.American Heart Association Recommendations and Considerations Related to Pre-participation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007 Update. Circulation, Mar 2007; 115: 1643 - 1655. 3.36th Bethesda Conference: Eligibility Recommendations for Competitive Athletes With Cardiovascular Abnormalities. Journal of the American College of Cardiology Vol. 45, No. 8, 2005 4.Drezner, J. et al Electrocardiographic Interpretation in Athletes: The ‘Seattle Criteria’ 5.http://www.nhlbi.nih.gov/health-pro/guidelines/current/hypertension-pediatric-jnc-4/blood-pressure-tables.htm 6.Image http://www.vetgo.com/cardio/concepts/concsect.php?conceptkey=46http://www.vetgo.com/cardio/concepts/concsect.php?conceptkey=46 7.Hergenroeder, A. UpToDate. The Preparticipation Sports Examination in Children and Adolescents. (6-17-2014) 8.Pelliccia, A.,Link, M. UpTo Date. Risk of Sudden Cardiac Death in Athletes. (3-1-2013) 9. Seattle Criteria Online Training www.amssmfoundation.org/ECG-Training-Module.php 10. Mellion, M. et al. Team Physician’s Handbook 3 rd edition.Hanley & Belfus Inc. 2002. 11. HCM Image http://www.doctorwiki.net/2007/01/background-apical-hypertrophic.htmlhttp://www.doctorwiki.net/2007/01/background-apical-hypertrophic.html 12. HCM Image 2 http://www.aafp.org/afp/20000501/2683.htmlhttp://www.aafp.org/afp/20000501/2683.html 13.Myocarditis http://www.amc.edu/amr/archives/200408/EKG2_ans.htmlhttp://www.amc.edu/amr/archives/200408/EKG2_ans.html 14.ARVD Image http://www.hosp.u-toyama.ac.jp/clla/seiri/ecg/kongetu_ecg/arvd.html 15.Epsilon Wave Image http://commons.wikimedia.org/wiki/Image:ARVD-Epsilon_wave.pnghttp://commons.wikimedia.org/wiki/Image:ARVD-Epsilon_wave.png 16.Long QT Image http://www.emedu.org/ecg/crapsanyallans.phphttp://www.emedu.org/ecg/crapsanyallans.php 17. Brugada Table http://askdrwiki.com/mediawiki/index.php?title=Brugada_syndrome 18. Brugada Image http://scienceblogs.com/purepedantry/2007/11/the_differential_diagnosis_of.phphttp://scienceblogs.com/purepedantry/2007/11/the_differential_diagnosis_of.php 19. Brugada Criteria http://emcrit.org/065-132/074-dysrhythm.htmhttp://emcrit.org/065-132/074-dysrhythm.htm 20. AV Block Image http://www.pacemakerproject.com/cardiac_phy/cp_AV_block.htmhttp://www.pacemakerproject.com/cardiac_phy/cp_AV_block.htm 21. Heart Block Image http://www.learnwell.org/EKG200.htmhttp://www.learnwell.org/EKG200.htm 22. Bundle Branch Block Image http://forlag.fadl.dk/sample/ppaulev/chapter11/kap.11.htmhttp://forlag.fadl.dk/sample/ppaulev/chapter11/kap.11.htm 23. All Murmur Sound Courtesy of http://www.egeneralmedical.com/listohearmur.html