Cardiac Issues in Athletic Cardiac Issues in Athletic Participation:Participation:

To Screen or Not to Screen? To Screen or Not to Screen? George C. Phillips, MD, FAAP, CAQSM George C. Phillips, MD, FAAP, CAQSM

September 18, 2008September 18, 2008

Sports Medicine RoundsSports Medicine Rounds

Cardiac Issues in SportsCardiac Issues in Sports

12 million high school athletes in the U.S. 12 million high school athletes in the U.S. Estimated 0.5% risk of sudden cardiac Estimated 0.5% risk of sudden cardiac

death in young athletesdeath in young athletes ~60,000 athletes with a potentially life-~60,000 athletes with a potentially life-

threatening condition threatening condition Estimated 1/200,000 high school athletes Estimated 1/200,000 high school athletes

suffer sudden cardiac death each year (60)suffer sudden cardiac death each year (60) Currently, routine screening includes a Currently, routine screening includes a

history and physical examhistory and physical exam

Cardiac History Screening Cardiac History Screening 1.01.0

Previous murmur or high BPPrevious murmur or high BP Family history of early MI or sudden Family history of early MI or sudden

deathdeath Exercise-related symptomsExercise-related symptoms Survey of PPE forms from 254 high Survey of PPE forms from 254 high

schools, only 17% had all three schools, only 17% had all three questionsquestions

Cardiac History Screening Cardiac History Screening 2.02.0

Unpublished data from Rausch and Unpublished data from Rausch and Phillips: Phillips: Review of standard physical forms from Review of standard physical forms from

47 states 47 states 85% (40/47) had all three elements for 85% (40/47) had all three elements for

cardiac screening on their PPE formcardiac screening on their PPE form

Cardiac History ScreeningCardiac History Screening

Preparticipation Physical Evaluation, 3Preparticipation Physical Evaluation, 3rdrd Ed.Ed.

Have you ever passed out or nearly Have you ever passed out or nearly passed out during exercise? passed out during exercise?

Have you ever passed out or nearly Have you ever passed out or nearly passed out after exercise? passed out after exercise?

Have you ever had discomfort, pain, or Have you ever had discomfort, pain, or pressure in your chest during exercise? pressure in your chest during exercise?

Does your heart race or skip beats during Does your heart race or skip beats during exercise? exercise?

Cardiac History ScreeningCardiac History Screening

Has a doctor ever told you that you have high blood Has a doctor ever told you that you have high blood pressure, high cholesterol, a heart murmur, or a pressure, high cholesterol, a heart murmur, or a heart infection? heart infection?

Has a doctor ever ordered a test for your heart? Has a doctor ever ordered a test for your heart? Has anyone in your family ever died for no Has anyone in your family ever died for no

apparent reason? apparent reason? Does anyone in your family have a heart problem? Does anyone in your family have a heart problem? Has any family member or relative died of heart Has any family member or relative died of heart

problems or sudden death before age 50? problems or sudden death before age 50? Does anyone in your family have Marfan syndrome? Does anyone in your family have Marfan syndrome?

Cardiac History ScreeningCardiac History Screening

Same 47 state forms reviewedSame 47 state forms reviewed 17% (8/47) completely addressed all of 17% (8/47) completely addressed all of

the recommended screening questions the recommended screening questions Forms were generally better at questions Forms were generally better at questions

addressing exercise related symptoms addressing exercise related symptoms (79-100%) than past medical or family (79-100%) than past medical or family history (32-45%) with the exception of history (32-45%) with the exception of family history of early sudden/cardiac family history of early sudden/cardiac death (98%)death (98%)

Sudden Death in AthletesSudden Death in Athletes

Maron – 1985-1995, 158 sudden Maron – 1985-1995, 158 sudden deaths among trained athletesdeaths among trained athletes 134 were due to cardiovascular disease134 were due to cardiovascular disease Only 1 case had findings on PPEOnly 1 case had findings on PPE 68% played basketball or football68% played basketball or football

Hypertrophic Hypertrophic CardiomyopathyCardiomyopathy

Number one cause in Number one cause in athlete < 35 years oldathlete < 35 years old

Autosomal dominant, Autosomal dominant, frequency ~ 1:500frequency ~ 1:500 Only ~ 30% gene Only ~ 30% gene

penetrancepenetrance ~ 5% lifetime risk with ~ 5% lifetime risk with

disorder disorder Normal type histology, Normal type histology,

but with significant but with significant disarraydisarray

Hypertrophic Hypertrophic CardiomyopathyCardiomyopathy

Asymmetric septal Asymmetric septal hypertrophy (>15 mm)hypertrophy (>15 mm)

Anterior motion of Anterior motion of mitral valve in systolemitral valve in systole

Functional LV outflow Functional LV outflow tract obstruction tract obstruction Syncope with exerciseSyncope with exercise

Systolic ejection Systolic ejection murmur murmur Increases with Valsalva, Increases with Valsalva,

standing positionstanding position preload exacerbates preload exacerbates

the functional the functional obstructionobstruction

Hypertrophic Hypertrophic CardiomyopathyCardiomyopathy

Cellular abnormalities in the heart Cellular abnormalities in the heart cause other problems as wellcause other problems as well

Electrical conduction problems cause Electrical conduction problems cause arrhythmias arrhythmias Ventricular tachyarrhythmia Ventricular tachyarrhythmia

Congestive heart failure Congestive heart failure Myocardial ischemiaMyocardial ischemia

Commotio CordisCommotio Cordis

Perfectly timed blow to the chest Perfectly timed blow to the chest Many factors affect the transmission Many factors affect the transmission

of force from impact into a disruption of force from impact into a disruption of the cardiac electrical cycle of the cardiac electrical cycle Size and compliance of the chest wall Size and compliance of the chest wall Speed/force of impact (~40 mph) Speed/force of impact (~40 mph) Localization of impactLocalization of impact

No underlying cardiac history in No underlying cardiac history in victimsvictims

Reduced Risk of Sudden Death Reduced Risk of Sudden Death From Chest Wall Blows From Chest Wall Blows

(Commotio Cordis) With Safety (Commotio Cordis) With Safety BaseballsBaseballs

Mark S. Link, MD*; Barry J. Maron, MD‡; Paul Mark S. Link, MD*; Barry J. Maron, MD‡; Paul J. Wang, MD*; Natesa G. Pandian, MD*; J. Wang, MD*; Natesa G. Pandian, MD*; Brian A. VanderBrink, BA*; and N. A. Mark Brian A. VanderBrink, BA*; and N. A. Mark Estes III, MD* Estes III, MD*

(Pediatrics 2002) (Pediatrics 2002)

ARVDARVD

Normal heart tissue is replaced by Normal heart tissue is replaced by fibrofatty tissue fibrofatty tissue

Dilatation or formation of aneurysms Dilatation or formation of aneurysms in the right ventricular wall in the right ventricular wall

Very different experience from Italy Very different experience from Italy Genetics? Genetics? Effect of their screening programEffect of their screening program

Universal EKGsUniversal EKGs

The QuestionThe Question

Should young athletes in the U.S. be Should young athletes in the U.S. be routinely screened beyond the routinely screened beyond the preparticipation history and physical preparticipation history and physical for cardiac abnormalities? for cardiac abnormalities?

~30,000 Italian athletes ~30,000 Italian athletes Demographics (78% male, 98% white) Demographics (78% male, 98% white) Sports (31.3% soccer, 17.7% volleyball) Sports (31.3% soccer, 17.7% volleyball) Resting EKG – 6% abnormalResting EKG – 6% abnormal

Upon further review, only 1.2% true positives Upon further review, only 1.2% true positives Under age 30, only 0.65% true positives Under age 30, only 0.65% true positives

Exercise EKG – 4.9% abnormal Exercise EKG – 4.9% abnormal Under age 30, 4.1% abnormal Under age 30, 4.1% abnormal

159 athletes DQ’s = 0.46% 159 athletes DQ’s = 0.46%

Cardiovascular evaluation, including resting and exercise Cardiovascular evaluation, including resting and exercise electrocardiography, before participation in competitive electrocardiography, before participation in competitive sports: cross sectional studysports: cross sectional studyBMJ 2008BMJ 2008

What if in the U.S.? What if in the U.S.?

12 million high school athletes 12 million high school athletes Resting EKGs – 720,000 initially abnormalResting EKGs – 720,000 initially abnormal

Only 78,000 true positives Only 78,000 true positives Exercise EKGs – 492,000 abnormal Exercise EKGs – 492,000 abnormal DQs – 55,200 athletes (13,800 annually DQs – 55,200 athletes (13,800 annually

thereafter) thereafter) Cost: $600 million in year one, then $150 Cost: $600 million in year one, then $150

million annually thereafter if only one million annually thereafter if only one screening for entry into high school sportsscreening for entry into high school sports

What if in the U.S.?What if in the U.S.?

~$11,000 per athlete DQ’d ~$11,000 per athlete DQ’d Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy

Prevent 16 deaths annually Prevent 16 deaths annually $2.475 million per death prevented $2.475 million per death prevented

Commotio Cordis Commotio Cordis Prevent 8 of 12 deaths annually Prevent 8 of 12 deaths annually Safety baseballs @ 10 dozen per team, $3 per Safety baseballs @ 10 dozen per team, $3 per

baseball, and 15,500 HS teams baseball, and 15,500 HS teams ~$700,000 per death prevented~$700,000 per death prevented