Cardiovascular Risk Assessment inCardiovascular Risk Assessment in the Young Athlete

D id B G l MDDavid B. Gremmels, MDPediatric CardiologistChildren’s Heart ClinicChildren s Heart ClinicChildren’s Hospitals and Clinics of MN

No disclosure or financial relationships

Goals Background Clinical evaluation Clinical evaluation Diseases Testing

Athletes Are Challenging Stakes are high for diagnosis. CV system may be pushed to limit CV system may be pushed to limit. Consequences of misdiagnosis are

potentially devastatingpotentially devastating. < 30 years – congenital/structural abnl > 30 years – coronary artery disease

Difficult Problem Estimation of the incidence of sudden death

in the young in the United States is critical to understand the scope of the problem

Need to know the actual incidence to make recommendations as to the cost-effectiveness

Implementing any strategy to reduce the i idincidence

Devise appropriate preventative strategies Inform policy makers who allocate resources

Risk of Sudden Death 1 in 200,000 athletes will die suddenly. Annual U S Death rate 15 cases per 3 Annual U.S. Death rate 15 cases per 3

million high school athletes in sports.Male:female=5:1 Male:female=5:1.

Mortality Rates U.S. (2000)Automobile related deaths 15,000-18,000

Young adult homicide 6,000

S i id 5 000Suicide 5,000

Pregnancies < 18 yrs 1 000 000Pregnancies < 18 yrs 1,000,000

Sudden cardiac deaths/year 15y

Purposes of Sports Exam Excellent opportunity to provide health

educationeducation

Determine whether there are Determine whether there are contraindications to participation or manageable medical conditionsmanageable medical conditions

What Cardiac diseases? Hypertrophic Cardiomyopathy Coronary artery abnormalities Coronary artery abnormalities LV outflow tract obstruction Arrhythmias Myocarditis Arrhythmogenic right ventricular

dysplasiadysp as a G. Marfan’s syndrome

1/3 cases suspected to be of cardiac etiology don’t have a dx.

Sudden Death in Athletes

OthOther6%

CAD2%

MVP2%

Dilated CM

ARVD3%

HCMMyocarditis

3%

Dilated CM3%

HCM38%Aortic Stenosis

4%

3%

LVH10%

Coronary Abnl24%

Ruptured Ao5%

Circumstances of Pediatric SCD

Emotional upset

Routine47%

Sleep25%

upset5%

47%

Exercise23%

Sudden Cardiac Death: Can YouSudden Cardiac Death: Can You Identify the Patient at Risk?

“In the fields of observationIn the fields of observation, chance only favors the mind

that is prepared ”that is prepared.” Louis Pasteur

Pre-participation screening May identify <10% of athletes at risk of

SCDSCD Physical Exam is typically normal

History of prior exercise related History of prior exercise related symptoms is frequently present

? What questions are important?

Identification of Risk Factors: Personal History Syncope during exercise Frequent, severe dizziness or recurrentFrequent, severe dizziness or recurrent

syncope Chest pain during exerciseChest pain during exercise Prolonged “flu” Previous Kawasaki disease Previous Kawasaki disease Palpitations

S i Seizures

How often are symptoms y ppresent? Exercise related syncope in 20-25% Dizziness in 16% Dizziness in 16% Chest pain in 6% “Seizure” may be only symptom of

prolonged QT syndrome

Identification of Risk Factors: Family History Sudden death at <30 years of age Long QT syndrome Long QT syndrome Hypertrophic cardiomyopathy Marfan syndrome Arrhythmogenic right ventricular

dysplasia Very early-onset coronary artery e y ea y o set co o a y a te y

disease

PHYSICAL EXAM

Heart Rate/Rhythm Blood Pressure/Pulses Syndromesy Abnormal Heart Sounds and Murmurs

KEY POINT! Further testing should be performed if

any part of History and/or Physical isany part of History and/or Physical is suspiciousECG ECHO STRESS TEST ECG, ECHO, STRESS TEST, Cardiology consult

Screening tests without indication are not warranted.

Case #1 16-year-old boy playing soccer in

gym. Good health. Complained ofgym. Good health. Complained of chest pain while running. Asked to go sit down. Collapsed. CPR started.sit down. Collapsed. CPR started. Paramedics arrived and shocked him b/c of pulseless V-tach.b/c of pulseless V tach.

Hypertrophic Cardiomyopathy Autosomal dominant (50% spont

mutation)mutation) Variable penetrance and expression

Leading cause of SCD in athletes Leading cause of SCD in athletes Frequently clinically silent

Hypertrophic Cardiomyopathy Symptoms:

Exertional Chest Physical Exam:

Systolic Ejection Pain

DyspneaS

Murmur at LLSB. Increases valsalva

D tti Syncope Asymptomatic

Decreases squatting Normal exam

Case #2 17-year-old male collapsed playing

basketball. CPR started. In the ED,basketball. CPR started. In the ED, EKG showed significant ST abnormality. Occasional ventricularabnormality. Occasional ventricular tachycardia.

Echo obtained. Diagnosis made and surgical repair Diagnosis made and surgical repair

scheduledPatient doing great Patient doing great

Causes of Pediatric SCD:Coronary Abnormality Congenital

Origin of LCA from right coronary sinus Origin of LCA from right coronary sinus Single coronary Origin of LCA from pulmonary artery Origin of LCA from pulmonary artery

AcquiredK ki di Kawasaki disease

Coronary artery disease (cocaine)

Case #3 18-year-old participated in gym class

on Friday, but didn’t feel well/light headed. Presented to ER that night with mild increased work of breathing

d h CXR bt i dand cough. CXR obtained. Cardiomegaly. Echo showed severe LV dysfunctionLV dysfunction.

Hx: fever, 2-3weeks URI Sx. 10lb weight gainweight gain.

Myocarditis Viral prodrome Malaise and fatigue Malaise and fatigue Resting tachycardia Gallop ECG (ST segment changes) Echo shows depressed LV function

Arrhythmogenic Right yt oge c g tVentricular Dysplasia

Autosomal dominant 2nd most common etiology of SCD in 2 most common etiology of SCD in

ItalyPresents with ventricular tachycardia Presents with ventricular tachycardia

Echo may show RV dysfunction or normal

Diagnosed by cardiac MRI

Case #4 7-year-old girl 2 seizures post exertion recently 2 seizures post exertion recently.

Happened before many times when mad (assumed breath holding spells)mad (assumed breath holding spells).

Admitted for overnight EEGC / f Cardiology consult b/c of HR monitor alarm

Prolonged QT Syndrome Corrected QTc > 0.45 seconds Recurrent episodes of exertional or Recurrent episodes of exertional or

emotional syncopeFamilial Familial

Rx – B blockers, defibrillator

Athletes can present with psymptoms that are benign Dizziness caused by dehydration SOB: endurance concerns Chest pain: musculoskeletal pain Palpitations: benign premature contractions Palpitations: benign premature contractions SOB: bronchitis, exercise bronchospasm

Nevertheless, thorough investigation is often needed for the reassurance they need.needed for the reassurance they need.

Simple recommended evaluation

What to do when…

Family History: Risk FactorsFamily History: Risk Factors

Familial disorder ScreeningHypertrophic cardiomyopathy ECG, Echo

Arrhythmogenic right ventricular d l i

ECG, Echodysplasia

Long QT ECG

Marfan s ndrome Echo e e e amMarfan syndrome Echo, eye exam

Coronary artery disease, early onset Fasting lipid profile

Close relative with SCD at <30 years of age

ECG, possibly echo depending on other available information

Personal History: Risk FactorsPersonal History: Risk FactorsHistory ScreenS d i i C di ltSyncope during exercise Cardiac consult

Chest pain during exercise Cardiac consultPulmonary evaluation

Recurrent syncope or severe dizziness

ECG

History of Kawasaki disease Review records cardiac consult ifHistory of Kawasaki disease Review records, cardiac consult if not previously cleared

Frequent or symptomatic palpitations

ECG, (Event or Holter monitoring)palpitations

Prolonged “flu” (Myocarditis) CXR, ECG, Echo

Congenital heart disease Cardiac consult if high risk

Seizures ECG

Physical finding ScreenS dSyndromeTurnerDown

EchoEchoDown

MarfanEchoEcho, Eye exam

Abnormal murmur ECG, Cardiac consultb o a u u CG, Ca d ac co su

Loud P2 ECG, Echo

Cyanosis Pulse oximetry CardiacCyanosis Pulse oximetry, Cardiac consult

Abnormal or irregular ECG, (Holter or eventAbnormal or irregular HR

ECG, (Holter or event monitor)

Treatment for Potential SCD Relieve underlying disorder

e.g., Ablation for WPWg , Medication

e.g., Beta-blocker for Marfan syndromeg , y Pacemaker

e.g., Complete heart blocke.g., Complete heart block Implantable defibrillator Restrict activity Restrict activity

RESTRICTIONS Congestive heart failure Significant congenital heart disease Significant congenital heart disease Cardiomyopathy Myocarditis Arrhythmias Pulmonary hypertension Marfan syndrome? Marfan syndrome?

Restrictions for Poor Reasons Murmurs Fainting with a causeg Chest Pain at rest Palpitations Palpitations Certain repaired heart disease Family history of heart attacks (not early) Family history of heart attacks (not early) Remember parents have to sign participation

form alsoform also

Benign diagnosis Precordial Catch Syndrome

Healthy thin adolescenty Sudden, brief, severe, very sharp Out of the blue Anxiety provoking Rest > exertion

Of Often pleuritic

SUMMARY A. Hypertrophic CM B. Coronary artery abnl

Syncope during exercise Frequent, severe

dizziness or recurrent C. Aortic stenosis D. Arrhythmias E Myocarditis

dizziness or recurrent syncope

Chest pain during E. Myocarditis F. ARVD G. Marfan’s syndrome

exercise Prolonged “flu” Previous Kawasaki Previous Kawasaki

disease Palpitations Family History

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