The Cardiac Evaluation of the Athlete Daniel J. O’Rourke, MD, MS Veterans Affairs Medical Center Dartmouth-Hitchcock Medical Center

Competitive Athlete “One who participates in an organized team or individual sport requiring systematic training and regular competition against others while placing a high premium on athletic excellence.”“One who participates in an organized team or individual sport requiring systematic training and regular competition against others while placing a high premium on athletic excellence.” Maron et al. Circulation 1996;94:

Demographics 25 million children and young adults play sports25 million children and young adults play sports 4,000,000 high school (grades 9-12) athletes4,000,000 high school (grades 9-12) athletes 500,000 college athletes500,000 college athletes 5000 professional athletes5000 professional athletes

Scope of the Problem Prevalence of athletic field deaths: High school athletes: 1 in 300,000 Older athletes: 1 in 15,000 healthy male joggers

U.S. Vital Statistics CausesDeaths per year Accidents13,966700x Homicide 8,424421x Suicide 4,849242x Cancer 1,738 87x Congenital Heart Dz x HIV x SCD in the athlete 15-25

Maron BJ. JAMA 1996;276:

Maron BJ. Circulation 1980;62:

Gilman JK, Naccarelli GV. Curr Prob Cardiol Nov 1992.

Cardiac Evaluation of the Athlete 1. Primary Prevention of SCD (Screening) 2. Secondary Prevention of SCD 2. Secondary Prevention of SCD 26th Bethesda Conference. JACC. 1994;24:

Screening Disease should be:Disease should be: prevalentprevalent have significant M & Mhave significant M & M be treatablebe treatable Treatment results in a better outcomeTreatment results in a better outcome Good screening test must be availableGood screening test must be available Cost-benefit ratio should be favorableCost-benefit ratio should be favorable

Screening Purpose: to provide medical clearance for participation in competitive sports.Purpose: to provide medical clearance for participation in competitive sports. Assumption:intense training will increase the risk of sudden cardiac death or disease progression in trained athletes.Assumption:intense training will increase the risk of sudden cardiac death or disease progression in trained athletes. Expected Outcome: to reduce the risks associated with organized sports.Expected Outcome: to reduce the risks associated with organized sports.

Cause of SCD of Elite Athletes Jim FixxASCVDJim FixxASCVD Len BiasCocaineLen BiasCocaine Reggie LewisFocal MyocarditisReggie LewisFocal Myocarditis Flo HymanMarfan’s - Aortic ruptureFlo HymanMarfan’s - Aortic rupture Hank GathersHypertrophic CardiomyopathyHank GathersHypertrophic Cardiomyopathy Pete MaravichHypoplastic Coronary ArteriesPete MaravichHypoplastic Coronary Arteries

Fletcher GF. SCD in the Athlete. Futura Publishing, 1998.

Screening: H&P HistoryHistory Chest painChest pain SOBSOB Lightheadedness/SyncopeLightheadedness/Syncope Excessive fatiguabilityExcessive fatiguability Family h/o cardiac dzFamily h/o cardiac dz Family h/o premature deathFamily h/o premature death H/O murmurH/O murmur PalpitationsPalpitations Physical ExamPhysical Exam Auscultate in supine/standingAuscultate in supine/standing Sinus bradycardia commonSinus bradycardia common Assess BP bilateral armsAssess BP bilateral arms Assess femoral pulsesAssess femoral pulses Signs of Marfan’sSigns of Marfan’s Functional murmur commonFunctional murmur common S 3 gallop commonS 3 gallop common

Screening: ECG Sinus bradycardiaSinus bradycardia Rightward axisRightward axis First or second degree, type I AV blockFirst or second degree, type I AV block Incomplete RBBBIncomplete RBBB Ventricular hypertrophyVentricular hypertrophy Nonspecific ST-T changesNonspecific ST-T changes

Screening: Echocardiography Bicuspid Ao valveBicuspid Ao valve Hypertrophic CMHypertrophic CM RV dysplasiaRV dysplasia Coronary anomaliesCoronary anomalies Mitral Valve ProlapseMitral Valve Prolapse ScreeningScreening 4 studies4 studies >5000 pts>5000 pts No cases identifiedNo cases identified Cost is prohibitiveCost is prohibitive $500,000 for each new case of HCM identified$500,000 for each new case of HCM identified >$1,000,000 per life saved>$1,000,000 per life saved

Bruce BA et al. AJC 1980;46:

AHA Recommendations Careful, detailed history and physical exam every 2 years by qualified care providers.Careful, detailed history and physical exam every 2 years by qualified care providers. Intervening years, obtain an interim history.Intervening years, obtain an interim history. Selectively perform ETT in men (>40 yo) and women (>50 yo) having a high risk for CAD who wish to begin regular physical training.Selectively perform ETT in men (>40 yo) and women (>50 yo) having a high risk for CAD who wish to begin regular physical training. Develop a national standard for preparticipation medical evaluation.Develop a national standard for preparticipation medical evaluation.

Glover, Maron BJ. JAMA 1998;279:

Cummins RO et al. Circulation 1991;83:

Summary Sudden cardiac death (SCD) in the athlete is rare.Sudden cardiac death (SCD) in the athlete is rare. Identifying individuals at risk for SCD (i.e., primary prevention) is very difficult.Identifying individuals at risk for SCD (i.e., primary prevention) is very difficult. Guidelines for individuals with known cardiovascular disease (i.e., secondary prevention) have been published -- 26th Bethesda Conference.Guidelines for individuals with known cardiovascular disease (i.e., secondary prevention) have been published -- 26th Bethesda Conference.

Summary A detailed history and physical exam should be performed on all athletes.A detailed history and physical exam should be performed on all athletes. Noninvasive testing should be used selectively.Noninvasive testing should be used selectively. Must educate the public about the limits of screening and preventing SCD in the athlete. It is not possible to achieve zero-risk in competitive sports.Must educate the public about the limits of screening and preventing SCD in the athlete. It is not possible to achieve zero-risk in competitive sports. Community efforts should focus on developing and implementing systems of care that allows for prompt response and treatment.Community efforts should focus on developing and implementing systems of care that allows for prompt response and treatment.