1. Cardiac Issues in Athletic Participation: To Screen or Not to Screen?
George C. Phillips, MD, FAAP, CAQSM
September 18, 2008
Sports 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 condition
Estimated 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 BP
Family history of early MI or sudden death
Exercise-related symptoms
Survey 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Unpublished data from Rausch and Phillips: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 states
85% (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 reviewed
17% (8/47) completely addressed all of the recommended screening questions
Forms 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 athletes
134 were due to cardiovascular disease
Only 1 case had findings on PPE
68% played basketball or football

10. Hypertrophic Cardiomyopathy
Number one cause in athlete < 35 years old
Autosomal dominant, frequency ~ 1:500
Only ~ 30% gene penetrance
~ 5% lifetime risk with disorder
Normal type histology, but with significant disarray

11. Hypertrophic Cardiomyopathy
Asymmetric septal hypertrophy (>15 mm)
Anterior motion of mitral valve in systole
Functional LV outflow tract obstruction
Syncope with exercise
Systolic ejection murmur
Increases with Valsalva, standing position
preload exacerbates the functional obstruction

12. Hypertrophic Cardiomyopathy
Cellular abnormalities in the heart cause other problems as well
Electrical conduction problems cause arrhythmias
Ventricular tachyarrhythmia
Congestive heart failure
Myocardial 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 cycle
Size and compliance of the chest wall
Speed/force of impact (~40 mph)
Localization of impact
No 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 wall
Very different experience from Italy
Genetics?
Effect of their screening program
Universal EKGs

18. The Question
Should 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 athletes
Demographics (78% male, 98% white)
Sports (31.3% soccer, 17.7% volleyball)
Resting EKG – 6% abnormal
Upon further review, only 1.2% true positives
Under age 30, only 0.65% true positives
Exercise EKG – 4.9% abnormal
Under age 30, 4.1% abnormal
159 athletes DQ’s = 0.46%

20. What if in the U.S.? 12 million high school athletes
Resting EKGs – 720,000 initially abnormal
Only 78,000 true positives
Exercise EKGs – 492,000 abnormal
DQs – 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 Cardiomyopathy
Prevent 16 deaths annually
$2.475 million per death prevented
Commotio Cordis
Prevent 8 of 12 deaths annually
Safety 10 dozen per team, $3 per baseball, and 15,500 HS teams
~$700,000 per death prevented