Chapters Transcript Video Sports Cardiology (Including Exercise Testing and Family History Screening) All right, thank you so much for that introduction and for you all being here today. Um So yes, my talk is entitled Cardiac Clearance for the young athlete. And the question that's posed to the general practitioners is to play or not to play. So these are the headlines that none of us want to read a family and community shaken by the sudden and unexpected loss of a presumably healthy athlete playing or doing what they do best on the soccer field, basketball field or football field. So what can we do in order to prevent these episodes from happening? So thankfully, sudden cardiac death is rare, the exact incident um is variable and that's mainly due to how it is reported. But I've seen it as low as one in 300,000 and as high as one in 50,000 to kind of put that in perspective, about 10 million people per year fall within the category of a young athlete. And what's generally accepted as the definition of that is someone participating in sports. Less than 35 years of age, males have a tenfold higher risk of sudden cardiac death than females. And that's not because they have a higher incidence of cardiac disease, but rather a higher participation in sports, greater intensity in the sports that they play and the type of sports they're involved in. There's also a disproportionately higher number of athletes that are non Hispanic African Americans with the cases of sudden cardiac death. And that's likely due to health care disparities. And the fact that they're not being, this population is not being screened appropriately in the United States, in terms of which sports have the highest cases, it's basketball, followed by football and worldwide. It's soccer. So this pie chart breaks down the causes for sudden cardiac death in the light purple is about one third of cases is hypertrophic cardiomyopathy. These patients are at risk for ventricular arrhythmias in the pale yellow. About 20% are coronary artery anomalies and the highest number of cases are uh anomalous origins from the inappropriate sinuses followed by that at 6% is myocarditis. This is the reason that we restrict our patients in the acute and sub acute period from being involved in sports while we can assess whether the inflammation resulted in ischemia and infarction and therefore leads to risks for arrhythmias. About 4% are a RVC arrhythmogenic right ventricular cardiomyopathy. As in the name, these patients are at risk for arrhythmias because their heart muscle tissue is being replaced by fatty fibrous tissue. And then the ion channelopathy, Long Qt syndrome, Short Qt syndrome, Brugada syndrome and C PV T or catecholaminergic polymorphic ventricular tachycardia make up about 3%. So I just wanted to put this one slide in there about the patients that are known to have these cardiac diseases and therefore followed by cardiology, at least in our group. At the bottom of all of our notes that we send out back to the general practitioners. We have a line that's called the guidelines of physical activity or exercise restrictions. And these are the references for which we use on those recommendations. This first one is the 36 Bethesda conference which was published in 2005. And the second one was a joint statement between the A H A and AC C which was published in 2015. You may also see that we group sports together and that's this chart here is where we come up with those recommendations. It's a breakdown of sports in terms of their static and dynamic components in the top, right where you see the rower is the the greatest cardiovascular demand and in the bottom left where you see the golfer is the lowest cardiovascular demand. So what's currently being recommended for your patients with no known cardiac disease is the preparticipation physical evaluation. Now, this is a checklist and just because they have a positive response doesn't automatically restrict them from sports nor need a referral to cardiology. Rather, it's just supposed to prompt more follow up questions to investigate further and hopefully the rest of my talk sheds light on what those questions should be. So the P pe it's endorsed by most major medical societies A H AAA pac C all the letters. Um And right now it's considered best practice to screen this large general population of young athletes. There's no true recommendation of when the screening should start. However, most schools require it or when the kids enter middle school. So sixth grade when they're about 12 years old. However, if you needed a option of how to screen younger kids, of course, you can use the P PE as well. And then the P pe encompasses more than just cardiac screening. However, obviously, with the talk of the symposium, we'll just focus on that. And so the cardiac recommendations come from the American Heart Association. They started making these recommendations in about the 19 nineties with the most recent update in 2014. And as of now, there's 14 elements in the history and physical examination. I put that in the chart here to the right of the screen and it's also in uh your packet underneath our tip sheet in case you need a reference, this is the P pe form that is endorsed by uh New Jersey. These are all state derived. Um So each state has their own P pe and they use as many or as little of the elements that the A H A is recommending New Jersey encompasses all 14 of those elements. And if you ever need a copy to review it, it's the New jersey.gov, but I'm sure you guys know this form quite well. So the elements are broken down into history and physical examination. Um The A H A puts an asterisk by history because they state that the parents have to be present during the screening questions that increases the validity of the answers that the child is giving. You. Kids are not dumb. If they know they're there for sports clearance, they're not gonna be telling you that they have chest pain with exertion because they wanna be cleared. But if the parent is present, hopefully the there's more accuracy to these responses. So the first question that's asked is exertional, chest pain or discomfort. Dr Rosenthal just gave an amazing talk on this topic. So I would, for the sake of time, I'm not gonna go through all those red flags again. But again, they're available in the folder that we provided for you. So the biggest thing to focus on does it occur during exertion? And I agree with doctor Rosenthal just because they said it happens during sports or during gym class does not equate to what happened with exertion also are the symptoms recurrent. Did it happen one time after running after the child had a big pizza party? And maybe it's more of a reflux symptom than a cardiac symptom and have a higher alert if there's other associated cardiac symptoms such as palpitations or syncope. The next question to ask is exertional syncope or near syncope. And obviously, the most common of these is vasovagal or neurocardiogenic. Now, while you may be referring them to us such as that case of the child that may pass out post exertion, but really, that's just due to the reflex postural hypotension, I encourage you to not have the same degree of restrictions for these patients while they await that cardiac work up. So for example, you have the football player in full gear who's sprinting down the field towards their opponent to tackle them and pass out your level of concern for a cardiac diagnosis would be high compare that to the teammate who's standing on the sidelines in full gear, 100 degree weather, minimal to drink that day and really not participating in the sports that much. And so then they pass out your degree of suspicion is likely lower. So your restrictions that you're going to give them prior to their cardiac work up should be different. Number three is exertion, excessive exertional or unexplained dyspnea or fatigue with exercise. And when these patients come to me, sometimes it is hard to sort out. Is this just poor conditioning, should I be concerned about cardiac function being um a cause for all of this? So personally, I look for changes from baseline. Was this the star basketball athletes who never wanted to come out of the game highest score on the team. And now he's constantly being subbed out, doubled over, excessively, short of breath or is this the child who was a sedentary kid that all of a sudden decides they want to be on the football team? And wonders why he can't keep up with his friends during that first practice. Maybe that kid would have more of the poor conditioning and there is a footnote that the A H A puts in next to this question in terms of ruling out exercise induced bronchospasms. Does the kid have a history of cough, wheezing albuterol use? Have they tried albuterol prior to doing these sports? And those symptoms are relieved, then likely it's not cardiac, it's more pulmonary previous recognition of a heart murmur again. Thank you, Lauren. You basically answered all the questions in my talk. Um But how much does that murmur need to be investigated? One, is it still there, is there still any concerning cardiovascular examination findings or was this murmur worked up in the past and cleared by cardiology or was it just a benign murmur? And that's what's documented in the chart, elevated systemic blood pressure, you know, hypertension has never been implicated as a cause for sudden cardiac death, but it's a well known risk factor for cardiovascular disease hypertension at this institution as well as any that I've worked at is really worked up by our pediatric nephrologist. And so I'm sure just like we have recommendations for activity restrictions for cardiac diseases. They also put in their own recommendations. But because I was doing this talk, I did a little bit of a dive into what restrictions they place. And I've seen that if it's recognized, if it's being managed and if there's no end organ evidence of damage, then those patients have full clearance for sports. But again, I'll defer that to the nephrologist. And then I lumped these last two together, these were the last two additions that A H A placed in the P pe which is prior restriction from a sport and prior testing for the heart ordered by a physician. Um These are very vague and obviously require some follow up questions. Um I know we only have so much time with the patient. Um So often we get the history. Yeah, when they were younger, they saw a cardiologist and they did some testing, but I don't know what it is and I was told never to come back and that can be disconcerting. I really want you to focus on the patient in front of you. Then if we don't know all of that history, you do the best you can with the investigation and then focus on what their symptoms and medical history are and what the physical examination is at that point because there's a variety of reasons kids come to us for, for example EKG testing. So family history, I'm gonna put all of them up here at once. So the first question you should be asking, is there any, uh, history of premature sudden cardiac death, specifically? Less than the age of 50? So you do not have to differentiate males versus females. Sometimes they'll come to you with that history, but other times you have to tease it out of them. So some questions I'll ask any unexplained car accidents, any drownings, any infants that passed away from SIDS, then history of heart disease in close relatives? Less than 50. Well, how close is close? And so I'm gonna give you some examples on the following slide and then they want you to ask about specific inheritable cardiac conditions. So that would be hypertrophic or dilated cardiomyopathy, Long Qt syndrome or other ion channelopathy. So that's Brigada and C PV T and then Marfan syndrome. So I have some examples here for family history. My third cousin's daughter was born with a hole in the heart. We appreciate that diagnosis and that family history. However, it's a little bit farther removed than what's probably pertinent to the patient in front of you. So you should be focusing mainly on first and secondary relatives, a child. Their first degree relatives are their parents and their siblings and their second degree relatives are grandparents, aunts and uncles. I do ask about any distant family members having a diagnosis and if it's really just an isolated case, then I don't investigate any further. The next one, my grandfather and great grandfather had heart attacks in their forties. Well, that technically is a positive response to that second family history question you should be asking. And so I follow up that question with what is their risk factors? Do they have hypertension? Do they have diabetes? Do they have high cholesterol risk factors for early cardiovascular disease, which you could be screening for? Or sometimes the parents come back and just say they were morbidly obese, drank like a fish and smoked like a chimney and maybe it was just risk factors they put on to themselves. But for these cases, there's nothing more I do than anticipatory guidance and heart healthy lifestyle. So talk to them about diet, talk to them about exercise. It's hard to teach an old dog new tricks. So if they start this process early in life, they'll be able to continue it into adulthood. And I also have a low threshold for send, sending a screening lipid panel even if it's out of the range of the 9 to 11 and 17 to 21 years of age that we'll be talking about later. The next uh my son is adopted or this was an IVF pregnancy with a donor. And I don't know all the family history or my family never goes to the doctor because they don't believe in medicine. So I don't know what our history is. We get this a lot and I do not have a crystal ball nor a test that will tell them what their family history is. So I emphasize with you when you get this history too, again, like I said, previously, focus on what you know and what's in front of you, ask that patient a thorough history get as much as you can out of the physical exam and then determine if there's any concerning causes for restriction from exercise. Now, these uh examples are in contrast to the next three, my mom, grandma and aunt all have machines in their chest for some funny heartbeat. Now, that's concerning compared to oh my 90 year old grandma has it done for a pacemaker, not as concerning or and this is literally what I had in my office last year. A lot of men in the family in Italy are dying in their sleep in their twenties and thirties, but no autopsies were done. It's like Brigada is just combing in my brain. And the last one is my very athletic father died while swimming laps in our pool at home. That would be an unusual incidence of a drowning. That would be a possible reason that they need to be referred. So the next part of the P pe is the physical examination. Um So the heart murmur, so the A H A specifically says the murmur needs to be assessed in the supine position compared to a standing position or with the valsalva. So in order to make the patient do a valsalva, you can plug their nose and have them take a deep breath in through their mouth, close their mouth and try to force the air out if they're old enough and can understand, you can talk to them about straining as if they're trying to go to the bathroom. So what happens when we do a valsalva or make them stand? Is we decrease the blood flow return to the left ventricle which increases LV, outflow obstruction if it's present. And that could be a physical examination feature of hypertrophic cardiomyopathy. Obviously, a majority of these murmurs are benign and do not need to come to us necessarily for clearance for sports, you must palpate the femoral pulses. Um If they're weak or absent, be concerned about coarctation of the aorta, maybe this would prompt you to do blood pressures in the upper and lower extremities to see if there's a discrepancy. Look for physical stigmata of Marfan syndrome. These patients are at very high risk for the development of aortic aneurysms which could result in aortic dissections. So, on the physical exam, tall lengthy features, long arm to height ratio, long fingers, arachnodactyly PZ planus or fat feet, the cactus scoliosis, I mean, there's multiple um physical features that may clue you into this diagnosis and just because there's no family history of it, there's been more than one time where I've diagnosed a child with marines and look at the family and say you need to go get checked out too because you probably don't know you have it. And then the last physical examination is the brachial artery blood pressure. The A H A wants you to take it in both arms. And then in italics, this is my recommendation that if you have high blood pressure in the arms, check it in the legs if the arms are significantly higher than the legs. And so we say greater than 20 millimeters of mercury be referring to cardiology before nephrology. Otherwise, it's pediatric nephrology that does the diagnosis and management of hypertension. So there is controversy um behind the P pe. So just having a history and physical examination has a low sensitivity, there's a very high false positive rate. We're at the mercy of the physical exam skills of the provider which can be very heterogeneous. The questions that are in the screening are just expert opinions and have never been proven to show that they actually reduce sudden cardiac death. And it is based on the honesty of the athletes and sometimes the parents, there are some parents out there that will say anything for their child to get cleared um and that's on them, but that's where this limitation lies in the screening process. So why not add an EKG? So EKG S are currently recommended in European guidelines and for most sporting societies. But the A H A has taken a stance to not include EKG S in the screening in the United States, what they do say now. And it's very vague is if the practitioner thinks the EKG will help them determine if there is underlying cardiac disease, they're not opposed to it, but they don't recommend it. However, if it's done, it must be read by a trained physician or a cardiologist. So, reasons why the EKG has yet to be included, um, one has to do with the cost, you know, you think of a single EKG and it's relatively cheap, you times that by 10 million because that's the amount of kids per year. And then there's a high false positive rate even in the hands of cardiologists of what we find on the EKG. But an abnormal EKG begets more and more testing down the line and the cost of the testing overall significantly increases. So hopefully in the future, there will be some large randomized clinical trial which proves really power to determine um for the mortality needed to assess true impacts of if the pe is making a difference. So overall, there's no zero risk screening protocol, whether it's in the hands of the general practitioner or in the subspecialist. But what does not discriminate between patients that have known an unknown cardiac disease is the A ED and this is truly what can save lives both in the hands of medically trained professionals as well as laypersons. Thankfully in New Jersey, the Janet law was passed in September 2012. This law requires all public and private schools in New Jersey to have an A ED present, have trained responders have signs leading to where the A ED is located and have an emergency action plan. This was um, the mission of the family of Janet Zelinsky, who was an 11 year old girl who unfortunately had a sudden cardiac event while in cheerleading practice and actually went to our facility here at Overlook, of which Doctor Kaufman um was a part of the team that tried to save her. But the parents took their tragedy and they turned it into this mission and we um grateful for that. And just of note, there's only 20 other states in the United States which require A E DS in the school. So I thought this uh was a good segue into introducing you to some of the exercise testing um that we do have available here at Morristown. Um I'm proud to say we have one of the most comprehensive pediatric stress labs in New Jersey and that's thanks to the relationship we have with our adult cardiologist. Um All testing is done at the Gagnon Cardiovascular Institute here. Um and it has the state of the art technology. So we're able to do exercise stress testing. This involves putting EKG leads on the patient and having them either be on a treadmill or a stationary bike where we monitor their heart rate, rhythm and blood pressure as we es escalate the exercise. The kids always start off by rolling their eyes saying how easy this is. And then within 6 to 8 minutes they're crying for us to stop it. The next one is the cardiopulmonary exercise test. It's the same as the previous slide except we add in gas exchange analysis, kind of looks like a Hannibal Lecter mass. But the kids do really well with it. And here we can evaluate the interaction of the heart, the lungs, the metabolic and the muscular systems in response to exercise. Then there's stress echocardiography. Um We collaborate with adult cardiology for this test. The pediatric cardiologist interprets the stress portion. And the adult cardiologist perform focus echocardiograms before and at peak exercise. What we're looking for is areas of regional wall motion abnormalities which would be a sign of ischemia. And then the last test we have available is the nuclear stress test. Again, it's a collaboration between peds and adults. We focus on the stress portion. The second portion is an IV is placed and a radioactive tracer can evaluate blood flow to heart muscle both during rest and exercise. Again, identifying areas of ischemia or infarction. So I hope I've shown to you that we have the tools and the expertise in order to diagnose and manage these cardiac diseases. Um not all patients with the same presenting symptoms, get the same work up. So it's always hard to predict exactly which pathway they're gonna go down. So I always encourage you. Let the patients know all this testing will be decided and discussed before we do anything at the visit because there is a multitude of pathways that we have. And so I leave you with this, the happy healthy athletes. Thank you. Published Created by
