A symposium sponsored by the Brad Wilby Memorial Foundation educating doctors and coaches on the need for cardiac screening in athletes.

1. DanielTarditi, D.O.DanielTarditi, D.O.
andand
Steven Levi, M.D., FACCSteven Levi, M.D., FACC

2.  80-90% of SCD in young athletes occur during or
shortly after exercise
 Sex and sport related predilection
 Male to female ratio = 9:1
 Mean age ranges from 17-23 years of age
 Soccer and basketball = largest number

9.  Most common cause of sudden death in
young “healthy” individuals
 Characterized by thickened heart
muscle
 Inherited usually as autosomal
dominant in older children and adults
 Approximately 1 in 500 adults have HCM

10.  Clinical presentation varies depending on age of
onset (may be asymptomatic)
 Syncope
 Sudden death
 Heart failure
 Sudden death risk similar in adolescents versus
adults
 EKG abnormal in 70-90% of patients
 Should evaluate all 1st
degree relatives for HCM

11. Arrhythmogenic Right Ventricular
Dysplasia (ARVD)
 Incidence unknown, but estimated to affect
1:1000.
 Mean age of diagnosis is 30
 Principle symptoms1
 Palpitations – 67%
 Syncope – 32%
 Atypical chest pain – 27%
 Short of breath – 11%
Circulation 2004 Oct 5;110:1879-84.

12.  30% of cases are familial (probably
underestimate)
 Diagnosis of ARVD is based on clinical findings
but this can be difficult and ambiguous,
particularly in young family members
 Genetic testing can be used to help clarify
difficult diagnoses earlier in life
 Important implications for both the patient and family
members

14.  Physical exam: The
conditions that cause
SCD may be subtle and
not apparent on routine
exam.
 History: Symptoms
may not be present
prior to SCD
 The relative frequency
of these conditions is
low in the population
 The impact is HIGH
Sports Illustrated
December 10 2007

15.  American Heart Association (AHA) recommends
health questionnaire and physical examination
onlyonly

16.  A mandatory careful, detailed history and
physical examination
 To identify abnormalities known to cause SCD
 Every TWO years an interim history is recommended
 By “qualified” care providers

17.  There is none
 Inconsistent forms: Only 3 states use ALL 12 AHA
elements
 Nonmedical evaluations account for about 35%
 Consensus of expert opinion
 There are limitations to current system
 More false positives and false negatives with pre-
participation examination forms

18.  Prior occurrence of
exertional chest pain
 Syncope with exercise
 Shortness of breath or
fatigue with exercise
 History of a heart murmur
 History of hypertension
 Family history of premature
death, sudden or otherwise
(age <50)
 Specific knowledge of
family history of HCM,
LQTS, Marfan, DCM,
arrhythmias
 Disability from heart
disease in close relative <50
years old
 Parents need to be
responsible for ensuring
accuracy of historical data
HCM – Hypertrophic cardiomyopathy; LQTS – long QT
syndrome; DCM – dilated cardiomyopathy

19.  Listen to heart in both
lying and standing
position to identify
murmurs associated
with outflow tract
obstruction (HCM, etc)
 Assess femoral artery
pulses (pulse in groin)
 Recognize physical
stigmata of Marfan
syndrome
 Blood pressure
measurement while
sitting

20.  Recent analysis of high school pre-participation
screening - 2004
 80% of states ≥9 of AHA items
 2% of states ≤4 of AHA items
 However, states in which non-physician
examiners are permitted to perform screening
examinations has increased from 22% to 35%

21.  General ProblemsGeneral Problems
 Some not doing them AT ALL
 Non-uniform approach, correct questions are not
asked
 Who administers or performs evaluations?
 Questions not answered truthfully
 AND not helpful if symptoms are not present, family
history negative and examination “normal”

22.  Uniform comprehensive questionnaire – “a
national standard”
 Questionnaire and examination should be
administered by individuals with knowledge and
training
 Parents need to be involved
 Still will miss cases, but may find some too

29. Corrado, D. et al. J Am Coll Cardiol 2008;52:1981-1989
Flow Chart of the Italian Protocol of Cardiovascular Pre-
Participation Screening

36. (5-17%)(5-17%)

37. Conditions are rare enoughConditions are rare enough
NO DATANO DATA

38. YESYES

39.  Exertional chest pain/discomfort
 Unexplained syncope/near syncope – especially
when related to exertion
 Prior recognition of heart murmur - should assess
standing and sitting (outflow tract obstruction)
 Elevated systemic blood pressure
 Family history of sudden and unexpected premature
death (<50 years old)
 Family history of HCM, ARVD, long QT, Marfans or
congenital arrhythmia disorders (Brugada
syndrome, etc)

40.  SCD is the leading cause of death in young
athletes
 Pre-participation screening strategies are of help
to identify athletes of risk for SCD
 Parents, get involved when they go for pre-
participation physical
 Establishing emergency action plan at ALL
athletic venues is needed

41. Questions?
 Thank you.