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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
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No disclosure or financial relationships
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Goals Background Clinical evaluation Clinical evaluation Diseases Testing
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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
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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
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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.
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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
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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
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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
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1/3 cases suspected to be of cardiac etiology don’t have a dx.
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Sudden Death in Athletes
OthOther6%
CAD2%
MVP2%
Dilated CM
ARVD3%
HCMMyocarditis
3%
Dilated CM3%
HCM38%Aortic Stenosis
4%
3%
LVH10%
Coronary Abnl24%
Ruptured Ao5%
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Circumstances of Pediatric SCD
Emotional upset
Routine47%
Sleep25%
upset5%
47%
Exercise23%
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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
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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?
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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
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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
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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
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PHYSICAL EXAM
Heart Rate/Rhythm Blood Pressure/Pulses Syndromesy Abnormal Heart Sounds and Murmurs
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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.
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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.
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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
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Hypertrophic Cardiomyopathy Symptoms:
Exertional Chest Physical Exam:
Systolic Ejection Pain
DyspneaS
Murmur at LLSB. Increases valsalva
D tti Syncope Asymptomatic
Decreases squatting Normal exam
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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.
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Echo obtained. Diagnosis made and surgical repair Diagnosis made and surgical repair
scheduledPatient doing great Patient doing great
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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)
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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.
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Myocarditis Viral prodrome Malaise and fatigue Malaise and fatigue Resting tachycardia Gallop ECG (ST segment changes) Echo shows depressed LV function
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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
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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
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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
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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.
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Simple recommended evaluation
What to do when…
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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
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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
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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)
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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
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RESTRICTIONS Congestive heart failure Significant congenital heart disease Significant congenital heart disease Cardiomyopathy Myocarditis Arrhythmias Pulmonary hypertension Marfan syndrome? Marfan syndrome?
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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
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Benign diagnosis Precordial Catch Syndrome
Healthy thin adolescenty Sudden, brief, severe, very sharp Out of the blue Anxiety provoking Rest > exertion
Of Often pleuritic
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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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BibliographBibliography Sparrow MJ et al. ”Precordial Catch”: A Benign Syndrome of Chest
Pain in Young Persons. NZ med J 1978;88:325-26. Zavaras-Angelidou KA et al. Review of 180 Episodes of Chest Pain in
134 Children Ped Emer Care 1992; 8:(4):189 93134 Children. Ped Emer Care 1992; 8:(4):189-93 Basso C et al. Clinical Profile of Congenital Coronary Artery Anomalies
With Origin From the Wrong Aortic Sinus Leading to Sudden Death in Young Competitive Athletes. J Am Coll Cardiol 2000;35:1493-501Young Competitive Athletes. J Am Coll Cardiol 2000;35:1493 501
Driscoll DJ et al. Chest Pain in Pediatrics: A Prospective Study. Pediatrics 1976;57:648-51
Rowland TW, Richards MM. The Natural History of Idiopathic Chest y pPain in Children. A Follow-up Study. Clin Pediatr 1986 Dec;25(12):612-4
Berezin S, et al. Chest Pain of Gastrointestinal Origin. Arch Dis Child 1988 D 63(12) 1457 601988 Dec; 63(12):1457-60
Polanczyk CA, et al. Cardiac Troponin I as a Predictor of Major Cardiac Events in ED Patients with Acute Chest Pain. JACC 1998;32:8-14
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Selbst SM. Chest Pain in Children. Pediatrics in Review 1997;18:169-73
Selbst SM. Evaluation of Chest Pain in Children. Pediatrics in Review 1986;8:56-62
Selbst SM et al. Pediatric Chest Pain:A Prospective Study. Pediatrics 1988;82:319-23.S lb t SM t l Ch t P i i Child F ll f P ti t Selbst SM et al. Chest Pain in Children: Follow-up of Patients Reported. Clin Pediatr 1990;29:374-7.
Tunaoglu FS, et al. Chest Pain in Children Referred to a Cardiology Clinic Pediatr Cardiol 1995 Mar-Apr;16(2):69-72Clinic. Pediatr Cardiol 1995 Mar Apr;16(2):69 72
Evangelista JA, et al. Chest Pain in Children: Diagnosis Through History and Physical Examination. J Pediatr Health Care 2000 Jan-Feb;14(1):3-8
Woodward GA, Selbst SM. Chest Pain Secondary to Cocaine Use. Pediatr Emerg Care 1987 Sep;3(3):153-4