Pre-Sports Evaluation: Pre-Sports Evaluation Thomas R. Kimball, MD Professor of Pediatrics University of Cincinnati Director Echocardiography Cardiovascular Imaging Core Research Laboratory


Acknowledgement: Acknowledgement Waldemar Carlo Current PL-III at Cincinnati Children’s Hospital Future pediatric cardiology fellow at Texas Children’s Hospital


Case Discussion: Case Discussion CC: Sports pre-participation physical HPI: 15yo boy presents prior to football season for you to fill out his pre-participation form. Has been healthy. Passed out one time after feeling his heart racing after running 5 miles last week. ROS: any recent injuries, eye problems, hypertension, chest pain PMH: none


Case Discussion: Case Discussion Meds: none FHx: no sudden deaths, no heart disease SHx: denies steroids or supplements, drugs, alcohol, smoking, sex Physical Exam: normal As the pediatrician, what do you do?


Slide5: Outline What are the issues? Sports Intensity Problematic Pediatric Cardiovascular Diseases Learning from the Past: Profile of Sudden Death Victims Often, party interests are competing (not complementary) Sports were not created all equal Leading causes of cardiac sudden death: Hypertrophic cardiomyopathy Coronary artery anomalies Sudden death victim profile: Asymptomatic high school male Track, cross country, basketball Current practice: Hx, FH, PE Future practice: Echo Current Customary Practice Future Practice?


Slide6: Major Players Athlete Family School/NCAA Lawyers and Courts Physicians Consensus Guidelines


Unique Pressures for Primary Care Physicians: Unique Pressures for Primary Care Physicians See many patients (high denominator), low prevalence of disease (small numerator) First symptom is frequently sudden death Usually no physical findings Athlete may by stubborn and/or non-compliant


Athlete’s Issues: Athlete’s Issues Desire to play outweighs almost every concern Spend enormous effort on sport Self worth is wrapped up in sport Sense of invincibility Sahara Marathon


Problem of Public Health or Perception: Problem of Public Health or Perception Athlete is a symbol of health to society High visibility of sudden death events High stakes of sports as business Athlete has celebrity status Event is riveting, puzzling and challenging Intense interest may be disproportionate to its actual public health problem


Cost-Effectiveness Issues: Cost-Effectiveness Issues Not possible to achieve zero-risk Implied acceptance of risk on part of athlete Testing is expensive Occurrence of HCM is 1:500 Echo ~$500 $250,000 to detect even 1 previously undiagnosed case Problem of false positives F/U of abnormal results leads to more costly procedures


Scope of the Problem: Scope of the Problem 200-300 young athletes / year in USA 200,000 competitive athletes screened 1000 with CHD 0.5% 10 with disease capable of causing sudden death 1% 1 with sudden death 10%


All Sports are not Created Equal: All Sports are not Created Equal Dynamic (soccer, long distance running, racquet sports Static (weight-lifting, karate, water skiing, gymnastics, field events) Combination (football, sprint running)


Slide13: Sports Intensity: Static Classification High Static Low Static


Slide14: Sports Intensity: Dynamic Classification Low Dynamic High Dynamic


Sports Classification: Mitchell JH, et al. JACC 45:1364-67. 2005 Sports Classification MVC = maximum voluntary contraction Max O2 = maximum oxygen consumption


Slide16: Cardiac Etiologies of Sudden Death in < 35 y.o.


Marc-Vivien Foe: Marc-Vivien Foe Cameroon midfielder 28 y.o. Expires in 72nd minute in soccer match vs. Columbia in Lyon, France in 6/2003 2 autopsies: No obvious cause of death Hypertrophic cardiomyopathy


Hypertrophic Cardiomyopathy: Hypertrophic Cardiomyopathy Relatively common 1:500 Primary disease of cardiac muscle (molecular defect in cardiac sarcomere) LV hypertrophy without dilatation More common in African-Americans Male to female ratio of 9:1 for sudden cardiac death Autosomal dominant


Slide19: Hypertrophic Cardiomyopathy Most common cause of SCD in athletes Patients with HCM who die suddenly: 70% die before 30 y.o. 50% show no limitations before death 40% engaged in physical activity Death probably due to dysrhythmia


Slide20: HCM Phenotype Cardiac Defects Abnormal cellular architecture Hypertrophied LV Intramural coronaries Risks Myocardial ischemia Arrhythmogenic cardiac tissue LVOT obstruction Annual risk of SCD is 1%


Slide21: HCM History ½ pts are asymptomatic ½ pts have DOE, angina, syncope, palpitations, etc. FHx EKG LVH Signs Prominent LV impulse Frequently have no murmur If present, murmur increases with a decrease in venous blood return (supine  standing) ECHO


Slide22: LVH and sudden cardiac death From Spirito P, et al. NEJM 342:1778-1785, 2000.


Slide23: Activity level and sudden cardiac death in HCM Adapted from Spirito P, et al. JACC 15:1521-6, 1990.


Slide24: HCM Treatment Treatment Medications (e.g.β-blockers) reduce symptoms but not incidence of sudden death Ventricular septal myomectomy Alcohol septal ablation Avoid Competitive sports (except class 1A) Digitalis Diuresis/Dehydration Screen 1st degree relatives


Slide25: Athlete’s Heart vs. HCM


Long QT Syndrome: Long QT Syndrome Ion channel mutation Delayed myocardial repolarization Prolonged QTc Risk of Torsades QTc > 470 (men), 480 (women) Annual mortality rate 4.5%


Cardiac Events in Long QT: Cardiac Events in Long QT From Zareba W, et al. NEJM 339:960-965, 1998


SCD in Long QT syndrome: SCD in Long QT syndrome Schwartz PJ, et al. Circulation. 2001;103:89. (particularly swimming)


Long QT Recommendations: Long QT Recommendations Symptomatic LQTS patients – Class 1A Asymptomatic LQTS patients with prolonged QTc – Class 1A Genotype positive / phenotype negative patients – no restrictions * * Except no water sports for LQT1 patients


Implantable cardiac defibrillator: Implantable cardiac defibrillator Risk of ICD damage/displacement Recommendations Class 1A sports only


Congenital Coronary Artery Anomalies: Congenital Coronary Artery Anomalies Coronary arises from wrong sinus Passes between great vessels Can be compressed when cardiac output increased Can be surgically corrected EKG is usually normal Found in 1% of population Cause up to 20% of sudden deaths on the athletic field Nl pattern


Slide32: Single Coronary Artery Pete Maravich – Atlanta Hawks, New Orleans and Utah Jazz, Boston Celtics, expired at 40 y.o. in 1988 during pick-up game


Slide33: Anomalous Coronary Artery Possible Consequences Myocardial ischemia during exercise Ventricular tachyarrythmias from scarred myocardium Recommendations No competitive sports Three months after surgical correction, may participate in all sports, with normal maximal stress testing


Slide34: Kawasaki Disease Acquired coronary artery aneurysm(s) Sports participation depends on presence and size of aneurysms


Slide35: Hank Gathers Basketball star for Loyola Marymount University In 1989, at 22 y.o. collapses during LMU game against UCSB Echo shows damaged area in LV Diagnosed with exercise-induced ventricular tachycardia, treated with propranolol, LMU bought defibrillator for courtside Felt medication adversely affected play, cut back on dosage In 1990, at 23 y.o., collapses during tournament game against Portland DOA at hospital Autopsy – cardiomyopathy/myocarditis


Slide36: Myocarditis Inflammatory disease of the myocardium Etiology Viral (enterovirus, parvovirus, adenovirus) Drugs Symptoms Chest pain, dyspnea on exertion, fatigue, syncope, arrythmias, acute CHF Non-specific


Slide37: Myocarditis Frequent cause of non-structural SCD Pathogenesis Myocardial inflammatory infiltrates, myocyte necrosis, replacement fibrosis Arrythmogenic substrate


Slide38: Recommendations 6 month off period Re-evaluation by cardiologist EKG, ECHO Stress test Holter monitor Serum markers of inflammation, heart failure


Flo Hyman: Flo Hyman American volleball player, 6’5” Known as “Clutchman” and could spike ball at 110 mph Gold medal in 1982 World Championship Silver medal in 1984 Olympic Games Died at 31 y.o. after being substituted for during a game in Japan in 1986 Aortic dissection due to Marfan Syndrome


Slide40: Marfan Syndrome Connective tissue disorder Autosomal dominant Mutation in fibrillin-1 gene Ocular, skeletal Cardiovascular Dilation of ascending aorta* Aortic dissection* Mitral regurgitation Mitral valve prolapse Abdominal aortic aneurysm


Slide41: Recommendations Aortic root involvement Moderate/severe mitral valve regurgitation FH of Marfan-related sudden death or aortic dissection Class IA


Serginho: Serginho Brazilian soccer player for São Caetano Died on field at 30 y.o. (2004) Autopsy reveals “enlarged heart” Team owner and doctor charged with homicide


ARVD: ARVD 3rd leading cause of SCD in young athletes Prevalence 1 in 5000 in general population Pathology Fibrofatty replacement of RV myocardium Etiology Unclear Diagnostic Criteria


ARVD and exercise: ARVD and exercise Fibrofatty RV is arrhythmogenic Adrenergic stimulation (exercise) induces these arrhythmias


ARVD: ARVD Prognosis 3% mortality rate without treatment 1% mortality with pharmacotherapy Treatment Beta Blockers Radiofrequency ablation Implantable cardiac defibrillator No athletic competition except maybe class 1A ?


Slide46: Sergei Grinkov Along with partner and wife, Ekaterina Gordeeva, three-time World Figure Skating Pairs Champion and 1988 and 1994 Winter Olympic Champion Died suddenly at 28 y.o. (1995) in Lake Placid while practicing Autopsy – atherosclerotic coronary artery disease and hypertension (diastolic of 110)


Slide47: Maron, B. J. et al. JAMA 2002;287:1142-1146. Commotio Cordis


Slide48: Commotio Cordis Chest wall impact Rare but likely underreported Associated with competitive or recreational athletics


Slide49: Copyright restrictions may apply. Maron, B. J. et al. JAMA 2002;287:1142-1146. Sports Participated in at the Time of Commotio Cordis Events


Slide50: Copyright restrictions may apply. Maron, B. J. et al. JAMA 2002;287:1142-1146. Age at Time of Commotio Cordis Event


Pathophysiology: Pathophysiology No underlying heart disease No major damage to the heart or great vessels Unimpressive force of impact


Pathophysiology: Pathophysiology Transfer of energy Increased compliance of pediatric chest wall Energy of impact Greatest at around 30 - 50 mph Hardness Location – center of the heart Timing - repolarization


Prevention (?): Prevention (?) Chest Wall Protectors Soft Balls


Slide54: Those Etiologies Readily Detectable by Hx and PE Screening Cardiac Etiologies of Sudden Death in < 35 y.o.


Level of Competition: Level of Competition


Slide56: Sports in which Sudden Death Occurs


Slide57: Median age = 17 y.o. Male (90%) No obvious race predilection High school level of competition Asymptomatic (82%) Sports Cross-country, track, basketball Profile of the Athlete with Sudden Death


Purpose of Preparticipation Evaluation: Purpose of Preparticipation Evaluation Identify individuals Known to be at risk Not known to be at risk Make recommendations regarding participation


Legal Considerations: Legal Considerations Must use reasonable care No clear legal precedent Malpractice liability for failure to discover a latent condition requires proof that a physician deviated from customary medical practice Medical profession allowed to establish the nature and scope of pre-participation screening


Slide60: Risk Ratio between Athletes and Non-Athletes From Corrado D, et al. JACC 42:1959-1965, 2003. Athletes Non-athletes


What is “Customary Practice”?: What is “Customary Practice”?


Customary Practice: Customary Practice No accepted standards Medical clearance by a health care worker consisting of H and P is generally considered customary In Ohio, the Ohio High School Athletic Association requires completion of preparticipation form


Slide63: Limitations of Screening False positives Athlete disqualifications Cost efficiency Screening volume


Slide64: American Guidelines (1996) Family and personal history, physical exam Negative Positive Eligible for competition Further testing Positive Negative Further management


Slide65: European Guidelines (2005) Family and personal history, physical exam, and EKG Negative Positive Eligible for competition Further testing Positive Negative Further management


Slide66: Efficacy of Screening with EKG


AHA Recommendations: AHA Recommendations Preparticipation exam is warranted Complete Hx, Family hx and PE targeted to identify cardiovascular lesions known to cause sudden death (Noninvasive testing not prudent in large populations) Repeat evaluation every 2 years Develop a national standard for evaluation


Cardiovascular History: Cardiovascular History Exertional chest pain, syncope, or excessive shortness of breath Detection of murmur or hypertension FH of premature death or disability < 50 y.o. or specific knowledge of: HCM, DCM Long QT syndrome Marfan syndrome


Practical Tools: Practical Tools Physical Activity Readiness Questionnaire (PAR-Q) Has a doctor ever told you that you have a heart condition and recommended only medically supervised activity? Do you have chest pain brought on by physical activity? Have you developed chest pain in the past month? Have you on one or more occasions lost consciousness or fallen over as a result of dizziness? Do you have a bone or joint problem that could be aggravated by the proposed activity? Has a doctor ever recommended medication for your blood pressure or a heart condition? Are you aware of any other physical reason that would prohibit you from exercising without medical supervision? Stanford University Pre-Participation Form Internet-based Extensive (18 pages)


Cardiovascular Examination: Cardiovascular Examination BP Auscultation Femoral arteries Marfan’s stigmata Referral when abnormalities in Hx and PE


Noninvasive Screening Tests: Noninvasive Screening Tests Echo will enhance detection of abnormalities Cardiomyopathy AS Aortic dilatation Coronary artery anomalies But no guarantee Some coronary anomalies Arrhythmogenic RV dysplasia


Echocardiogram: Echocardiogram Miniaturization of technology Targeted, limited examination Decreasing costs


Cost Effectiveness of Screening Modalities: Cost Effectiveness of Screening Modalities Med Sci Sports Exerc 32:887, 2000 (Sierra Heart Institute, Reno, NV) High school athletes (HSA) 3 screening modalities CV-specific Hx/PE EKG Echo Assume 700,000 evaluations would occur in search of 70 HSA EKG is most cost-effective To be equally cost-effective: Hx/PE would need 2X increase in sensitivity Echo would need 4X decrease in cost


A Heart For Sports: A Heart For Sports Orange County, CA Individual screenings (EKG and Echo) for $65 tax-deductible donation “Recommended for”: If you want to learn more about your heart health If you suffer high blood pressure, diabetes, sleep apnea, high cholesterol, chronic lung condition, alcohol dependency, smoke cigarettes, suffered a previous stroke, or any heart condition If you have a family history of heart disease, or sudden death If you have been diagnosed with a heart murmur If you are an athlete and concerned about your heart health If you are not feeling well and are concerned about your heart health If you don’t know your Ejection Fraction (EF) If you have not had an EKG or an echocardiogram in the past year If you are looking for peace of mind


Eddie Curry: Eddie Curry Chicago Bulls center 2 bouts of irregular heart rhythm Suspected to have HCM, genetic testing recommended Curry refuses testing, Bulls refuse to play him In 9/2005, traded to NY Knicks who were willing to play him (2005-2006 season: 72 games, 26 min/gm) “Genetic discrimination” vs. privacy rights


Jason Collier: Jason Collier #1 NBA draft pick of Milwaukee Bucks in 2000 Atlanta Hawks center Died on 10/15/05 (at 28 y.o.) at home


NBA Mandatory Screening: NBA Mandatory Screening Begins 2006 season Consists of: Personal and family hx Physical examination Blood work EKG Resting echo Stress echo Administered annually If positive, no ban No training camp until tests complete


Other League Policies: Other League Policies MLB and NHL No uniform league-wide heart screening program NFL Mandates cardiovascular exam and EKG Partnered with Living Heart Foundation Active and retired players especially those at risk – i.e. large body mass index Echo, EKG, Pulmonary Function Test, Cholesterol Analysis, Cardiac Risk Score, Blood Glucose, Urine Drug check, Body Fat and Body Mass Index, and vital signs


NCAA: NCAA Left to individual athletic departments Georgia Tech Echo required for all volleyball, basketball and football Purdue 2.5 min echo ($35) on all incoming athletes Ohio State University Currently performing echo on every OSU athlete (research study)


Will Kimble:Athletics is His Life: Will Kimble: Athletics is His Life In 2002 - starting center for Pepperdine University Fainted Echo shows HCM, defibrillator placed, restricted from playing “I felt like I’d had something taken away from me. It felt like the world had just come down on me. I had invested so much time and had worked so hard” Transferred to UTEP, NCAA grants medical waiver, Kimble plays 2005 season Not without controversy: “The defibrillator was never designed to operate in intercollegiate basketball. The reliability is unknown” Barry Maron, MD


Fred Hoiberg:Risks Are Too Much : Fred Hoiberg: Risks Are Too Much Diagnosed with bicuspid aortic valve at Iowa State in 1995 Drafted by Pacers, traded to Bulls, then Timberwolves Shooting guard, led league in 3-point percentage in 2004-2005 Echo as part of insurance policy in 2005 – Sinus of Valsalva aneurysm Surgery and pacemaker in 6/2005 1st NBA player to play with a pacemaker??? Announces retirement on 4/17/06 Now coach for Timberwolves


Rony Turiaf:Possible Success Story: Rony Turiaf: Possible Success Story Signed rookie contract with LA Lakers in 2005 PE and echo show enlarged aortic root Lakers void rookie contract However, Lakers also pay for aortic root replacement (7/26/05) In 1/06 signs new contract with Lakers After rookie season played for France in 2006 World Championships


Take-Home Messages: Take-Home Messages Sudden death is rare Issue of public perception (not necessarily of public health) Most common causes are HCM Coronary anomalies No legal precedent for malpractice Standard care Follow AHA recommendations Refer to cardiology if any positive Hx, FH, or PE Echo is becoming and will continue to become more critical part of evaluation


Frequently Asked Questions: Frequently Asked Questions What are the American Heart Association recommendations for preparticipation evaluation? http://www.americanheart.org/presenter.jhtml?identifier=1478 What are the American College of Cardiology recommendations for allowing participation in the case of known cardiac disease? Recommendations for Determining Eligibility for Competition in Athletes with Cardiovascular Abnormalities: Bethesda Conference 26: (Revision of Bethesda Conference #16), January 6-7, 1994. (J Am Coll Cardiol 1994;24:845-99) What are the American College of Sports Medicine recommendations for screening, staffing and emergencies at health facilities? http://www.acsm-msse.org Where can I find the Ohio High School Athletic Association preparticipation form? http://www.ohsaa.org/medicine/physicalform.pdf Where can I find the internet-based Stanford University preparticipation form? http://www.stanford.edu/dept/sportsmed/visitors/visitors98.html