Sports Cardiology Essentials (eBook)

Christine E. Lawless, MD, MBA, FACC. Section Director of Preventive and Sports Cardiology, Associate Professor of Internal Medicine, Division of Cardiovascular Medicine, Davis Heart & Lung Research Institute, Ohio State University Medical Center, Columbus, OH

Chapter 1: Sudden Cardiac Death in Athletes: Scope of the Problem and Emergency Response 13
Incidence 13
Introduction 13
Causes 14
Specific Causes 15
Hypertrophic Cardiomyopathy 15
Commotio Cordis 17
Coronary Arterial Abnormalities 17
Myocarditis 17
Marfan’s Syndrome 18
Long QT Syndrome and Wolff–Parkinson–White Syndrome 19
Long QT Syndrome 19
Arrhythmogenic Right Ventricular Dysplasia 21
Immediate Treatment 22
AED Utilization: NCAA Collegiate Experience 24
Case 1 26
Summary 27
References 29
Chapter 2: Cardiovascular Screening of Athletes: Focused Exam, Electrocardiograms, and Limited Echocardiograms 33
Introduction 33
Rationale for Pre-participation Cardiovascular Screening with and Without ECG 33
Appropriate Workup of Athletes with Past History of Heart Disease, Symptoms, Positive Family History, or Abnormal Physical Exam 35
Chest Pain 36
Dyspnea 36
Syncope, Near-Syncope, and Dizziness 36
Family History 37
Case Study of Positive Family History 37
ECG-Based Screening 39
Barriers to Routine ECG-Based Screening in the USA 42
Large Numbers of Athletes and Size of Appropriate Physician Workforce to Conduct the Screenings 42
Cost of Conducting Such Screening in Such a Large Number of Eligible Athletes 44
Mortality Rate from SCD in Athletes is Already Quite Low 45
Lack of a Randomized Trial Demonstrating Clear Superiority of the ECG-Based Screening over a Standardized PPE Without ECG 45
Lack of Standardization for Interpretation of ECGs in Athletes 45
Lack of Normative Data in Certain Demographic and Ethnic Groups 46
How to Implement ECG-Based Screening Programs 46
How to Interpret ECGs in Athletes 48
The Role of Echocardiography in Screening of Athletes 49
What Issues Still Need to be Addressed Before Wide-Spread Screening Can be Implemented in the USA 50
Efficacy of ECG Screening 50
Summary 51
References 51
Chapter 3: Echocardiography and Advanced Cardiac Imaging in Athletes 54
Case 1: Electrocardiographic Evidence of Left Ventricular Hypertrophy 54
Summary 57
Case 2: Exertional Myocardial Ischemia in the Young Athlete 58
Summary 60
Case 3: Arrhythmia and Right Ventricular Dilation 60
Summary 65
References 66
Chapter 4: Exercise Training and Prescription 71
Aerobic Power 71
Anaerobic Power and Capacity 73
Muscle Strength and Endurance 73
Prescribing Exercise 74
Specificity of Training 74
Progressive Overload 75
Intensity 75
Frequency and Duration 76
Resistance Training 77
Types of Training Programs 78
Interval Training 78
Fartlek 78
Tempos 79
The Patient-Athlete 79
Hypertrophic Cardiomyopathy 82
Mitral Valve Prolapse and Myocarditis 82
Valvular Heart Disease 82
Congenital Heart Disease 83
Cardiac Transplantation 84
Elderly 84
Case Presentation 1 87
Medical History 87
Examination 87
Testing 87
Diagnosis 87
Hospital Course 87
Post Discharge Plan 88
Case Presentation 2 88
Medical History 88
Examination 89
Testing 89
Diagnosis 90
Plan 90
Summary 91
References 91
Chapter 5: Role of Genetic Testing for Sudden Death Predisposing Heart Conditions in Athletes1 93
Introduction 93
Hypertrophic Cardiomyopathy Case Vignette 94
Summary of Cardiomyopathy Genetic Testing 94
Hypertrophic Cardiomyopathy 94
Arrhythmogenic Right Ventricular Cardiomyopathy 98
Long QT Syndrome Case Vignette 99
Summary of Channelopathy Genetic Testing 100
Long QT Syndrome 100
Catecholaminergic Polymorphic Ventricular Tachycardia 101
Brugada Syndrome 102
Short QT Syndrome 103
Indications for Genetic Testing in the Athlete 103
The “Borderline” Patient 103
“Gold Standard” Diagnostic Marker for the Asymptomatic Athlete Who Is Part of a Family with a Sudden Death Predisposing Heart C 104
References 106
Chapter 6: Shortness of Breath 110
Introduction 110
Common Causes of Shortness of Breath During Exercise 111
Case 1 111
Exercise-Induced Bronchospasm 111
Case 2 115
Vocal Cord Dysfunction 117
Gastroesophageal Reflux Disease 118
Less Common Causes of Dyspnea During Exercise 118
Conclusion 119
References 119
Chapter 7: Chest Pain in the Athlete: Differential Diagnosis, Evaluation, and Treatment 122
Cardiac Chest Pain 125
History 125
Physical Examination 125
Aortic Dissection 126
Noncardiac Causes of Chest Pain 126
Musculoskeletal Etiologies of Chest Pain 126
Chest Wall Pain 126
Traumatic Rib Fracture 127
Rib Stress Fractures 128
Sternoclavicular Injury 129
“Stitch” 130
Costochondritis 130
Tietze’s Syndrome 131
Slipping Rib Syndrome 131
Precordial Catch Syndrome 131
Cervical Disk Disease/“Cervical Angina” 131
Pulmonary Chest Pain 132
Asthma/Exercise-Induced Bronchospasm 132
Pneumothorax 133
Pulmonary Contusion 134
Pneumomediastinum 135
Pulmonary Embolus 135
Pneumonia 137
Pleurisy 137
Hyperventilation 139
Gastrointestinal Chest Pain 139
Gastroesophageal Reflux Disease 139
Dysphagia 140
Psychiatric Etiologies of Chest Pain 140
Substance Abuse 141
Conclusion 141
Clinical Cases 142
Case 1 (Fig. 7.4) 142
Case 2 (Fig. 7.5) 142
References 143
Chapter 8: The Collapsed Athlete 147
Approach to the Down Athlete 149
Cardiac Causes 149
Hyperthermia/Exertional Heat Stroke 151
Background 151
Diagnosis 152
Treatment 153
Hypothermia 155
Background 156
Diagnosis 157
Treatment 157
Exercise-Associated Hyponatremia 158
Background 158
Diagnosis 159
Treatment 160
Hypoglycemia 160
Background 160
Diagnosis 161
Treatment 161
Exercise-Associated Collapse 162
Background 162
Diagnosis 162
Treatment 163
Seizures 163
Trauma 164
Case #1 164
Summary 165
References 165
Chapter 9: Syncope/?Presyncope in the Competitive Athlete 168
Introduction 168
Definitions 169
Syncope/Presyncope 169
Competitive Athlete 169
Exercise-Related Syncope 170
Epidemiology 170
Pathophysiology of Exercise-Related Syncope 171
Differential Diagnosis 172
Neurally Mediated Causes 172
Cardiac Causes 173
Evaluation 173
Physical Examination 175
Echocardiography 178
Further Diagnostic Testing 178
Ambulatory Monitoring 179
Continuous-Loop Event Monitoring 179
Tilt Table 179
Electrophysiologic Studies 180
Management of Syncope 180
Return to Play 182
Conclusion 182
References 183
Chapter 10: Electrophysiological Approach to Syncope and Near-Syncope in the Athlete 185
Case 185
Introduction 185
Significance of Syncope and Near-Syncope in the Athlete 186
Epidemiology 188
Mechanisms and Causes of Syncope and Near-Syncopein the Athlete 189
Evaluation of the Athlete with Syncope and Near-Syncope 191
History 192
Physical Examination 193
Diagnostic Testing 193
Noninvasive Testing 193
Electrocardiography 193
Electrocardiographic Monitoring (Holter Monitor, Event Monitor, Implantable Loop Recorder) 194
Echocardiogram 194
Tilt-Table Testing 195
Exercise Testing 196
Other Noninvasive Testing 196
Invasive Testing 197
Electrophysiology Testing 197
Cardiac Catheterization 198
Endomyocardial Biopsy 198
Management of Syncope in the Athlete 198
Treatment of Neurocardiogenic Syncope 199
Treatment of Arrhythmic Syncope 199
Implanted Devices in the Athlete 201
Athletic Restrictions 201
Illustrative Cases 202
Eighteen-Year-Old Female with Syncope 202
Nineteen-Year-Old Male Swimmer with Frequent Palpitationsand Near Syncope 203
Twenty-Year-Old Male with Syncope While Playing Basketball 204
Eighteen-Year-Old Male with Near Syncope and Palpitations During Basketball 204
Thirty-Seven-Year-Old Distance Runner with Episodesof Syncope at Rest After Exercise 206
Nine-Year-Old Female Who has Recurrent Collapse During Activity 207
Nineteen-Year-Old with Syncope During Football 207
Twenty-Year-Old Female with Syncope with Exertion 208
Forty-Year-Old Male Physician Who Has Syncope at RestWhile Examining Patients 209
Sixteen-Year-Old Female with Syncope 210
Thirty-Five-Year-Old Male with Near Syncope Playing Hockey 210
Conclusions 212
References 212
Chapter 11: Heart Murmurs 217
Introduction 217
Patient History 217
Physical Examination 219
Approach to Murmurs 223
Aids to Physical Examination 226
Training Tools 226
Diagnostic Evaluation 227
Management of Specific Valvular Conditions 228
Case 1 228
Patient History 228
Past Medical History 231
Physical Exam 233
Diagnostic Tests 234
Treatment 234
Outcome 234
Discussion 235
Case 2 236
Patient History 236
Past Medical History 236
Physical Examination 236
Diagnostic Tests 237
Treatment/Disposition 237
References 237
Chapter 12: Management of Hypertension in Athletes 239
Introduction 239
Classification of Blood Pressure 239
White Coat Hypertension 240
Secondary Hypertension in Athletes 240
Clinical Evaluation 241
Treatment of Hypertension in Athletes 243
Diuretics 244
Angiotensin-Converting Enzyme Inhibitors 247
Angiotensin Receptor Blockers 247
Beta-Adrenergic Blockers 247
Calcium Channel Blockers 248
Alpha Blockers 248
Alpha Agonists 248
Combination Therapy 249
Recommendations for Athletic Participation in Hypertensive Athletes 249
References 249
Chapter 13: Hypertrophic Cardiomyopathy 252
Case Vignette 252
Introduction 253
Definition and Etiology 254
Screening for Hypertrophic Cardiomyopathy 257
Screening for Families with Known HCM 257
General Pre-Participation Screening 257
Differentiating Hypertrophic Cardiomyopathy from Physiologic Hypertrophy 259
Clinical Features and Management of Hypertrophic Cardiomyopathy 260
Pathophysiology of HCM 260
Clinical Evaluation of Patients with HCM 261
Physical Examination in HCM 261
Electrocardiography 261
Echocardiography 262
Magnetic Resonance Imaging 263
Risk Stratification for Sudden Cardiac Death 263
Management of Patients with Hypertrophic Cardiomyopathy 266
Physical Exercise 266
Medical Therapy 268
Septal Reduction Therapy 268
Natural History of Hypertrophic Cardiomyopathy 269
References 269
Chapter 14: Commotio Cordis: Practical Aspects in Sports 272
Commotio Cordis-Clinical Characteristics 272
Experimental Models of Commotio Cordis 274
Commotio Cordis-Prevention 275
Commotio Cordis-Current Practical Management 277
Conclusion 278
References 278
Chapter 15: Coronary Artery Anomalies and Sports Activities 280
Introduction: Three Stories 280
Case 1: Sudden Cardiac Death in a Top High-School Athlete 280
Case 2: Sudden Crib Death in an Infant 281
Case 3: A Surprising Accidental Finding in an 83-Year-Old Woman 282
Comment 283
Coronary Artery Anomalies: A Brief Appraisal of a Complex Entity 284
Sports Activities and Coronary Anomalies 291
Screening, Diagnosis, and Counseling 293
Prevention and Treatment of Sudden Cardiac Death in Athletes 296
Conclusions 298
References 298
Chapter 16: Participation in Sports for the Athlete with the Marfan Syndrome 302
Introduction 302
The Evaluation 306
History 306
Examination 307
Diagnostic Testing 307
Treatment 308
Medical 308
Surgical 308
Recommendation for Athletic Participation 309
Types of Exercise 309
Case 1 311
Discussion 312
Case 2 312
Discussion 312
Conclusion 312
References 313
Chapter 17: Congenital Heart Disease: Exercise and Sports Participation 315
Introduction 315
Common Lesions in Adults with Congenital Heart Disease 316
Shunt Lesions 316
Atrial Septal Defect 316
Patent Foramen Ovale 317
Ventricular Septal Defect 317
Patent Ductus Arteriosus 317
Anomalous Venous Return 318
Eisenmenger’s Syndrome and Pulmonary Hypertension 318
Valvular Lesions 318
Bicuspid Aortic Valve 318
Aortic Stenosis 319
Aortic Insufficiency 319
Coarctation of the Aorta 320
Pulmonic Stenosis 320
Ebstein’s Anomaly 321
Complex Congenital Heart Lesions 321
Tetralogy of Fallot 321
Transposition of the Great Vessels 322
Single Ventricle Variants 322
Congenital Coronary Anomalies 323
Evaluation for Preparticipation Screening 323
History and Physical Examination 324
Electrocardiogram 325
Echocardiogram 325
Stress Testing 326
MRI/MRA and CT 326
Cardiac Catheterization 326
Recommendations 326
Cases 331
Case 1: Bicuspid Aortic Valve 331
Case 2 331
References 332
Chapter 18: Athlete with a Device: Implantable Cardioverter Defibrillators and Pacemakers 334
Postulated Risks of Sports 335
Triggering of Arrhythmia 335
Unknown Efficacy of the ICD During Sports 336
Nonarrhythmic Injury to the Athlete 337
Damage to the ICD System 337
Preliminary Safety and Efficacy Data: Survey Data 337
Current Recommendations by Physicians 337
Physician-Reported Sports Participation and Outcomes 338
Potential Safety-Related Precautions 342
Limitations to Survey Data 343
Ongoing Research 343
References 343
Chapter 19: Long QT Syndrome and Other Channelopathies 346
Introduction 346
Long QT Syndrome 347
Case Report #1 347
Case Report #2 348
Case Report #3 349
Case Report #4 352
Short QT Syndrome 354
Brugada Syndrome 355
Case Report #5 355
Catecholaminic Polymorphic Ventricular Tachycardia 359
Recommendations for Sport Participation in Patients with Channelopathies 360
References 366
Chapter 20: Cardiac Effects of Ergogenic Aides and Supplements 372
Introduction 372
Anabolic Androgenic Steroids 373
Atherogenic 374
Thrombogenic 375
Vasospasm 375
Direct Myocardial Effects 375
Are the Cardiac Effects of Anabolic Steroid Use Reversible? 375
Polysubstance Abuse 376
Dehydroepiandrosterone (DHEA) 376
Peptide Hormones and Analogues 377
Human Growth Hormone (hGH) 377
Mechanism of Action 378
Adverse Effects of GH Abuse 378
Specific Cardiovascular Concerns 378
Future Concerns 379
Erythropoietin (EPO) 379
Stimulants 379
Amphetamines 380
Cocaine 380
Ephedra and Ephedrine 380
Cardiovascular and Systemic Side Effects 381
Ephedra/Ephedrine as a Controlled or Restricted Drug in Sport 381
Caffeine/Gaurana 382
Caffeine as a Controlled or Restricted Drug in Sport 383
Effects of Caffeine Intake in Children 383
Guarana 383
Conclusion 384
References 384
Chapter 21: Return-to-Play Decisions in Athletes with Cardiac Conditions: Guidelines and Considerations 387
Introduction 387
Guidelines for Sports Participation for Athletes with Known Cardiac Conditions 387
Recommendations for Young Patients with Genetic Cardiovascular Diseases 388
Recommendations for Masters Athletes 391
Return-to-Play: General Considerations 391
Implanted Defibrillators 391
Ablations 392
Beta Blockers 392
Corrective Cardiac Surgery 392
The Grey-Zone Athlete 393
Grey-Zone Athlete: Case Study 393
Specific Considerations for Conditions That Predispose to SCD Episodes 394
Cardiomyopathies and Inflammatory Diseases 394
Congenital Heart Disease 395
Aortic Reconstruction: Case Study 395
Rhythm Disturbances 396
Supraventricular Rhythm Disturbances 396
AV Nodal Reentrant Tachycardia 396
Wolff–Parkinson–White Syndrome 396
Ventricular Rhythm Disturbances 397
Nonsustained or Sustained Ventricular Tachycardia 397
Ventricular Fibrillation 397
Common Valvular Diseases 398
Bicuspid Aortic Valve 398
Aortic Stenosis 398
Aortic Insufficiency 398
Mitral Valve Prolapse 398
Summary 399
References 399
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