Cardiovascular Considerations in an Athlete Flashcards
Normal Physical exam findings of an athlete
- Reversible!!!! Left Ventricular Hypertrophy - LV wall thickness (LVWT) and LV cavity size, permits enhanced filling. - Increased CO maintained at high HR
- Bradycardia•Increased VO2max
- Sinus Arrhythmia
- Transient Split S2 - Changes with inspiration and expiration - Less common in adults
Post exercise syncope
Exhaustion, Exercise-induced hyponatremia, heat illness, rapid reduction in preload and functional sympatholysis with elevated contractility and HR
Syncope during exercise
More concerning; linked to HCOM, arrhythmogenic right ventricular cardiomyopathy.
Screening recommendations for syncope in an athlete
- Until diagnosis or pathologic causes excluded, exercise is generally restricted.
- R/O post vs during; ask bystanders
- Screen for defects (Marfan’s, HCOM etc)
Dehydration
- Performance suffers, earlier fatigue
- Can reduce exercise SV and CO, - Especially in the heat but can happen even without hyperthermia
- Less able to tolerate hyperthermia
- Eventually MAP may drop
- When coupled with heat illness can potentially trigger arrhythmias
- Rehydration Strategy (NATA)
Sudden cardiac death
- SCD is the leading cause of non traumatic mortality in athletes
- Low overall prevalence ; ~100 to 150/year; OR 2.3 to 4.4/100,000 per year•Black/African American 5.6/100,000 per year
- Athletes aren’t at a greater risk for SCD than general population*
Which sports does SCD most often happen in?
Football and basketball
How much more does SCD happen in males v females
9x
Most common causes of SCD
Youths: HCM (33-50%), Coronary Anomalies (15-20%), Several others each <5%
•Adults: 80% due to undiagnosed CAD, plaque rupture
Most common mechanism of death in SCD
- ventricular tachyarrhythmia
- exception of marfan syndrome: usually aortic dissection/ rupture
Hypertrophic Cardiomyopathy
- Strong genetic link to HCOM
- (55% of cases with familial relative)
- More common in Black/African Americans
- Ejection murmur changes with position
- Softens during sitting/squatting
- Amplifies during standing/Valsalva
- Persistent Split S2
- No change with breath holds
- S4 Gallop possible too
- Syncope or Dyspnea during exercise
- Persistent hypertrophy despite detraining
Coronary Anomalies
- The most common anomalies are left coronary artery origins in the right sinus of Valsalva and right coronary artery origins in the left sinus of Valsalva.
- SCD results from ventricular arrhythmia triggered by ischemia during exercise.
- Coronary blood flow is impaired by the abnormal ostium, compression of the artery and/or coronary spasm triggered by endothelial dysfunction.
- Usually asymptomatic, although angina associated with syncope should raise suspicion
Myocardial Bridge definition
- epicardial coronary artery, is tunneled within the myocardium
- characterized by systolic compression of the tunneled segment
symptoms of myocardial bridge
- asymptomatic
- atypical or angina-like chest pain
- resting ECGs are frequently normal
- stress testing may induce nonspecific signs of ischemia, conduction disturbances, or arrhythmias
- diagnosed with angiogram
- surgical intervention in some cases
potential complications of myocardial bridge
- Angina, myocardial ischemia, myocardial infarction, left ventricular dysfunction, myocardial stunning, paroxysmal AV blockade, as well as exercise-induced ventricular tachycardia and SCD
- there is a high prevelence in heart transplant recipients and in patients with HCOM
Marfans syndrome
Marfan’ssyndrome results from a gene mutation overproduction of transforming growth factor beta (TGF-β)
Cardiovascular disorders found in patients with marfans
- Aortic tear or rupture - Most often in ascending/thoracic aorta
- Mitral valve prolapse
- Aortic regurgitation
- Arrhythmias (atrial & ventricular)
Intervention of marfans syndrome
- Close monitoring
- Medications for arrhythmias
- Surgery to correct defects
- Activity modification
Commotio cordis
- Sudden blunt impact (ball, puck, opponent) to the chest causes sudden death in the absence of cardiac damage.
- Most Common Sports - Baseball, ice hockey, lacrosse, football, and martial arts.
- Usually triggers ventricular fibrillation
- 3% of SCD in young athletes
- 35% able to be resuscitated
Prevention of Commotio cordis
- Shields not demonstrated to be to effective
- Having Defibrillators present at events
- Educate coaches and players to turn away chest from inside pitches
AHA Screening recommendations
- Indicated for any athlete 12-25
- Yes to any of the 14 question warrants further examination before participation in sports.
- AHA does not support the usage of mass ECG screenings - Cost, logistics, low incidence and type 1 errors with ECG
ECG Screening in the athlete
- In Italy, a 12-lead ECG and limited stress test is routinely obtained as part of a mandatory comprehensive screening program.
- The International Olympic Committee, mandates medical screening including a baseline ECG•Pre-draft testing with ECG occurs in ≈90% of the 122 major professional sports teams in North America - NBA is the most rigorous
ECG athlete facts
- ECGs are abnormal in >90% of patients with HCM
- HCOM most common cause of SCD in patients <35 y/o
- Advanced interpretation can reduce false positive rate
- ECG screening for adults >35 y/o may not be as effective
- Cost savings may be different in a single payer healthcare system
ECG Screening athlete “the seattle criteria”
Normal, ECG findings in athletes.- Results from adaptation of the cardiac autonomic nervous system to conditioning.
1. Sinus bradycardia (>= 30 bpm)
2. Sinus arrhythmia
3. Ectopic atrial rhythm
4. Junctional escape rhythm
5. 1°AV block (PR interval > 200 ms)
6. Mobitz Type I (Wenckebach) 2°AV block
7. Incomplete RBBB
8. Isolated QRS voltage criteria for LVH
9. Early repolarisation
10. Convex (‘domed’) ST segment elevation combined with T-wave inversion in leads V1–V4 in black/African athletes
•Reduced the false-positive rate from 17% to 4.2%
Physical therapy implications
- Recreational Athletes likely at low risk, increased with uncontrolled risk factors
- Risk of adverse event during exercise including SCD decreases with increased frequency and volume of exercise
- For someone who has never exercised before, recommend gradually increasing activity starting with low <3METs (walking)
- Take Vitals, check for arrhythmias, report undiagnosed findings to PCP
- Utilize PARQ or ACSM Pre-Activity Screen
- Consider SubMax ETT or Response to low-mod exercise: walking, stairs etc
- Effectively educate staff on CPR, have access to defibrillators
- Climate control in clinic/facility, access to water and electrolytes
