Pre-Sports Evaluation

Thomas R. Kimball, MD
Professor of Pediatrics
University of Cincinnati
Director
Echocardiography
Cardiovascular Imaging Core
Research Laboratory
 Acknowledgement

• Waldemar Carlo
– Current PL-III at Cincinnati Children’s Hospital
– Future pediatric cardiology fellow at Texas
Children’s Hospital
 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
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?

 Outline
Problematic
What are the Pediatric Current
issues? Cardiovascular Customary
Diseases Practice • 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
Sports Intensity Learning from Future • Current practice:
the Past: Profile Practice? – Hx, FH, PE
of Sudden • Future practice:
Death Victims – Echo
 Major Players
• Athlete
• Family
• School/NCAA
• Lawyers and Courts
• Physicians
• Consensus Guidelines
 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
• Desire to play outweighs
almost every concern
• Spend enormous effort on
sport
• Self worth is wrapped up
in sport
Sahara Marathon • Sense of invincibility
 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
• 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
• 200-300 young
athletes / year in USA
200,000 competitive
athletes screened
0.5%

1000 with CHD

1% 10 with disease capable of

causing sudden death
10%
1 with sudden death
 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)
 Sports Intensity:
Static Classification

High Low
Static Static
 Sports Intensity:
Dynamic Classification

Low High
Dynamic Dynamic
 Sports Classification

MVC = maximum voluntary contraction

Max O2 = maximum oxygen consumption Mitchell JH, et al. JACC 45:1364-67. 2005
Cardiac Etiologies of Sudden Death
in < 35 y.o.
ARVD
Poss myo DCM
Myo CAD
AS
Ao aneur

O ther

HCM

Cor Anom

Poss HCM
 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
• 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
 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
 HCM Phenotype
• Cardiac Defects • Risks
– Abnormal cellular – Myocardial ischemia
architecture – Arrhythmogenic cardiac
– Hypertrophied LV tissue
– Intramural coronaries – LVOT obstruction
– Annual risk of SCD is
1%
 HCM
• History • Signs
– ½ pts are asymptomatic – Prominent LV impulse
– ½ pts have DOE, angina, – Frequently have no
syncope, palpitations, murmur
etc. – If present, murmur
– FHx increases with a decrease
in venous blood return
(supine  standing)
• EKG
– LVH
• ECHO
LVH and sudden cardiac death

From Spirito P, et al. NEJM 342:1778-1785, 2000.

Activity level and sudden cardiac
death in HCM
25

20
# of HCM patients

15

10

0
Sedentary Walking Exercise

Adapted from Spirito P, et al. JACC 15:1521-6, 1990.

 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
 Athlete’s Heart vs. HCM
Athlete’s Heart HCM

LV thickness < 16mm > 16mm

LVH pattern Concentric Asymmetric

LV cavity Large Small

Diastolic Fxn Normal Impaired

Left Atrial Size Normal Dilated

 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

From Zareba W, et al. NEJM 339:960-965, 1998

SCD in Long QT syndrome

(particularly swimming)

Schwartz PJ, et al. Circulation. 2001;103:89.

 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
• Risk of ICD
damage/displacement
• Recommendations
– Class 1A sports only
 Congenital Coronary Artery
Anomalies
Nl pattern
• 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
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
 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
 Kawasaki Disease
• Acquired coronary
artery aneurysm(s)
• Sports participation
depends on presence
and size of aneurysms
 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
 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
 Myocarditis
• Frequent cause of non-structural SCD
• Pathogenesis
– Myocardial inflammatory infiltrates, myocyte
necrosis, replacement fibrosis
– Arrythmogenic substrate
 Recommendations
• 6 month off period
• Re-evaluation by cardiologist
– EKG, ECHO
– Stress test
– Holter monitor
– Serum markers of inflammation, heart failure
 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
 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
 Recommendations
• Aortic root involvement
• Moderate/severe mitral
valve regurgitation
• FH of Marfan-related
sudden death or aortic
dissection

Class IA
 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

• 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
• Fibrofatty RV is
arrhythmogenic
• Adrenergic stimulation
(exercise) induces
these arrhythmias
 ARVD
• Prognosis • Treatment
– 3% mortality rate – Beta Blockers
without treatment – Radiofrequency
– 1% mortality with ablation
pharmacotherapy – Implantable cardiac
defibrillator ?
– No athletic competition
except maybe class 1A
 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)
 Commotio Cordis

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

 Commotio Cordis
• Chest wall impact
• Rare but likely underreported
• Associated with competitive or recreational
athletics
 Sports Participated in at the Time of
Commotio Cordis Events

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

Copyright restrictions may apply.

 Age at Time of Commotio Cordis Event

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

Copyright restrictions may apply.

 Pathophysiology
• No underlying heart
disease
• No major damage to
the heart or great
vessels
• Unimpressive force of
impact
 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 (?)

• Chest Wall Protectors

• Soft Balls
Cardiac
Those Etiologies
Etiologies of Sudden
Readily Death
Detectable
by Hx andin PE
< 35 y.o.
Screening
ARVD
Poss myo DCM
Myo CAD
AS
Ao aneur

O ther

HCM

Cor Anom

Poss HCM
Level of Competition
High
School
77%

College
Pro Youth
3%
9% 11%
Sports in which Sudden Death Occurs

Other Soccer
Baseball
Track

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

• Identify individuals
– Known to be at risk
– Not known to be at risk
• Make recommendations
regarding participation
 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
Risk Ratio between Athletes and
Non-Athletes
Athletes

Non-athletes

From Corrado D, et al. JACC 42:1959-1965, 2003.

What is “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
 Limitations of Screening
• False positives
• Athlete disqualifications
• Cost efficiency
• Screening volume
 American
Guidelines
(1996)

Family and personal history, physical

exam
Negative Positive
Eligible for Further
competition testing
Negative

Positive

Further
management
 European
Guidelines
(2005)

Family and personal history, physical

exam, and EKG
Negative Positive
Eligible for Further
competition testing
Negative

Positive

Further
management
 Efficacy of Screening with EKG
30
% of SCD attributed to HCM

25

20
Italy
15
USA
10

0
Athletes Non-athletes
 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
• 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
• Physical Activity
Practical Tools
Readiness Questionnaire • Stanford University
(PAR-Q) Pre-Participation
• Has a doctor ever told you that you
have a heart condition and
recommended only medically
Form
supervised activity? • Internet-based
• Do you have chest pain brought on by
physical activity? • Extensive (18 pages)
• 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?
Cardiovascular Examination
• BP
• Auscultation
• Femoral arteries
• Marfan’s stigmata

Referral when
abnormalities in Hx
and PE
 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
• Miniaturization of technology
• Targeted, limited examination
• Decreasing costs
 Cost Effectiveness of
Screening Modalities
Hx/PE EKG Echo

• Med Sci Sports Exerc 32:887, 2000 Sensitivity (%) 6 70 80

(Sierra Heart Institute, Reno, NV)
• High school athletes (HSA) Specificity (%) 97.8 84.3 100
• 3 screening modalities
– CV-specific Hx/PE Screening cost ($) 0 10 350
– EKG
– Echo Abnl response cost ($) 500 365 0
• Assume 700,000 evaluations would
occur in search of 70 HSA Years saved (yrs) 10% - 40
• EKG is most cost-effective 90% - 20
• To be equally cost-effective:
– Hx/PE would need 2X increase in
sensitivity Overall cost (mill $) 7.7 47.2 245
– Echo would need 4X decrease in
cost Years gained 93 1080 1232
Cost effectiveness 84,000 44,000 200,000
(cost/yr saved)
 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
• 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
• #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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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