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Cardiovascular Approach to the Preparticipation Physical
Abstract & Commentary
By Matt Shores MD, St. Joseph's Hospital and Medical Center, Family Medicine Residency, Phoenix, AZ, is Associate Editor for Urgent Care Alert.
Dr. Shores reports no financial relationship relevant to this field of study.
Synopsis: A discussion on the importance of cardiovascular screening in the preparticipation evaluation and a review on the consensus guidelines.
Source: Giese EA, et al. The athletic preparticipation evaluation: Cardiovascular assessment. Am Fam Physician. 2007;75:1008-1014
Each year, thousands, likely hundreds of thousands, of athletes present to their physicians for preparticipation physicals. In this review article written for the American Family Physician, Giese and colleagues focus on the most critical aspect of the preparticipation physical, the cardiovascular assessment. Giese et al use solid evidence rating C recommendations for the approach to the cardiovascular assessment, including the athlete's history, the family history, and the physical exam, particularly auscultation of murmurs. The article details which direction the history and physical should lead and when to seek further work-up as red flags present themselves. Approximately one in 200,000 young athletes suffer a sudden cardiac death annually. The purpose of the cardiovascular assessment in the preparticipation physical is to catch some of these sudden deaths before they occur. Among the leading offenders are hypertrophic cardiomyopathy and coronary artery anomalies. A detailed history and a focused physical exam can help sift through some these risk factors.
Attaining a thorough history from the athlete is essential. In fact, a thorough history may very well be considered the most important aspect of the preparticipation evaluation. The athlete's parents should be encouraged to get involved in filling in the patient's history, as often times the parents will have a much more fundamental knowledge of the family history and the patient's personal medical history. It is important to determine an accurate family history. A family history that reveals family members with heart problems, sudden death, or death before the age of 50 may be an indication that a further work-up is necessary. A brief screening for family members with a history of Marfan syndrome may also prove beneficial. Parents may also contribute to the patient's personal medical history. Any history of heart murmurs or elevated blood pressure at previous doctor visits should be investigated in depth. Finally, completing the history should involve a review of any symptoms the athlete has experienced in the past while participating in various activities.
As the patient begins to describe various symptoms that they may have experienced in the past during an activity, close attention should be paid to "red flag" symptoms. Any description of syncope in the past should definitely be worked-up further to evaluate for a structural cardiac defect. In addition, if an athlete describes chest pain with exertion, then further investigation looking for an outflow tract obstruction or coronary artery anomalies may be indicated. An athlete that has experienced palpitations may have an arrhythmia and a work-up including an ECG, electrolytes, and thyroid studies may be beneficial. Finally, athletes that detail dyspnea on exertion are a little more difficult to approach, as this description may simply represent poor conditioning, or it may underlie a more serious problem such as primary pulmonary hypertension, anemia, or exercise-induced asthma; ultimately, the decision in which direction to head must be made clinically.
The cardiovascular portion of the preparticipation physical exam may be broken down into 4 components: blood pressure, evaluation of radial and femoral pulses, a dynamic cardiac auscultation, and finally an evaluation for Marfan syndrome. Elevated blood pressure may be classified as prehypertension (BP 90%-95%), stage 1 hypertension (BP 95%-99%), or stage 2 hypertension (BP >99%). Athletes with prehypertension may be cleared for full participation and should have BP rechecked in 6 months. An athlete with stage 1 hypertension may be cleared for participation (except power lifting), but 2 follow-up visits should occur to recheck blood pressure (1-2 weeks after the initial visit). Patients with stage 2 hypertension should be restricted from participation until the hypertension is under control. Included in the physical exam should be a close examination of radial and femoral pulses; both pulses should be palpated at the same time to evaluate for the possibility of coarctation of the aorta. Dynamic auscultation of the heart refers to a thorough evaluation of heart sounds, including examination using Valsalva maneuvers and/or having the patient go from a squat to standing position. If a murmur is noted, it should be described by its timing, location, character, and intensity. If a murmur becomes louder or longer during a Valsalva maneuver or when the patient returns to standing position from a squat, then further evaluation may be necessary to evaluate for hypertrophic cardiomyopathy or mitral valve prolapse. Finally, a brief screening for Marfan syndrome concludes the cardiac portion of the preparticipation physical. If a male athlete is taller than 6 feet or a female athlete is taller than 5 feet 10 inches, and these athletes possess 2 other characteristics of Marfan syndrome, then further work-up is indicated.
Although most athletes receive their annual preparticipation physical from their primary care physician or school's team physician. As we all know, many young healthy athletes don't have a primary care physician or their school doesn't have a team physician. Oftentimes, these athletes present to an urgent care to get their last minute sports physical taken care of so they can start practice. Typically the institution the athlete intends on participating for supplies a template form for the preparticipation physical. Often this form contains a "yes or no" history section and brief check box physical exam section. It becomes the responsibility of the physician to determine what is important and to do it in a timely manner. This cardiovascular assessment article in the American Family Physician does a solid job of breaking down the cardiovascular assessment and focusing on what is important in a young athlete.
Essentially, the starting point in locating any risk factors for sudden death in a young athlete is a detailed personal and family history (evidence rating C). Any athlete with a history of "red flag" symptoms such as syncope or chest pain while participating in an activity should be restricted from play until further evaluation has been completed (evidence rating C). Once a detailed history has been taken, the cardiovascular physical exam should start with blood pressure. Athletes with stage 2 hypertension (BP > 99% or adults, that is > 18-years-old, with >160/100) should be restricted until their blood pressure is controlled (evidence rating C). Routine screening with tests such as ECG, Echo, or treadmill stress tests are not recommended for all athletes (evidence rating C). However, patients that present with physical exam findings such as a murmur that gets louder with a Valsalva maneuver should be further evaluated to rule out HOCM or mitral valve prolapse (evidence rating C).
Ultimately, the physician is the last line of defense for young healthy athletes that have a life-threatening cardiac abnormality that may later become unmasked when participating in a high-demand activity. A few simple questions, coupled with few quick cardiovascular exam tools, can help assure that these young healthy athletes do not become one of the sudden cardiac deaths that occur each year.