Cardiovascular Risks to Young Persons on the Athletic Field

Abstract & Commentary

Synopsis: An American Heart Association consensus panel agreed that inclusion of noninvasive tests in the routine screening of all young athletes is impractical.

Source: Maron BJ. Cardiovascular risks to young persons on the athletic field. Ann Intern Med 1998;129:379-386.

Sudden death in young athletes is rare, occurring in only approximately one out of every 200,000 high school athletes per academic year. Its major causes are hypertrophic cardiomyopathy and congenital coronary anomalies. These abnormalities infrequently result in premonitory signs or symptoms and, therefore, are difficult to diagnose during a preparticipation physical examination. Nonetheless, a preparticipation cardiovascular screening exam consisting of a targeted personal and family history as well as a physical examination is recommended for every competitive athlete. Although echocardiography and electrocardiography are helpful in identifying life-threatening cardiac abnormalities in young people, an American Heart Association (AHA) consensus panel agreed that inclusion of such noninvasive tests in the routine screening of all young athletes is impractical, given the considerable size of this population, which is estimated to be 8 to 10 million.

Other causes of sudden death in young athletes discussed by Maron include ruptured aortic aneurysm associated with Marfan syndrome, idiopathic dilated cardiomyopathy, aortic valve stenosis, the long QT syndrome, and myocarditis secondary to viral disease or drug use. Cardiac arrest may also occur from a relatively modest nonpenetrating chest blow, which occurs during the vulnerable phase of cardiac repolarization. This phenomenon has been called commotio cardis and has been most commonly described following blows to the chest from batted baseballs.

Comment by Letha Y. Griffin, MD, PhD

The AHA’s statement on preparticipation cardiac screening of competitive athletes recommends such screenings for all young athletes by a health care worker knowledgeable in cardiovascular evaluations.1 This evaluation should include a cardiovascularly targeted personal and family history with key questions designed to determine 1) prior occurrence of exertional chest pain or syncope, shortness of breath, or exertional fatigue; 2) history of heart murmur or increased blood pressure; and 3) family history of premature cardiovascular death or severe cardiac disease. The physical examination should emphasize 1) precordial auscultation in both the supine and standing positions, 2) assessment of femoral artery pulses, 3) recognition of stigmata of Marfan syndrome, and 4) a seated brachial blood pressure.

Although the AHA initially recommended a complete examination every two years, it modified this recommendation in 1998 to include a formal cardiovascular evaluation upon entrance into an athletic program with annual updates of the medical history and blood pressure measurement. If the history reveals any pertinent changes in the athlete’s medical status, a full cardiovascular examination must be done. Two important symptoms that should trigger more extensive cardiovascular evaluations are exertional syncope and intense chest pain or discomfort brought on by exercise.

Reference

1. American Heart Association. Cardiac preparticipation screening of competitive athletes. Circulation 1996; 94:850-856.