PPE Findings That Require Further Cardiac Evaluation

Transcription

1 PPE Findings That Require Further Cardiac Evaluation Jaron Santelli, MD University of Maryland Assistant Professor, Team Physician Primary Care Sports Medicine and Emergency Medicine Department of Orthopaedics May 4, 2018

2 None Disclosures

3 Objectives Review PPE process Briefly review appropriate physiology Discuss pertinent findings that require further cardiac work up Briefly discuss appropriate work ups for the above findings

4 Why do we do this anyway? to detect underlying cardiovascular abnormalities that may predispose an athlete to sudden death 1

5 Rates of sudden cardiac death are the topic of much debate within the literature. Reported rates are anywhere from 1:917,000 athlete years (AY) to 1:3,000 AY Accepted rates of SCD in college athletes are 1:50,000 AY and 1:50,000 to 1:80,000 in high school students AY At risk groups include men, basketball players, African Americans Initial reports show that hypertrophic cardiomyopathy is the most common cause of SCD however on autopsy of all young people the most common finding on autopsy is a structurally normal heart Other causes include congenital coronary artery anomalies, repolarization abnormalities, and Marfan syndrome

6 What does the literature say An Italian study identified a 2.5-times relative risk for SCD in adolescents and young adults engaged in competitive sports versus an age-matched nonathletic population 1,4,5. French investigation found the relative risk of sports-related sudden death was 4.5 times greater in competitive young athletes ages 10 to 35 years compared with noncompetitive sports participants of the same age 1,4,5 A prospective study examining SCA/D in over 4,000,000 US high school youth found athletes were 2.7 times more likely to suffer SCA/D than nonathletes 2,6 In contrast, studies in Denmark found exertional SCD in competitive athletes to occur less frequently than SCD occurring at any time in the general population 1,7

7 Preparticipation Physical Evaluation. 3rd ed. Minneapolis, Minn.: McGraw-Hill/Physician and Sportsmedicine, 2005:19.

8 PPE: Screening Questions 2 1. Have you ever passed out or nearly passed out during or after exercise? 2. Have you ever had discomfort, pain, or pressure in your chest during exercise? 3. Does your heart race or skip beats during exercise? 4. Has a doctor ever told you that you have high blood pressure, high cholesterol, a heart murmur, or a heart infection? 5. Has a doctor ever ordered a test for your heart (e.g., electrocardiography, echocardiography)? 6. Has anyone in your family died for no apparent reason? 7. Does anyone in your family have a heart problem? 8. Has anyone in your family died of heart problems or of sudden death before 50 years of age? 9. Does anyone in your family have Marfan syndrome?

9 PPE: Physical Exam The four components of the pre-participation cardiovascular evaluation 1. blood pressure measurement 2. palpation of radial and femoral pulses 3. dynamic cardiac auscultation 4. evaluation for Marfan syndrome

10 PPE: Physical Exam Blood pressure Blood pressure should be measured using an appropriately sized cuff at the brachial artery while the patient is seated, legs uncrossed, with a back rest

11 PPE: Blood Pressure in Peds Hypertension is defined as an average systolic blood pressure and/or diastolic blood pressure that on at least three occasions is above the 95th percentile for patient sex, age, and height If an athlete's blood pressure is initially above the 90th percentile, the measurement should be repeated twice after the patient sits quietly for at least five minutes If BP remains high repeat in 6 months

12 PPE: Blood Pressure in Adults Stage 1 HTN :>140/90 Stage 2 HTN: >160/100

13 PPE: Physical Exam Pulse Palpation of the pulse allows for evaluation of the patient's heart rate and rhythm A normal arterial pulse has a smooth, rapid upstroke; a smooth summit; and a more gradual downstroke Radial and femoral pulses should be palpated simultaneously

14 PPE: Pulse Abnormalities 2,8 1. Femoral pulse is diminished or delayed relative to the radial pulse Coartation of the aorta may be present 2. Abnormal rate or rhythm Arrhythmia or conduction delay 3. Alternating amplitude (weak then bounding), pulsus alternans Left ventricular systolic dysfunction 4. Large amplitude, rapidly rising pulse, water hammer pulse Hypertrophic cardiomyopathy, aortic regurgitation, severe mitral regurgitation, patent ductus arteriosus 5. Small amplitude, slowly rising pulse, pulsus parvus et tardus Aortic stenosis, low cardiac output 6. Pulse amplitude decreases or disappears on inspiration, pulsus paradoxus Cardiac tamponade, severe congestive heart failure, severe chronic obstructive pulmonary disease or asthma, constrictive pericarditis 7. Double-peak pulse, pulsus bisferiens Aortic regurgitation with or without aortic stenosis, hypertrophic cardiomyopathy

15 PPE: Auscultation Murmurs should be characterized based on timing location character intensity Dynamic auscultation should also be done Squat to stand and with valsalva

16 PPE: Auscultation 2 Auscultate for splitting of first and second heart sounds: S 1 and S 2 S 2 is composed of closure of the aortic valve followed by closure of the pulmonic valve Inspiration causes increased blood flow into the pulmonary vascular bed, slightly delaying closure of the pulmonic valve physiologic split or widening of S 2 during inspiration, is a normal finding in a young athlete fixed split of S 2, no variation with inspiration, can be a sign of an atrial septal defect paradoxical split, or narrowing on inspiration, can be a sign of severe aortic stenosis, hypertrophic cardiomyopathy, or left bundle branch block

17 Physiology Review Squatting increases venous return to the heart (preload), thereby increasing left ventricular blood volume, chamber size, and SV Standing and Valsalva maneuver decrease venous return (preload), thereby decreasing left ventricular size and SV

18 Physiology Review9

19 PPE: Auscultation of Murmurs 1 Likely Benign Associated with normal, physiologic splitting of S2; absence of clicks, gallops Early to midsystolic Crescendo-decrescendo murmur Musical, vibratory, or buzzing quality Often heard best over pulmonic area or mid-left sternal border Softer murmur (grade 1 or 2) Likely Pathologic Associated arrhythmia Associated ventricular parasternal heave Associated with abnormal jugular venous pulse; wide pulse pressure; or brisk, rapidly rising pulse or weak, slowly rising pulse Change in intensity with maneuvers (louder with Valsalva or squat-to-stand maneuvers) Diastolic murmur Family history of sudden death or cardiac disease Long duration (mid- or late-peak or holosystolic murmur) Loud murmur (grade 3 or more) Other abnormal heart sounds (e.g., loud S1, fixed or paradoxically split S2, midsystolic click) Presence of associated symptoms (e.g., chest pain, dyspnea on exertion, syncope) Radiation to axilla or carotids

20 Marfan Syndrome Connective tissue disorder of the gene that makes fibrilin, autosomal dominant 75% inherited, 25% sporatic 10 Can lead to tall thin stature, increased flexibility, scoliosis, lens dislocation, mitral valve prolapse and aortic aneurysm, etc See Ghent Criteria for exam finding to help with diagnosis

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22 So when should I be concerned? Screening exam: + family history or personal history findings h/o familial HCOM or early cardiac death lens dislocation or stigmata of Marfan Syndrome Consider hypertrophic cardiomyopathy, long QT syndrome, arrhythmogenic right ventricular cardiomyopathy, Marfan syndrome, and coronary anomalies -EKG and echo, lipid panel -Genetic screening, echo for Marfan Syndrome -Cardiology consult

23 So when should I be concerned? Screening exam: + for syncope, presyncope/lightheadedness or chest pain while playing Possible causes: left ventricular outflow tract obstruction, arrhythmia, congenital coronary anomalies, or ischemia. Other causes include vasovagal syncope, exerciseassociated collapse, hypoglycemia, and medication use -For all: EKG, ECHO -For dynamic EKG changes or ischemia: consider cardiac MRI, cardiac CT, catheterization -Cardiology consult

24 So when should I be concerned? Screening exam: + palpitations Consider arrhythmia, SVT, long QT, atrial fibrillation or atrial flutter Consider thyroid dysfunction, anemia Consider hypoglycemia, medications, caffeine, alcohol, drugs -EKG, electrolyte testing, complete blood count, -Holter or event monitor -Cardiology consult

25 So when should I be concerned 11? Consider CBC, CMP, UA, EKG, Renal US

26 So when should I be concerned? For adults with Stage 2 HTN (>160/100) or evidence of end organ damage, hold from participation until controlled Consider CBC, CMP, UA, Renal US, EKG, Troponin* Hypertension + forceful upper extremity pulse and relatively weaker or delayed femoral pulse aortic coarctation Cessation of vigorous athletic participation is advised, Echo, consultation with a cardiologist

27 So When should I be concerned? PPE: Murmur (See previous slide for complete list) New diastolic murmur Loud systolic murmur Murmur that gets louder or longer with Valsalva or standing -EKG, Echo, -Cardiology Consult

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29 References 1. Asif IM, Harmon KG. Incidence and Etiology of Sudden Cardiac Death: New Updates for Athletic Departments. Sports Health May/Jun;9(3): Geise EA, O Connor FG, Brennan FH, Depenbrock PJ, et al. The athletic preparticipation evaluation: cardiovascular assessment. Am Fam Physician Apr 1;75(7): Preparticipation Physical Evaluation. 3rd ed. Minneapolis, Minn.: McGraw-Hill/Physician and Sportsmedicine, 2005: Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program. JAMA. 2006;296: Marijon E, Tafflet M, Celermajer DS, et al. Sports-related sudden death in the general population. Circulation. 2011;124: Toresdahl BG, Rao AL, Harmon KG, Drezner JA. Incidence of sudden cardiac arrest in high school student athletes on school campus. Heart Rhythm. 2014;11: Holst AG, Winkel BG, Theilade J, et al. Incidence and etiology of sports-related sudden cardiac death in Denmark implications for preparticipation screening. Heart Rhythm. 2010;7: Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History Taking. 8th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins, 2003: accesses May National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 suppl):555 76