the Young Athlete David B. Gremmels, MD Pediatric Cardiologist Children s Hospitals and Clinics of MN

Transcription

1 Cardiovascular Risk Assessment in the Young Athlete David B. Gremmels, MD Pediatric Cardiologist Children s Heart Clinic Children s Hospitals and Clinics of MN

2 No disclosure or financial relationships

3 Goals Background Clinical evaluation Diseases Testing

4 Athletes Are Challenging Stakes are high for diagnosis. CV system may be pushed to limit. Consequences of misdiagnosis are potentially devastating. < 30 years congenital/structural abnl > 30 years coronary artery disease

5 Difficult Problem Estimation of the incidence of sudden death in the young in the United States is critical to understand the scope of the problem Need to know the actual incidence to make recommendations as to the cost-effectiveness Implementing any strategy to reduce the incidenceid Devise appropriate preventative strategies Inform policy makers who allocate resources

6 Risk of Sudden Death 1 in 200,000 athletes will die suddenly. Annual U.S. Death rate 15 cases per 3 million high school athletes in sports. Male:female=5:1.

7 Mortality Rates U.S. (2000) Automobile related deaths 15,000-18,000 Young adult homicide 6,000 Suicide id 5,000 Pregnancies < 18 yrs 1,000,000 Sudden cardiac deaths/year 15

8 Purposes of Sports Exam Excellent opportunity to provide health education Determine whether there are contraindications to participation or manageable medical conditions

9 What Cardiac diseases? Hypertrophic Cardiomyopathy Coronary artery abnormalities LV outflow tract obstruction Arrhythmias Myocarditis Arrhythmogenic right ventricular dysplasia a G. Marfan s syndrome

10 1/3 cases suspected to be of cardiac etiology don t have a dx.

11 Sudden Death in Athletes Dilated CM 3% Myocarditis 3% Aortic Stenosis 4% ARVD 3% Ruptured Ao 5% MVP 2% CAD 2% Other 6% Coronary Abnl 24% HCM 38% LVH 10%

12 Circumstances of Pediatric SCD Sleep 25% Emotional upset 5% Routine 47% Exercise 23%

13 Sudden Cardiac Death: Can You Identify the Patient at Risk? In the fields of observation, chance only favors the mind that is prepared. Louis Pasteur

14 Pre-participation screening May identify <10% of athletes at risk of SCD Physical Exam is typically normal History of prior exercise related symptoms is frequently present What questions are important?

15 Identification of Risk Factors: Personal History Syncope during exercise Frequent, severe dizziness or recurrent syncope Chest pain during exercise Prolonged flu Previous Kawasaki disease Palpitations Seizures

16 How often are symptoms present? Exercise related syncope in 20-25% Dizziness in 16% Chest pain in 6% Seizure may be only symptom of prolonged QT syndrome

17 Identification of Risk Factors: Family History Sudden death at <30 years of age Long QT syndrome Hypertrophic cardiomyopathy Marfan syndrome Arrhythmogenic right ventricular dysplasia Very early-onset coronary artery eyea yo set co o a y a te y disease

18 PHYSICAL EXAM Heart Rate/Rhythm Blood Pressure/Pulses Syndromes Abnormal Heart Sounds and Murmurs

19 KEY POINT! Further testing should be performed if any part of History and/or Physical is suspicious ECG, ECHO, STRESS TEST, Cardiology consult Screening tests without indication are not warranted.

20 Case #1 16-year-old boy playing soccer in gym. Good health. Complained of chest pain while running. Asked to go sit down. Collapsed. CPR started. Paramedics arrived and shocked him b/c of pulseless V-tach.

21 Hypertrophic Cardiomyopathy Autosomal dominant (50% spont mutation) Variable penetrance and expression Leading cause of SCD in athletes Frequently clinically silent

22 Hypertrophic Cardiomyopathy Symptoms: Exertional Chest Pain Dyspnea Syncope Asymptomatic Physical Exam: Systolic Ejection Murmur at LLSB. Increases valsalva Decreases squatting Normal exam

23 Case #2 17-year-old male collapsed playing basketball. CPR started. In the ED, EKG showed significant ST abnormality. Occasional ventricular tachycardia.

24 Echo obtained. Diagnosis made and surgical repair scheduled Patient doing great

25 Causes of Pediatric SCD: Coronary Abnormality Congenital Origin of LCA from right coronary sinus Single coronary Origin of LCA from pulmonary artery Acquired Kawasaki disease Coronary artery disease (cocaine)

26 Case #3 18-year-old participated in gym class on Friday, but didn t feel well/light headed. Presented to ER that night with mild increased work of breathing and cough. CXR obtained. Cardiomegaly. Echo showed severe LV dysfunction. Hx: fever, 2-3weeks URI Sx. 10lb weight gain.

27 Myocarditis Viral prodrome Malaise and fatigue Resting tachycardia Gallop ECG (ST segment changes) Echo shows depressed LV function

28 Arrhythmogenic Right Ventricular Dysplasia Autosomal dominant 2 nd most common etiology of SCD in Italy Presents with ventricular tachycardia Echo may show RV dysfunction or normal Diagnosed by cardiac MRI

29 Case #4 7-year-old girl 2 seizures post exertion recently. Happened before many times when mad (assumed breath holding spells). Admitted for overnight EEG Cardiology consult b/c of HR monitor alarm

30 Prolonged QT Syndrome Corrected QTc > 0.45 seconds Recurrent episodes of exertional or emotional syncope Familial Rx B blockers, defibrillator

31 Athletes can present with symptoms that are benign Dizziness caused by dehydration SOB: endurance concerns Chest pain: musculoskeletal pain Palpitations: benign premature contractions SOB: bronchitis, exercise bronchospasm Nevertheless, thorough investigation is often needed for the reassurance they need.

32 Simple recommended evaluation What to do when

33 Family History: Risk Factors Familial disorder Hypertrophic cardiomyopathy Arrhythmogenic right ventricular dysplasia Long QT Marfan syndrome Coronary artery disease, early onset Screening ECG, Echo ECG, Echo ECG Echo, eye e exam Fasting lipid profile Close relative with SCD at <30 years of age ECG, possibly echo depending on other available information

34 Personal History: Risk Factors History Screen Syncope during exercise Cardiac consult Chest pain during exercise Cardiac consult Pulmonary evaluation Recurrent syncope or severe dizziness History of Kawasaki disease Frequent or symptomatic palpitations Prolonged flu (Myocarditis) Congenital heart disease Seizures ECG Review records, cardiac consult if not previously cleared ECG, (Event or Holter monitoring) CXR, ECG, Echo Cardiac consult if high risk ECG

35 Physical finding Screen Syndrome Turner Echo Down Echo Marfan Echo, Eye exam Abnormal murmur u ECG, Cardiac ac consult Loud P2 Cyanosis Abnormal or irregular HR ECG, Echo Pulse oximetry, Cardiac consult ECG, (Holter or event monitor)

36 Treatment for Potential SCD Relieve underlying disorder e.g., g, Ablation for WPW Medication e.g., g, Beta-blocker for Marfan syndrome Pacemaker e.g., Complete heart block Implantable defibrillator Restrict activity

37 RESTRICTIONS Congestive heart failure Significant congenital heart disease Cardiomyopathy Myocarditis Arrhythmias Pulmonary hypertension Marfan syndrome?

38 Restrictions for Poor Reasons Murmurs Fainting with a cause Chest Pain at rest Palpitations Certain repaired heart disease Family history of heart attacks (not early) Remember parents have to sign participation form also

39 Benign diagnosis Precordial Catch Syndrome Healthy thin adolescent Sudden, brief, severe, very sharp Out of the blue Anxiety provoking Rest > exertion Often pleuritic

40 SUMMARY A. Hypertrophic CM B. Coronary artery abnl C. Aortic stenosis D. Arrhythmias E. Myocarditis F. ARVD G. Marfan s syndrome Syncope during exercise Frequent, severe dizziness or recurrent syncope Chest pain during exercise Prolonged flu Previous Kawasaki disease Palpitations Family History

41 Bibliography Sparrow MJ et al. Precordial Catch : A Benign Syndrome of Chest Pain in Young Persons. NZ med J 1978;88: Zavaras-Angelidou KA et al. Review of 180 Episodes of Chest Pain in 134 Children. Ped Emer Care 1992; 8:(4): Basso C et al. Clinical Profile of Congenital Coronary Artery Anomalies With Origin From the Wrong Aortic Sinus Leading to Sudden Death in Young Competitive Athletes. J Am Coll Cardiol 2000;35: Driscoll DJ et al. Chest Pain in Pediatrics: A Prospective Study. Pediatrics 1976;57: Rowland TW, Richards MM. The Natural History of Idiopathic Chest Pain in Children. A Follow-up Study. Clin Pediatr 1986 Dec;25(12):612-4 Berezin S, et al. Chest Pain of Gastrointestinal Origin. Arch Dis Child 1988 Dec; 63(12): Polanczyk CA, et al. Cardiac Troponin I as a Predictor of Major Cardiac Events in ED Patients with Acute Chest Pain. JACC 1998;32:8-14

42 Selbst SM. Chest Pain in Children. Pediatrics in Review 1997;18: Selbst SM. Evaluation of Chest Pain in Children. Pediatrics in Review 1986;8:56-62 Selbst SM et al. Pediatric Chest Pain:A Prospective Study. Pediatrics 1988;82: Selbst SM et al. Chest Pain in Children: Follow-up of fpatients t Reported. Clin Pediatr 1990;29: Tunaoglu FS, et al. Chest Pain in Children Referred to a Cardiology Clinic. Pediatr Cardiol 1995 Mar-Apr;16(2):69-72 Evangelista JA, et al. Chest Pain in Children: Diagnosis Through History and Physical Examination. J Pediatr Health Care 2000 Jan- Feb;14(1):3-8 Woodward GA, Selbst SM. Chest Pain Secondary to Cocaine Use. Pediatr Emerg Care 1987 Sep;3(3):153-4