Evaluation of the sports participation candidate (incomplete!)

I. Identifying patients at risk for sudden cardiac death:

  1. Conditions associated with sudden cardiac death in athletes:
    1. Marfan syndrome
    2. Hypertrophic cardiomyopathy
    3. Congenital cardiac anomalies
    4. Anomalous coronary arteries
    5. Electrical disorders e.g. Wolff-Parkinson-White or long QT syndrome
    6. Commotio cordis (sudden cardiac death after direct chest trauma).
  2. History: Chest pain, dyspnea, presyncope, or syncope associated with exercise
  3. Family history of:
    1. Premature (< 50yo) cardiac death or cardiac disability
    2. Known hypertrophic or dilated cardiomyopathy, long QT syndrome or other ion-channelopathies, Marfan syndrome, or significant dysrhythmias
  4. Px: BP, exam for cardiac murmurs.  Systolic ejection murmurs are common in athletes; maneuvers that decrease preload (e.g. squat-to-stand or Valsalva) make such murmurs softer; if the murmur gets louder may suggest hypertrophic cardiomyopathy (see below).  Also physical stigmata of Marfan Syndrome
  5. If murmur or worrisome symptoms are present:
    1. Assess change with maneuvers that decrease preload (see above)
    2. Palpate femoral arteries and look for physical stigmata of Marfan syndrome (the former for coarctation of the aorta)
    3. Consider 12-lead ECG (note-often will show sinus bradycardia, first-degree AV block, and/or voltage criteria for LVH in highly conditioned athletes) and echocardiogram

Potential contraindications to sports participation:

I. Hypertrophic cardiomyopathy

  1. The leading cause of sudden crdiac death in athletes younger than 30yo
  2. Often have h/o exertional syncope, dizziness, or chest pain
  3. Systolic murmur that increases with Valsalva
  4. Thickened ventricular septum on Echo
  5. If symptomatic, shouldn't play sports; if asymptomatic, should only do low-intensity sports

II. Mitral valve prolapse

  1. Only limit sports participation if documented arrhythmogenic syncope, repetitive SVT or other arrhythmia, family h/o sudden death ass'd with MVP, h/o thromboembolism (if any, can only do low-intensity sports)

III. Wolff-Parkinson-White syndrome

  1. If no structural heart disease and asymptomatic, can do all sports; otherwise, limit to low-intensity sports

IV. Long QT sd.-must not do any sports; high risk of sudden death with activity

V. Other cardiac conditions that may limit participation: aortic stenosis, coarctation of aorta (usually dx'd before a sports physical takes place), myocarditis, HTN

VI. Seizure disorders-if well controlled can do any sports, even though head trauma may precipitate sz in people with epilepsy; avoid sports in which a seizure could result in serious injury (weight lifting, archery, swimming)

VII. Concussion history-Click HERE for details

VIII. Fever or ongoing carditis are contraindications to sports participation until resolved

IX. Atlantoaxial instability

  1. Can occur in patients with Down Syndrome or juvenile rheumatoid arthritis; may result in spinal cord injury with neck trauma.
  2. Generally needs individualized risk stratification

(Sources include "26th Bethesda Conference" J. Am. Coll. Cardiol. 24:845, 1994, cited in Phys. Sportsmed. 24:47, 1996; Core Content Review of Family Medicine, 2012).