Sports Medicine: Just the Facts

CHAPTER 25 • CARDIOVASCULAR CONSIDERATIONS 143

sickle cell trait, and blunt chest trauma (commotio

cordis).

SCREENING FOR SUDDEN DEATH

• The American Heart Association (AHA) Science and
  Advisory Committee published consensus guidelines
  for preparticipation cardiovascular screening for high
  school and college athletes in 1996 (Maron et al, 1996).
  It is recommended that a complete personal and family
  history and physical examination be done for all ath-
  letes. It should focus on identifying those cardiovascu-
  lar conditions known to cause sudden death. It should
  be done every 2 years with an interim history between
  examinations. The 26th Bethesda Conference specifies
  participation guidelines for different conditions
  (Maron and Mitchell, 1994). These are summarized in
  Table 25-3.
  •Family history should include a specific inquiry for a
  family history of premature coronary artery disease,
  diabetes mellitus, hypertension, sudden death, syn-
  cope, significant disability from cardiovascular dis-
  ease in relatives younger than age 50, HCM, ARVC,
  Marfan’s syndrome, prolonged QT syndrome, or
  significant arrhythmias.
  
  
  • Personal past history should include specific inquiries
    on the detection of heart murmur, diabetes mellitus,
    hypertension, hyperlipidemia, smoking, or on the pres-
    ence of HCM, ARVC, Marfan’s syndrome, prolonged
    QT syndrome, or significant arrhythmias. Recent
  
  
  
  

history inquiries must include a history of syncope,

near syncope, profound exercise intolerance, exer-

tional chest discomfort, dyspnea, or excessive fatigue.

•Physical examination should specifically address

hypertension, heart rhythm, cardiac murmur, and

the findings of unusual facies or body habitus asso-

ciated with a congenital cardiovascular defect, espe-

cially Marfan’s syndrome (Table 25-4) (Pyeritz,

1986). Cardiac auscultation should be performed in

the supine and standing positions and murmurs

should be assessed with Valsava and position

maneuvers when indicated.

• The classic murmur of obstructive HCM accentu-
  ates with Valsalva, this may also be seen in mitral
  valve prolapse. The murmur of aortic stenosis inten-
  sifies with squatting, and decreases with Valsalva.


• Femoral pulses should be assessed and blood pres-
  sure measured with the appropriately sized cuff in
  the sitting position.


• Ancillary testing should be directed by the patient’s his-
  tory, physical, and age. Lipid profiles should be checked
  in the older athlete and should be considered in athletes
  of any age. Exercise stress testing is not recommended as
  a routine screening device for the detection of early coro-
  nary artery disease because of low predictive value and
  high rates of false positive and false negative results.
  Exercise testing may be required prior to beginning an
  exercise program in select cases (see chapters 15 and 20)


• EKG and echocardiograms are not currently recom-
  mended as screening tools(Basilico, 1999; Kugler and
  O’Connor, 1999; Kugler, O’Connor and Oriscello,
  2001 ). As mentioned above, the normal adaptations of
  the “athletic heart” make interpretation of the routine
  EKG and echocardiogram problematic (Pelliccia et al,
  2000). High rates of false positivety, high relative costs,
  limited availability, and low prevalence of disease make

TABLE 25-3 Guidelines on Restriction of Exercise
for Cardiovascular Disease

Contraindications to Vigorous Exercise

Hypertrophic cardiomyopathy
Idiopathic concentric left ventricular hypertrophy
Marfan’s syndrome
Coronary heart disease
Uncontrolled ventricular arrhythmia’s
Severe valvular heart disease (especially aortic stenosis and pulmonic
stenosis)
Coarctation of the aorta
Acute myocarditis
Dilated cardiomyopathy
Congestive heart failure
Congenital anomalies of the coronary arteries
Cyanotic congenital heart disease
Pulmonary hypertension
Right ventricular cardiomyopathy
Ebstein’s anomaly of the tricuspid valve
Idiopathic long Q-T syndrome

Require Close Monitoring and Possible Restriction

Uncontrolled hypertension
Uncontrolled atrial arrhythmia’s
Hemodynamic significant valvular heart disease (aortic insufficiency,
mitral stenosis, mitral regurgitation)

SOURCE: (Maron and Mitchell, 1994; Kugler and O’Connor, 1999)

TABLE 25-4 Features of Marfan Syndrome

on Physical Examination

Musculoskeletal

Tall stature

Thin body habitus (armspan to height ratio >1.05)

Arachnodactly (long thin fingers; able to wrap hand around opposite

wrist and overlap thumb and small finger)

Pectus deformity

High arched palate

Kyphoscoliosis

Joint laxity

Cardiovascular

Systolic murmur (mitral valve prolapse)

Evidence of easing bruising

Diastolic murmur (aortic regurgitation)

Ocular

Myopia

Retinal detachment

Lens subluxation