Fit-to-Play Hearts

What should be included in the optimal cardiovascular evaluation of a highschool athlete?
---- MD
First, ask specific questions about risk factors for and symptoms of cardiovasculardisease (Box). A positive response to any of these questionswarrants confirmation and may require further evaluation.Physical examination. Auscultate the heart with the patient in bothstanding and supine positions. In addition, auscultate while the patientperforms various maneuvers (eg, squat-to-stand, deep inspiration, Valsalva maneuver);such maneuvers can clarify the classification of a murmur.Diagnostic testing. Order diagnostic studies (eg, echocardiography)and/or consultation to further evaluate the following:

• Any systolic murmur grade 3/6 or louder.
• Any murmur that disrupts normal heart sounds.
• Any diastolic murmur.
• Any murmur that intensifies with the maneuvers mentioned above.

Sinus bradycardia and systolic murmurs are commonly found and usuallydo not warrant further evaluation in an asymptomatic patient.

¹

Third andfourth heart sounds are also frequently heard in asymptomatic athletes withoutunderlying heart disease.

^1,2

Noninvasive cardiac testing should not be routinely included in thescreening examination. ECGs, echocardiograms, and exercise stress tests arenot cost-effective in a population at relatively low risk for cardiac abnormalities;moreover, these tests cannot consistently identify persons at actual risk.

^3-7

For example, a substantial percentage (11%) of participants in a study of collegeathletes had a clinically significant increase in ventricular wall thickness thathindered interpretation of echocardiographic findings.

³

Furthermore, abnormal findings on noninvasive tests may not affect athleticperformance. Some patients with hypertrophic cardiomyopathy are ableto tolerate intense athletic training and competition for many years--and evenmaintain high levels of achievement--without incurring symptoms, diseaseprogression, or sudden death.

⁴

However, for patients with an abnormal cardiovascular history or examination,echocardiography and stress testing are the most commonly recommendeddiagnostic tests. In conjunction with clinical information, echocardiographycan be used to distinguish nonobstructive hypertrophic cardiomyopathyfrom the athletic heart syndrome.

⁸

---- Peter J. Carek, MD
Associate Professor
Department of Family Medicine
Medical University of South Carolina
Charleston

References:

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2.

Crawford MH, O’Rourke RA. The athlete’s heart.

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3.

Lewis JF, Maron BJ, Diggs JA, et al. Preparticipation echocardiographic screening for cardiovascular diseasein a large, predominantly black population of collegiate athletes.

Am J Cardiol.

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4.

Maron BJ, Klues HG. Surviving competitive athletes with hypertrophic cardiomyopathy.

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5.

Fuller CM, McNulty CM, Spring DA, et al. Prospective screening of 5,615 high school athletes for risk ofsudden death.

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6.

Fuller CM. Cost-effectiveness of analysis of high school athletes for risks of sudden death.

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7.

Pelliccia A, Maron BJ, Culasso F, et al. Clinical significance of abnormal electrocardiographic patterns intrained athletes.

Circulation.

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8.

Maron BJ, Pelliccia A, Spirito P. Cardiac disease in young trained athletes: insights into methods for distinguishingathlete’s heart from structural heart disease with particular emphasis on hypertrophic cardiomyopathy.

Circulation.

1995;91:1596-1601.