Cardiac Conditions - Knee & Sports

Introduction

Epidemiology
- cardiac pathology is the most common cause of sudden death in young athletic patients
Common conditions include
- syncope
- hypertrophic cardiomyopathy
- CAD
- commotio cordis
- long QT syndrome

Presentation

Symptoms
- history and physical exam is the best screening tool to identify cardiovascular problems in high school athletes
- chest pain
- palpitations
- syncope
Physical exam
- pre-participation physicals
  - diastolic murmur warrants further workup
  - II/VI systolic murmur

Evaluation

Syncope

Overview
- a syncopal episode in a young athlete is a red flag for a serious cardiac condition.
Treatment
- medical evaluation
  - requires a medical evaluation prior to returning to athletic activity

Hypertrophic Cardiomyopathy

Overview
- most common cause of cardiac sudden death in young athletic patients
Presentation
- symptoms
  - dyspnea on exertion
  - chest pain
  - positive family history
- physical exam
  - II/VI systolic murmur
    - a murmur that increases with standing or Valsalva maneuver should raise concern for hypertrophic cardiomyopathy
    - increase in murmur caused by dynamic obstruction of blood outflow caused by enlarged ventricle
Evaluation
- echocardiogram
  - study of choice to make diagnosis
  - will show nondilated, thickened left ventricular wall thickness compared to normal individuals of the same age.
Treatment
- avoid vigorous exercise
  - considered an absolute contraindication to vigorous exercise and sports

Coronary Artery Disease and Abnormalities

Epidemiology
- 2nd most common cause of sudden cardiac death
- most common in older patients
Pathophysiology
- coronary artery disease (CAD)
  - usually seen in older patients
  - risk factors
    - hypertension
    - family history
- left main coronary artery with abnormal origin is a risk because the artery can become compressed and lead to ischemia
Presentation
- symptoms
  - mostly asymptomatic
  - but when symptoms present they are commonly
    - chest pain
    - palpitations
    - syncope
Imaging
- coronary angiography and MR angiography are gold standards
Treatment
- lifestyle changes
  - healthy eating, stress reduction, quit smoking, lose weight
- medications
  - b-blocker, aspirin, ACE inhibitors, nitroglycerin, calcium channel blockers
- surgery
  - angioplasty and stenting
  - coronary artery bypass grafting

Commotio Cordis

A rare but catastrophic condition that is caused by blunt chest trauma
- it results in cardiac ventricular fibrillation and is universally fatal unless immediate defibrillation is performed
Epidemiology
- most common in children and adolescents due to high number of athletes
Treatment
- CPR vs.cardiac defibrillation
  - best method of treatment is cardiac defibrillation
Prevention
- chest protectors in baseball and hockey have not yielded the protective results desired

Long QT Syndrome

An abnormality of ventricular repolarization that can lead to
- ventricular tachycardia
- torsades de pointes
- sudden cardiac death if not recognized and treated
Symptoms
- syncope or near-syncope with exercise
- often times asymptomatic
Diagnosis
- ECG is gold standard
Treatment
- sports return to play
  - determination of play by genetic makeup, presentation, and need for pacemaker