Updated: 10/6/2016

Cardiac Conditions

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Questions
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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
  • EKG
    • normal EKG findings in endurance athletes
      • ventricular hypertrophy
      • primary AV block
      • nonspecific STT wave changes in the lateral leads on ECG
      • resting sinus bradycardia at 40 beats per minute
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 
 

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(OBQ09.196) A high school basketball player dies suddenly on the basketball court. An autopsy is most likely to find which of the following conditions to be the cause of death? Review Topic

QID: 3009
1

Hypertrophic obstructive cardiomyopathy

97%

(2350/2433)

2

Dilated cardiomyopathy

2%

(47/2433)

3

Mitral valve prolapse

0%

(5/2433)

4

Aortic root rupture

1%

(21/2433)

5

Ventricular dysplasia

0%

(3/2433)

ML 1

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PREFERRED RESPONSE 1
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(SAE07SM.73) A 20-year-old soccer player who collapsed after a goal kick reports weakness and nausea. He appears slightly confused. Examination reveals that he is not sweating. His skin is warm and dry. The outdoor temperature is 80 degrees F (26.6 degrees C) with a relative humidity of 80%. Management should consist of Review Topic

QID: 8735
1

a drink of water.

3%

(3/114)

2

a sports drink with electrolytes.

12%

(14/114)

3

placement in the reverse Trendelenburg position in a shaded area.

3%

(3/114)

4

immersion in a warm water bath.

0%

(0/114)

5

transportation to the emergency department.

82%

(93/114)

ML 1

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PREFERRED RESPONSE 5

(SBQ07SM.27) A 15-year-old asymptomatic male presents for a pre-participation high school physical for basketball. He has no personal or family history of asthma. He had two relatives who died while playing sports due to a medical problem that runs in his family. Which of the following tests would be most helpful in obtaining his diagnosis and preventing possible sudden death? Review Topic

QID: 1412
1

Renal ultrasound

0%

(6/1984)

2

Pulmonary function test

0%

(8/1984)

3

Echocardiogram

89%

(1762/1984)

4

EKG

10%

(195/1984)

5

Cervical MRI

0%

(9/1984)

ML 1

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PREFERRED RESPONSE 3

(SBQ07SM.11) An otherwise healthy 14-year-old male baseball pitcher goes into cardiac arrest after being struck in the chest by a batted ball. Commotio cordis is suspected. What is the most appropriate treatment? Review Topic

QID: 1396
1

IV epinephrine

2%

(16/1002)

2

Placement of a large gauge needle into the pericardial sac

7%

(69/1002)

3

Immediate Cardiac defibrillation

89%

(895/1002)

4

Rescue breathing

2%

(18/1002)

5

Fluid bolus

0%

(3/1002)

ML 1

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PREFERRED RESPONSE 3

(OBQ05.199) What is the most common cause of sudden cardiac death in otherwise healthy 20-30 year-old athletes? Review Topic

QID: 1085
1

Coronary artery disease

0%

(8/1735)

2

Hypertrophic cardiomyopathy

98%

(1696/1735)

3

Commotio cordis

1%

(24/1735)

4

Ruptured aortic aneurysm

0%

(3/1735)

5

Rheumatic fever

0%

(1/1735)

ML 1

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PREFERRED RESPONSE 2

(OBQ05.56) The use of EKG for routine pre-participation screening of youth athletes is not presently standard of care in the United States. With respect to this observation, all of the following statements are correct EXCEPT: Review Topic

QID: 942
1

Echocardiography is used to confirm hypertrophic subaortic cardiomyopathy

5%

(28/514)

2

History and physical examination are considered more cost-effective than EKG for screening

4%

(22/514)

3

Athletes with a family history of sudden cardiac death should receive additional testing

4%

(22/514)

4

Electrocardiography will result in a large number of false-positive results

18%

(92/514)

5

Electrocardiography cannot detect potential causes for sudden cardiac death

68%

(350/514)

ML 3

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PREFERRED RESPONSE 5
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