Summary Cardiac conditions are the most common cause of sudden death in young athletic patients and comprise of hypertrophic cardiomyopathy (most common), coronary artery disease, and commotio cordis. Diagnosis requires a thorough history and physical exam to identify a history of chest pain, palpitations, syncope during exercise, and evaluation for murmurs. An EKG or echocardiogram should be performed when there is a high suspicion of hypertrophic cardiomyopathy. Treatment is focused on prevention with avoidance of vigorous exercise when hypertrophic cardiomyopathy is diagnosed. If commotio cordis develops, prompt treatment with cardiac defibrillation is required for survival. Overview Common conditions affecting athletes include syncope hypertrophic cardiomyopathy coronary artery disease long QT syndrome commotio cordis sudden cardiac death 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 login to view 2 more bullets Evaluation EKG normal EKG findings in endurance athletes login to view 4 more bullets Syncope Overview sudden loss of consciousness caused by a sudden loss of blood pressure a syncopal episode in a young athlete is a red flag for a serious cardiac condition. Epidemiology incidence annual incidence of 7% Demographics age any age sex more common in females than in males risk factors cardiac conditions dehydration female gender Etiology pathophysiology transient loss of consciousness due to decreased cerebral perfusion can be caused by any condition disrupting cerebral perfusion 50% are neurocardiogenic also known as vasovagal syncope login to view 4 more bullets associated conditions cardiovascular disorder login to view 3 more bullets cerebrovascular disease login to view 1 more bullet disruption of vascular tone and blood flow login to view 1 more bullet Presentation symptoms lightheadedness dizziness palpitations sweating physical examination unconsciousness cold clammy skin Treatment medical evaluation requires a medical evaluation prior to returning to athletic activity Hypertrophic Cardiomyopathy Overview a genetic condition causing mutations in the cardiac muscle leading to increased ventricular wall thickness resulting in outflow obstruction, diastolic dysfunction, and increased risk of sudden cardiac death most common cause of cardiac sudden death in young athletic patients Epidemiology incidence 1 in 500 demographics age login to view 2 more bullets sex login to view 2 more bullets risk factors hypertension genetic predisposition Etiology pathophysiology abnormal thick or thin cardiac myofilament proteins resulting in abnormal structure and function of the cardiac muscle with hypertrophy of the left ventricular wall and septum leads to asymmetric hypertrophy resulting in left ventricular outflow obstruction login to view 2 more bullets genetics inheritance pattern login to view 3 more bullets mutations login to view 5 more bullets associated conditions increased risk for sudden cardiac death and arrhythmias Presentation history family history cardiac murmur symptoms dyspnea on exertion chest pain dizziness presyncope or syncope physical exam II/VI systolic crescendo-decrescendo murmur login to view 10 more bullets double carotid pulse arrhythmia double apical pulse Imaging echocardiogram will show nondilated, thickened left ventricular wall thickness compared to normal individuals of the same age. 80% diagnostic accuracy evaluate the structure of cardiac chambers, along with systolic and diastolic function determines the degree of outflow obstruction evaluates for valvular disease cardiac mri gold standard for diagnosis performed in patients in which hypertrophic cardiomyopathy is suspected with inconclusive echocardiogram Studies electrocardiogram most sensitive diagnostic test left ventricular hypertrophy with right atrial enlargement is highly suggestive of hypertrophic cardiomyopathy login to view 4 more bullets ambulatory electrocardiogram recommended in all patients diagnosed with hypertrophic cardiomyopathy worn for 24-48 hours used in the assessment of ventricular arrhythmias and sudden cardiac death stress test exercise is preferred over pharmacologic stress test used for assessment of left ventricular outflow obstruction tract gradient login to view 1 more bullet Diagnosis diagnosis is made based on an echocardiogram, electrocardiogram, genetic testing, and family history Treatment lifestyle modifications indications login to view 1 more bullet management login to view 5 more bullets outcomes login to view 1 more bullet medical therapy indications login to view 1 more bullet management login to view 3 more bullets outcomes login to view 2 more bullets Complications cardiac complications includes sudden cardiac death, arrhythmias, congestive heart failure, stroke Prognosis 1-2% annual mortality rate Coronary Artery Disease 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 login to view 2 more bullets 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 login to view 3 more bullets 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 Overview it results in cardiac ventricular fibrillation and is universally fatal unless immediate defibrillation is performed caused by direct impact during ventricular repolarization a rare but catastrophic condition that is caused by blunt chest trauma Epidemiology incidence less than 30 cases per year demographics age login to view 2 more bullets sex login to view 1 more bullet risk factors contact sports younger age Etiology pathophysiology mechanism of injury login to view 1 more bullet pathoanatomy anterior chest wall blow occurring during the upstroke of the T-wave with enough energy (>50 joules) leading to myocardial cell membrane stretch login to view 3 more bullets results in activation of ion channels through mechanical-electrical coupling resulting in aberrant depolarization resulting in ventricular fibrillation Presentation history patient experiences a sudden blow to the chest, typically during an athletic event symptoms loss of consciousness physical exam pulselessness unconsciousness death Studies electrocardiogram will show ventricular fibrillation Diagnosis diagnosis is made by witnessed blow to the chest followed by collapse with electrocardiogram showing ventricular fibrillation Treatment CPR vs.cardiac defibrillation the best method of treatment is cardiac defibrillation return to sport no restrictions from returning to sport athletes should take precautions against future blows to the chest Prevention chest protectors in baseball and hockey have not yielded the protective results desired Prognosis poor prognosis with a mortality rate of 59% improved mortality rate with early defibrillation Long QT Syndrome overview a prolongation in the ventricular action potential duration, QT interval, potentially leading to cardiac arrhythmias Epidemiology incidence 1 in 2,500 to 10,000 demographics age login to view 1 more bullet sex login to view 1 more bullet risk factors genetic predisposition medications login to view 1 more bullet Etiology pathophysiology congenital login to view 1 more bullet acquired login to view 1 more bullet Genetics inheritance pattern login to view 1 more bullet mutations login to view 13 more bullets associated conditions Romano Ward Syndrome login to view 4 more bullets Presentation history majority of patients are asymptomatic family history or medications leading to acquired long QT syndrome symptoms often times asymptomatic syncope or near-syncope with exercise cardiac arrest palpitations physical examination arrhythmia Studies labs basic metabolic panel and magnesium level login to view 1 more bullet Diagnosis ECG is gold standard Treatment sports return to play determination of play by genetic makeup, presentation, and need for pacemaker monitoring with intermittent electrocardiogram no restriction from exercise Complications torsades de pointes can occur from prolonged QT syndrome 50% are asymptomatic Sudden Cardiac Death Overview defined as death resulting from cardiovascular cause occurring within one hour of symptom onset Epidemiology incidence 0.76 to 13 per 100,000 2.8x more common in adolescent and teenage athletes than in non-athletes demographics age login to view 2 more bullets sex login to view 1 more bullet risk factors login to view 4 more bullets Etiology pathophysiology mechanism login to view 2 more bullets Presentation history family history of sudden cardiac death prior restriction from sports due to cardiac history of heart murmur symptoms syncope chest pain, tightness, pressure or discomfort elevated blood pressure heart murmur pulselessness physical exam blood pressure assessment pulse check auscultation for heart murmur Imaging cardiac MRI coronary angiography echocardiogram Studies labs cardiac enzyme assay genetic testing login to view 1 more bullet other studies exercise stress test electrophysiology testing electrocardiogram Treatment cardiac resuscitation involving CPR and AED defibrillation Prognosis overall, poor prognosis with >90% mortality rate early recognition and use of an AED significantly improve survival