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Keeping sudden cardiac death off the playing field

Gary Dorshimer

NEW ORLEANS — Following guidelines for athletes developed by the American Heart Association and other associations can minimize the risk for sudden cardiac death, according to a presenter at the American College of Physicians annual meeting.

“It’s a challenge to try to find the proverbial needle in the haystack, that is, preventing sudden cardiac death,” Gary W. Dorshimer, MD, FACP, clinical assistant professor of medicine at the Perelman School of Medicine at the University of Pennsylvania, told attendees.

Previously published data in the Journal of Internal Medicine suggest the risk for sudden cardiac death approximately doubles during physical activity and is two- to three-fold higher in athletes vs. nonathletes.

There are guidelines for both competitive and recreational athletes, Dorshimer said.

Competitive athletes

The American Heart Association guidelines state that a history and physical exam take place before a person participates in organized high school and college sports, and should be repeated every 2 years. These guidelines do not recommend a routine ECG in most patients but do recommend ascertaining other information, he said. One recommendation is to ask about a history of chest pain, though this symptom is of limited clinical value in most cases, Dorshimer said

“Chest pain doesn’t bother me for the vast majority of patients because when I ask, the patient often responds by saying ‘I don’t have pain, I have a fill in the blank’ with many other words that the patient will use.”

Other questions to ask include asking if the patient has experienced tightness, pressure or discomfort when engaging in activity; had a syncope or near-syncope determined to be vasovagal in origin and cannot be explained; had “excessive” exertional and unexplained dyspnea/fatigue or palpitations linked to exercise; detected a heart murmur previously; had an elevated systemic BP or previous limits to engaging in sports and previous heart tests.

According to Dorshimer, the internist or clinician should also ask competitive athletes ‘Has there ever been a sudden and unexpected death, or disability before age 50 years linked to heart disease in one or more of their relatives? Are there clinically significant arrhythmias, long-QT syndrome or other ion channelopathies, hypertrophic or dilated cardiomyopathy, or Marfan syndrome in family members?’

The last part, the physical exam, involves looking for an organic heart murmur, femoral pulses to exclude aortic coarctation, physical stigmata of Marfan syndrome, and taking the patient’s brachial artery BP while the patient is seated, preferably in both arms, he said.

Recreational athletes

There are some differences when screening recreational athletes, which Dorshimer defined as those who engaged in “high-intensity sports” for at least 2 hours a week.

Much like the competitive athlete, taking a thorough personal and family medical history is suggested, as is a physical exam, Dorshimer said. But in this group, he suggested the ECG, getting an estimation of the patient’s risk for cardiovascular disease using the Systemic Coronary Risk Evaluation (SCORE) chart and testing the person’s blood for serum glucose and total cholesterol levels.

He cautioned that regardless of activity level, not all patients will be forthcoming about their medical past.

“I find that players like to tell you nothing,” Dorshimer, who is also a team physician for the Philadelphia Flyers and Philadelphia Eagles and has served as a consultant at the Olympic Games, told attendees. “They tell you they are as healthy as can be and they’ve never had to take a medicine in their life and never had a problem, so it is up to you and try to figure out more.” – by Janel Miller

References:

American College of Cardiology. “ACC/AHA Release Recommendations For Congenital and Genetic Heart Disease Screenings in Youth.” http://www.acc.org/latest-in-cardiology/articles/2014/09/15/14/24/acc-aha-release-recommendations-for-congenital-and-genetic-heart-disease-screenings-in-youth. Accessed April 15, 2018.

Dorshimer, GW. The Athlete as Patient. Presented at: American College of Physicians Internal Medicine Meeting; April 17-21, 2018; New Orleans.

Menafoglio A, et al. Br J Sports Med. 2014;doi:10.1136/bjsports-2014-093857.

Schmied C and Borjesson M. J Intern Med. 2014;doi:10.1111/joim.12184. Accessed April 15, 2018.

Disclosure: Dorshimer reports no relevant financial disclosures.