TAKING CARE OF THE ATHLETIC HEART

A Pre-participation Evaluation in Young Athletes

MA. CONSUELO Z. GARCIA,

MD
School Physician
St. Paul University, Quezon City
Do I have the heart
to play?
 Am I safe to play?

Majority of sudden death in athletes

are due to silent CARDIOVASCULAR disease
 Physiology of Cardiac
Conduction
• The excitatory & electrical conduction
system of the heart is responsible for the
contraction and relaxation of the heart
muscle.
• The sinoatrial node (SA node) is the
pacemaker where the electrical impulse is
generated.
 Cardiac conduction pathway
1. SA node fires to the AV node through gap jxn’s

2. AV node delays 0.1 s for atrial diastole

3. AV node fires to the AV bundle (HIS)

4. AV bundle depolarizes through right & left bundle branches

5. Bundle branches carry impulses through Purkinje fibers to

the ventricular myocardium for ventricular systole

Total time of conduction = 0.22 s

 Sudden Cardiac Arrest
Unexpected, death within one hour of the onset
of symptoms and subsequent cardiac arrest
How Is Sudden Cardiac Arrest Different from
a Heart Attack?
• Sudden cardiac arrest is not a heart
attack (myocardial infarction) but can occur during a
heart attack.

• Heart attacks occur when there is a blockage in one

or more of the arteries to the heart, preventing the
heart from receiving enough oxygen-rich blood. If
the oxygen in the blood cannot reach the heart
muscle, the heart becomes damaged.
Cholesterol Producers Developmental process
of atherosclerosis

HEART ATTACK
 (also known as "MYOCARDIAL INFARCTION") Atherosclerosis
How Is Sudden Cardiac Arrest Different from a Heart Attack?

• In contrast, sudden cardiac arrest occurs when the

electrical system to the heart malfunctions and
suddenly becomes very irregular. The heart beats
dangerously fast. The ventricles may flutter or quiver
(ventricular fibrillation), and blood is not delivered to
the body. In the first few minutes, the greatest
concern is that blood flow to the brain will be
reduced so drastically that a person will lose
consciousness. Death follows unless emergency
treatment is begun immediately.
 Risk Factors of Sudden Cardiac Arrest
(In General)
• Previous heart attack

• A person's risk of SCD is higher during the first 6

months after a heart attack.

• Coronary artery disease

• Risk factors for coronary artery disease

include smoking, hypertension, family history of heart
disease, and high cholesterol
Risk Factors of Sudden Cardiac Arrest
(In General)
• Ventricular tachycardia or ventricular fibrillation
after a heart attack
• History of congenital heart defects or blood
vessel abnormalities
• History of syncope (fainting episodes of
unknown cause)
• Prior episode of sudden cardiac arrest
• Family history of sudden cardiac arrest or SCD
 Risk Factors of Sudden Cardiac Arrest
(In General)
• Hypertrophic cardiomyopathy: a thickened heart
muscle that especially affects the ventricles
• Significant changes in blood levels of potassium
and magnesium (from using diuretics, for
example), even if there is no underlying heart
disease
• Obesity
• Diabetes
• Recreational drug abuse
 Cause of SCD in Athletes
• Many cases of SCD are related to undetected
heart disease.

• In the younger population, SCD is often caused

by congenital heart defects

• Older athletes (35 years and older), the cause is

more often related to coronary artery disease.
 Causes of SCD in Athletes
• Hypertrophic Cardiomyopathy
• Coronary Artery Abnormalities
• Myocarditis
• Long QT syndrome
• Brugada syndrome
Hypertrophic Cardiomyopathy
 Causes of SCD in Athletes
Aortic rupture/Marfan Syndrome
Aortic Stenosis
Familial coronary atherosclerotic disease
Post-operative congenital heart disease
Flora Jean “Flo” Hyman
Aortic Rupture in Marfan’s
Aortic Aneurysm in Marfan
 Causes of SCD in Athletes
• Drugs – cocaine, amphetamine

• Stimulants – ephedrine, anabolic steroids,

caffeine, phenylpropanolamine

• Primary Pulmonary Hypertension

• Commotio cordis
COMMOTIO CORDIS
Type of Sport in SCD
 All STUDENTS (>12y)
who pursue competitive sports SHOULD
undergo CARDIAC screening to identify athletes
who might be at risk for Sudden Cardiac Arrest
(SCA).

Students with heart disease should be

evaluated by a pediatric / adult cardiologist for
final recommendation.
 Preparticipation CV Screening
Systematic practice of evaluating athletes before participation
in sports for the purpose of identifying or raising suspicion of
abnormalities that could provoke disease progression or sudden
death.

Principal objective is to REDUCE the cardiovascular risks

associated with physical activity and enhance the safety of
athletic participation (AHA)

To detect SILENT CV abnormalities that can lead to sudden

death (ACC)
 Pre-participation Evaluation
- Personal & Family History
- Physical Examination
- Electrocardiogram (ECG)
- At SPUQC: Chest X-ray
Complete blood count (CBC)
 Pre-participation Evaluation
• Must be done at least 2 months
prior to the sports event to give
time for further evaluation,
assessment and treatment if
deemed necessary.
 Red Flags in the Personal History
• Exertional chest pain/discomfort/tightness
• Exertional syncope/lightheadedness (during exercise)
• Excessive exertional and/or unexplained dyspnea/fatigue
associated with exercise
• A history of palpitations/Irregular heart beat related to
exercise
 Red Flags in the Personal History
• A history of heart disease/murmur/cardiac
work-up
• A history of elevated systemic blood pressure
• A prior history of Kawasaki disease/recent viral
illness (myocarditis)
• Illicit drug use/ Intake of ergogenic supplement
(anabolic steroids/stimulants)
 Red Flags in Family History
• Premature death (sudden/unexpected) before
age 50 due to heart disease in one or more
relatives
• Disability from heart disease in a close relative
younger than 50 years
• Specific knowledge of certain conditions in family
members known to cause sudden cardiac death
(scd)
 Red Flags in PHYSICAL EXAM

• Pathologic heart murmurs (especially due to

dynamic LV outflow obstruction)
• Decreased femoral pulses (compared to
brachial)
• Stigmata of Marfan’s syndrome
• Elevated brachial artery BP in a sitting
position
 ECG
• Controversial

• Not recommended by the American Heart Association

• Recommended by:
– European Society of Cardiology
– International Olympic Committee and
– Many other governing associations of several US and
international professional sports leagues
– ST. PAUL UNIVERSITY QUEZON CITY
 Why recommend ECG
• Studies showed the HIGHER SENSITIVITY of a
standardized history, PE and ECG vs history
and PE alone

• Another non-invasive cardiac exam

• Electrical disorders are diagnosed by ECG

ATHLETES WITH CV DISEASE

• Collaboration of athlete student and

cardiologist
 Recommendation
• Cleared for ALL sports without restriction

• Cleared for ALL sports with recommendations for

further evaluation or treatment for
________________________

• Not cleared
– Pending further evaluation
– For any sports
– For certain sports
 Take Home Messages
Cardiac screening is needed for 12 years old and older prior to
sports participation

School physicians can do history, PE and ECG as INITIAL

evaluation

Any RED flag in history, PE or ECG should alert the primary care
provider to refer student for further evaluation

Final sports recommendation for students with CV disease can

be prescribed by a cardiologist based on established guidelines

Cardiac screening has inherent limitation that should be

explained to the patient/parent/coaches
 REMINDERS
• Do not take any
stimulants
x
• Do not take drugs
x
 REMINDERS
• Avoid / Quit smoking

• Eat healthy foods &

follow a low fat diet
 REMINDERS

• Exercise regularly

• Drink lots of water

before, during &
after exercise or
sports activity
 REMINDERS
• Seek immediate medical
consultation if you feel any
abnormalities
If you believe it,
the mind can
achieve it,
and the heart
will protect
it.....
Have the heart
to win.....
Stay fit !!!
Thank
You!