|
Chapter 1: Sudden Cardiac Death in Athletes: Scope of the Problem and Emergency Response |
13 |
|
|
Incidence |
13 |
|
|
Introduction |
13 |
|
|
Causes |
14 |
|
|
Specific Causes |
15 |
|
|
Hypertrophic Cardiomyopathy |
15 |
|
|
Commotio Cordis |
17 |
|
|
Coronary Arterial Abnormalities |
17 |
|
|
Myocarditis |
17 |
|
|
Marfan’s Syndrome |
18 |
|
|
Long QT Syndrome and Wolff–Parkinson–White Syndrome |
19 |
|
|
Long QT Syndrome |
19 |
|
|
Arrhythmogenic Right Ventricular Dysplasia |
21 |
|
|
Immediate Treatment |
22 |
|
|
AED Utilization: NCAA Collegiate Experience |
24 |
|
|
Case 1 |
26 |
|
|
Summary |
27 |
|
|
References |
29 |
|
|
Chapter 2: Cardiovascular Screening of Athletes: Focused Exam, Electrocardiograms, and Limited Echocardiograms |
33 |
|
|
Introduction |
33 |
|
|
Rationale for Pre-participation Cardiovascular Screening with and Without ECG |
33 |
|
|
Appropriate Workup of Athletes with Past History of Heart Disease, Symptoms, Positive Family History, or Abnormal Physical Exam |
35 |
|
|
Chest Pain |
36 |
|
|
Dyspnea |
36 |
|
|
Syncope, Near-Syncope, and Dizziness |
36 |
|
|
Family History |
37 |
|
|
Case Study of Positive Family History |
37 |
|
|
ECG-Based Screening |
39 |
|
|
Barriers to Routine ECG-Based Screening in the USA |
42 |
|
|
Large Numbers of Athletes and Size of Appropriate Physician Workforce to Conduct the Screenings |
42 |
|
|
Cost of Conducting Such Screening in Such a Large Number of Eligible Athletes |
44 |
|
|
Mortality Rate from SCD in Athletes is Already Quite Low |
45 |
|
|
Lack of a Randomized Trial Demonstrating Clear Superiority of the ECG-Based Screening over a Standardized PPE Without ECG |
45 |
|
|
Lack of Standardization for Interpretation of ECGs in Athletes |
45 |
|
|
Lack of Normative Data in Certain Demographic and Ethnic Groups |
46 |
|
|
How to Implement ECG-Based Screening Programs |
46 |
|
|
How to Interpret ECGs in Athletes |
48 |
|
|
The Role of Echocardiography in Screening of Athletes |
49 |
|
|
What Issues Still Need to be Addressed Before Wide-Spread Screening Can be Implemented in the USA |
50 |
|
|
Efficacy of ECG Screening |
50 |
|
|
Summary |
51 |
|
|
References |
51 |
|
|
Chapter 3: Echocardiography and Advanced Cardiac Imaging in Athletes |
54 |
|
|
Case 1: Electrocardiographic Evidence of Left Ventricular Hypertrophy |
54 |
|
|
Summary |
57 |
|
|
Case 2: Exertional Myocardial Ischemia in the Young Athlete |
58 |
|
|
Summary |
60 |
|
|
Case 3: Arrhythmia and Right Ventricular Dilation |
60 |
|
|
Summary |
65 |
|
|
References |
66 |
|
|
Chapter 4: Exercise Training and Prescription |
71 |
|
|
Aerobic Power |
71 |
|
|
Anaerobic Power and Capacity |
73 |
|
|
Muscle Strength and Endurance |
73 |
|
|
Prescribing Exercise |
74 |
|
|
Specificity of Training |
74 |
|
|
Progressive Overload |
75 |
|
|
Intensity |
75 |
|
|
Frequency and Duration |
76 |
|
|
Resistance Training |
77 |
|
|
Types of Training Programs |
78 |
|
|
Interval Training |
78 |
|
|
Fartlek |
78 |
|
|
Tempos |
79 |
|
|
The Patient-Athlete |
79 |
|
|
Hypertrophic Cardiomyopathy |
82 |
|
|
Mitral Valve Prolapse and Myocarditis |
82 |
|
|
Valvular Heart Disease |
82 |
|
|
Congenital Heart Disease |
83 |
|
|
Cardiac Transplantation |
84 |
|
|
Elderly |
84 |
|
|
Case Presentation 1 |
87 |
|
|
Medical History |
87 |
|
|
Examination |
87 |
|
|
Testing |
87 |
|
|
Diagnosis |
87 |
|
|
Hospital Course |
87 |
|
|
Post Discharge Plan |
88 |
|
|
Case Presentation 2 |
88 |
|
|
Medical History |
88 |
|
|
Examination |
89 |
|
|
Testing |
89 |
|
|
Diagnosis |
90 |
|
|
Plan |
90 |
|
|
Summary |
91 |
|
|
References |
91 |
|
|
Chapter 5: Role of Genetic Testing for Sudden Death Predisposing Heart Conditions in Athletes1 |
93 |
|
|
Introduction |
93 |
|
|
Hypertrophic Cardiomyopathy Case Vignette |
94 |
|
|
Summary of Cardiomyopathy Genetic Testing |
94 |
|
|
Hypertrophic Cardiomyopathy |
94 |
|
|
Arrhythmogenic Right Ventricular Cardiomyopathy |
98 |
|
|
Long QT Syndrome Case Vignette |
99 |
|
|
Summary of Channelopathy Genetic Testing |
100 |
|
|
Long QT Syndrome |
100 |
|
|
Catecholaminergic Polymorphic Ventricular Tachycardia |
101 |
|
|
Brugada Syndrome |
102 |
|
|
Short QT Syndrome |
103 |
|
|
Indications for Genetic Testing in the Athlete |
103 |
|
|
The “Borderline” Patient |
103 |
|
|
“Gold Standard” Diagnostic Marker for the Asymptomatic Athlete Who Is Part of a Family with a Sudden Death Predisposing Heart C |
104 |
|
|
References |
106 |
|
|
Chapter 6: Shortness of Breath |
110 |
|
|
Introduction |
110 |
|
|
Common Causes of Shortness of Breath During Exercise |
111 |
|
|
Case 1 |
111 |
|
|
Exercise-Induced Bronchospasm |
111 |
|
|
Case 2 |
115 |
|
|
Vocal Cord Dysfunction |
117 |
|
|
Gastroesophageal Reflux Disease |
118 |
|
|
Less Common Causes of Dyspnea During Exercise |
118 |
|
|
Conclusion |
119 |
|
|
References |
119 |
|
|
Chapter 7: Chest Pain in the Athlete: Differential Diagnosis, Evaluation, and Treatment |
122 |
|
|
Cardiac Chest Pain |
125 |
|
|
History |
125 |
|
|
Physical Examination |
125 |
|
|
Aortic Dissection |
126 |
|
|
Noncardiac Causes of Chest Pain |
126 |
|
|
Musculoskeletal Etiologies of Chest Pain |
126 |
|
|
Chest Wall Pain |
126 |
|
|
Traumatic Rib Fracture |
127 |
|
|
Rib Stress Fractures |
128 |
|
|
Sternoclavicular Injury |
129 |
|
|
“Stitch” |
130 |
|
|
Costochondritis |
130 |
|
|
Tietze’s Syndrome |
131 |
|
|
Slipping Rib Syndrome |
131 |
|
|
Precordial Catch Syndrome |
131 |
|
|
Cervical Disk Disease/“Cervical Angina” |
131 |
|
|
Pulmonary Chest Pain |
132 |
|
|
Asthma/Exercise-Induced Bronchospasm |
132 |
|
|
Pneumothorax |
133 |
|
|
Pulmonary Contusion |
134 |
|
|
Pneumomediastinum |
135 |
|
|
Pulmonary Embolus |
135 |
|
|
Pneumonia |
137 |
|
|
Pleurisy |
137 |
|
|
Hyperventilation |
139 |
|
|
Gastrointestinal Chest Pain |
139 |
|
|
Gastroesophageal Reflux Disease |
139 |
|
|
Dysphagia |
140 |
|
|
Psychiatric Etiologies of Chest Pain |
140 |
|
|
Substance Abuse |
141 |
|
|
Conclusion |
141 |
|
|
Clinical Cases |
142 |
|
|
Case 1 (Fig. 7.4) |
142 |
|
|
Case 2 (Fig. 7.5) |
142 |
|
|
References |
143 |
|
|
Chapter 8: The Collapsed Athlete |
147 |
|
|
Approach to the Down Athlete |
149 |
|
|
Cardiac Causes |
149 |
|
|
Hyperthermia/Exertional Heat Stroke |
151 |
|
|
Background |
151 |
|
|
Diagnosis |
152 |
|
|
Treatment |
153 |
|
|
Hypothermia |
155 |
|
|
Background |
156 |
|
|
Diagnosis |
157 |
|
|
Treatment |
157 |
|
|
Exercise-Associated Hyponatremia |
158 |
|
|
Background |
158 |
|
|
Diagnosis |
159 |
|
|
Treatment |
160 |
|
|
Hypoglycemia |
160 |
|
|
Background |
160 |
|
|
Diagnosis |
161 |
|
|
Treatment |
161 |
|
|
Exercise-Associated Collapse |
162 |
|
|
Background |
162 |
|
|
Diagnosis |
162 |
|
|
Treatment |
163 |
|
|
Seizures |
163 |
|
|
Trauma |
164 |
|
|
Case #1 |
164 |
|
|
Summary |
165 |
|
|
References |
165 |
|
|
Chapter 9: Syncope/?Presyncope in the Competitive Athlete |
168 |
|
|
Introduction |
168 |
|
|
Definitions |
169 |
|
|
Syncope/Presyncope |
169 |
|
|
Competitive Athlete |
169 |
|
|
Exercise-Related Syncope |
170 |
|
|
Epidemiology |
170 |
|
|
Pathophysiology of Exercise-Related Syncope |
171 |
|
|
Differential Diagnosis |
172 |
|
|
Neurally Mediated Causes |
172 |
|
|
Cardiac Causes |
173 |
|
|
Evaluation |
173 |
|
|
Physical Examination |
175 |
|
|
Echocardiography |
178 |
|
|
Further Diagnostic Testing |
178 |
|
|
Ambulatory Monitoring |
179 |
|
|
Continuous-Loop Event Monitoring |
179 |
|
|
Tilt Table |
179 |
|
|
Electrophysiologic Studies |
180 |
|
|
Management of Syncope |
180 |
|
|
Return to Play |
182 |
|
|
Conclusion |
182 |
|
|
References |
183 |
|
|
Chapter 10: Electrophysiological Approach to Syncope and Near-Syncope in the Athlete |
185 |
|
|
Case |
185 |
|
|
Introduction |
185 |
|
|
Significance of Syncope and Near-Syncope in the Athlete |
186 |
|
|
Epidemiology |
188 |
|
|
Mechanisms and Causes of Syncope and Near-Syncopein the Athlete |
189 |
|
|
Evaluation of the Athlete with Syncope and Near-Syncope |
191 |
|
|
History |
192 |
|
|
Physical Examination |
193 |
|
|
Diagnostic Testing |
193 |
|
|
Noninvasive Testing |
193 |
|
|
Electrocardiography |
193 |
|
|
Electrocardiographic Monitoring (Holter Monitor, Event Monitor, Implantable Loop Recorder) |
194 |
|
|
Echocardiogram |
194 |
|
|
Tilt-Table Testing |
195 |
|
|
Exercise Testing |
196 |
|
|
Other Noninvasive Testing |
196 |
|
|
Invasive Testing |
197 |
|
|
Electrophysiology Testing |
197 |
|
|
Cardiac Catheterization |
198 |
|
|
Endomyocardial Biopsy |
198 |
|
|
Management of Syncope in the Athlete |
198 |
|
|
Treatment of Neurocardiogenic Syncope |
199 |
|
|
Treatment of Arrhythmic Syncope |
199 |
|
|
Implanted Devices in the Athlete |
201 |
|
|
Athletic Restrictions |
201 |
|
|
Illustrative Cases |
202 |
|
|
Eighteen-Year-Old Female with Syncope |
202 |
|
|
Nineteen-Year-Old Male Swimmer with Frequent Palpitationsand Near Syncope |
203 |
|
|
Twenty-Year-Old Male with Syncope While Playing Basketball |
204 |
|
|
Eighteen-Year-Old Male with Near Syncope and Palpitations During Basketball |
204 |
|
|
Thirty-Seven-Year-Old Distance Runner with Episodesof Syncope at Rest After Exercise |
206 |
|
|
Nine-Year-Old Female Who has Recurrent Collapse During Activity |
207 |
|
|
Nineteen-Year-Old with Syncope During Football |
207 |
|
|
Twenty-Year-Old Female with Syncope with Exertion |
208 |
|
|
Forty-Year-Old Male Physician Who Has Syncope at RestWhile Examining Patients |
209 |
|
|
Sixteen-Year-Old Female with Syncope |
210 |
|
|
Thirty-Five-Year-Old Male with Near Syncope Playing Hockey |
210 |
|
|
Conclusions |
212 |
|
|
References |
212 |
|
|
Chapter 11: Heart Murmurs |
217 |
|
|
Introduction |
217 |
|
|
Patient History |
217 |
|
|
Physical Examination |
219 |
|
|
Approach to Murmurs |
223 |
|
|
Aids to Physical Examination |
226 |
|
|
Training Tools |
226 |
|
|
Diagnostic Evaluation |
227 |
|
|
Management of Specific Valvular Conditions |
228 |
|
|
Case 1 |
228 |
|
|
Patient History |
228 |
|
|
Past Medical History |
231 |
|
|
Physical Exam |
233 |
|
|
Diagnostic Tests |
234 |
|
|
Treatment |
234 |
|
|
Outcome |
234 |
|
|
Discussion |
235 |
|
|
Case 2 |
236 |
|
|
Patient History |
236 |
|
|
Past Medical History |
236 |
|
|
Physical Examination |
236 |
|
|
Diagnostic Tests |
237 |
|
|
Treatment/Disposition |
237 |
|
|
References |
237 |
|
|
Chapter 12: Management of Hypertension in Athletes |
239 |
|
|
Introduction |
239 |
|
|
Classification of Blood Pressure |
239 |
|
|
White Coat Hypertension |
240 |
|
|
Secondary Hypertension in Athletes |
240 |
|
|
Clinical Evaluation |
241 |
|
|
Treatment of Hypertension in Athletes |
243 |
|
|
Diuretics |
244 |
|
|
Angiotensin-Converting Enzyme Inhibitors |
247 |
|
|
Angiotensin Receptor Blockers |
247 |
|
|
Beta-Adrenergic Blockers |
247 |
|
|
Calcium Channel Blockers |
248 |
|
|
Alpha Blockers |
248 |
|
|
Alpha Agonists |
248 |
|
|
Combination Therapy |
249 |
|
|
Recommendations for Athletic Participation in Hypertensive Athletes |
249 |
|
|
References |
249 |
|
|
Chapter 13: Hypertrophic Cardiomyopathy |
252 |
|
|
Case Vignette |
252 |
|
|
Introduction |
253 |
|
|
Definition and Etiology |
254 |
|
|
Screening for Hypertrophic Cardiomyopathy |
257 |
|
|
Screening for Families with Known HCM |
257 |
|
|
General Pre-Participation Screening |
257 |
|
|
Differentiating Hypertrophic Cardiomyopathy from Physiologic Hypertrophy |
259 |
|
|
Clinical Features and Management of Hypertrophic Cardiomyopathy |
260 |
|
|
Pathophysiology of HCM |
260 |
|
|
Clinical Evaluation of Patients with HCM |
261 |
|
|
Physical Examination in HCM |
261 |
|
|
Electrocardiography |
261 |
|
|
Echocardiography |
262 |
|
|
Magnetic Resonance Imaging |
263 |
|
|
Risk Stratification for Sudden Cardiac Death |
263 |
|
|
Management of Patients with Hypertrophic Cardiomyopathy |
266 |
|
|
Physical Exercise |
266 |
|
|
Medical Therapy |
268 |
|
|
Septal Reduction Therapy |
268 |
|
|
Natural History of Hypertrophic Cardiomyopathy |
269 |
|
|
References |
269 |
|
|
Chapter 14: Commotio Cordis: Practical Aspects in Sports |
272 |
|
|
Commotio Cordis-Clinical Characteristics |
272 |
|
|
Experimental Models of Commotio Cordis |
274 |
|
|
Commotio Cordis-Prevention |
275 |
|
|
Commotio Cordis-Current Practical Management |
277 |
|
|
Conclusion |
278 |
|
|
References |
278 |
|
|
Chapter 15: Coronary Artery Anomalies and Sports Activities |
280 |
|
|
Introduction: Three Stories |
280 |
|
|
Case 1: Sudden Cardiac Death in a Top High-School Athlete |
280 |
|
|
Case 2: Sudden Crib Death in an Infant |
281 |
|
|
Case 3: A Surprising Accidental Finding in an 83-Year-Old Woman |
282 |
|
|
Comment |
283 |
|
|
Coronary Artery Anomalies: A Brief Appraisal of a Complex Entity |
284 |
|
|
Sports Activities and Coronary Anomalies |
291 |
|
|
Screening, Diagnosis, and Counseling |
293 |
|
|
Prevention and Treatment of Sudden Cardiac Death in Athletes |
296 |
|
|
Conclusions |
298 |
|
|
References |
298 |
|
|
Chapter 16: Participation in Sports for the Athlete with the Marfan Syndrome |
302 |
|
|
Introduction |
302 |
|
|
The Evaluation |
306 |
|
|
History |
306 |
|
|
Examination |
307 |
|
|
Diagnostic Testing |
307 |
|
|
Treatment |
308 |
|
|
Medical |
308 |
|
|
Surgical |
308 |
|
|
Recommendation for Athletic Participation |
309 |
|
|
Types of Exercise |
309 |
|
|
Case 1 |
311 |
|
|
Discussion |
312 |
|
|
Case 2 |
312 |
|
|
Discussion |
312 |
|
|
Conclusion |
312 |
|
|
References |
313 |
|
|
Chapter 17: Congenital Heart Disease: Exercise and Sports Participation |
315 |
|
|
Introduction |
315 |
|
|
Common Lesions in Adults with Congenital Heart Disease |
316 |
|
|
Shunt Lesions |
316 |
|
|
Atrial Septal Defect |
316 |
|
|
Patent Foramen Ovale |
317 |
|
|
Ventricular Septal Defect |
317 |
|
|
Patent Ductus Arteriosus |
317 |
|
|
Anomalous Venous Return |
318 |
|
|
Eisenmenger’s Syndrome and Pulmonary Hypertension |
318 |
|
|
Valvular Lesions |
318 |
|
|
Bicuspid Aortic Valve |
318 |
|
|
Aortic Stenosis |
319 |
|
|
Aortic Insufficiency |
319 |
|
|
Coarctation of the Aorta |
320 |
|
|
Pulmonic Stenosis |
320 |
|
|
Ebstein’s Anomaly |
321 |
|
|
Complex Congenital Heart Lesions |
321 |
|
|
Tetralogy of Fallot |
321 |
|
|
Transposition of the Great Vessels |
322 |
|
|
Single Ventricle Variants |
322 |
|
|
Congenital Coronary Anomalies |
323 |
|
|
Evaluation for Preparticipation Screening |
323 |
|
|
History and Physical Examination |
324 |
|
|
Electrocardiogram |
325 |
|
|
Echocardiogram |
325 |
|
|
Stress Testing |
326 |
|
|
MRI/MRA and CT |
326 |
|
|
Cardiac Catheterization |
326 |
|
|
Recommendations |
326 |
|
|
Cases |
331 |
|
|
Case 1: Bicuspid Aortic Valve |
331 |
|
|
Case 2 |
331 |
|
|
References |
332 |
|
|
Chapter 18: Athlete with a Device: Implantable Cardioverter Defibrillators and Pacemakers |
334 |
|
|
Postulated Risks of Sports |
335 |
|
|
Triggering of Arrhythmia |
335 |
|
|
Unknown Efficacy of the ICD During Sports |
336 |
|
|
Nonarrhythmic Injury to the Athlete |
337 |
|
|
Damage to the ICD System |
337 |
|
|
Preliminary Safety and Efficacy Data: Survey Data |
337 |
|
|
Current Recommendations by Physicians |
337 |
|
|
Physician-Reported Sports Participation and Outcomes |
338 |
|
|
Potential Safety-Related Precautions |
342 |
|
|
Limitations to Survey Data |
343 |
|
|
Ongoing Research |
343 |
|
|
References |
343 |
|
|
Chapter 19: Long QT Syndrome and Other Channelopathies |
346 |
|
|
Introduction |
346 |
|
|
Long QT Syndrome |
347 |
|
|
Case Report #1 |
347 |
|
|
Case Report #2 |
348 |
|
|
Case Report #3 |
349 |
|
|
Case Report #4 |
352 |
|
|
Short QT Syndrome |
354 |
|
|
Brugada Syndrome |
355 |
|
|
Case Report #5 |
355 |
|
|
Catecholaminic Polymorphic Ventricular Tachycardia |
359 |
|
|
Recommendations for Sport Participation in Patients with Channelopathies |
360 |
|
|
References |
366 |
|
|
Chapter 20: Cardiac Effects of Ergogenic Aides and Supplements |
372 |
|
|
Introduction |
372 |
|
|
Anabolic Androgenic Steroids |
373 |
|
|
Atherogenic |
374 |
|
|
Thrombogenic |
375 |
|
|
Vasospasm |
375 |
|
|
Direct Myocardial Effects |
375 |
|
|
Are the Cardiac Effects of Anabolic Steroid Use Reversible? |
375 |
|
|
Polysubstance Abuse |
376 |
|
|
Dehydroepiandrosterone (DHEA) |
376 |
|
|
Peptide Hormones and Analogues |
377 |
|
|
Human Growth Hormone (hGH) |
377 |
|
|
Mechanism of Action |
378 |
|
|
Adverse Effects of GH Abuse |
378 |
|
|
Specific Cardiovascular Concerns |
378 |
|
|
Future Concerns |
379 |
|
|
Erythropoietin (EPO) |
379 |
|
|
Stimulants |
379 |
|
|
Amphetamines |
380 |
|
|
Cocaine |
380 |
|
|
Ephedra and Ephedrine |
380 |
|
|
Cardiovascular and Systemic Side Effects |
381 |
|
|
Ephedra/Ephedrine as a Controlled or Restricted Drug in Sport |
381 |
|
|
Caffeine/Gaurana |
382 |
|
|
Caffeine as a Controlled or Restricted Drug in Sport |
383 |
|
|
Effects of Caffeine Intake in Children |
383 |
|
|
Guarana |
383 |
|
|
Conclusion |
384 |
|
|
References |
384 |
|
|
Chapter 21: Return-to-Play Decisions in Athletes with Cardiac Conditions: Guidelines and Considerations |
387 |
|
|
Introduction |
387 |
|
|
Guidelines for Sports Participation for Athletes with Known Cardiac Conditions |
387 |
|
|
Recommendations for Young Patients with Genetic Cardiovascular Diseases |
388 |
|
|
Recommendations for Masters Athletes |
391 |
|
|
Return-to-Play: General Considerations |
391 |
|
|
Implanted Defibrillators |
391 |
|
|
Ablations |
392 |
|
|
Beta Blockers |
392 |
|
|
Corrective Cardiac Surgery |
392 |
|
|
The Grey-Zone Athlete |
393 |
|
|
Grey-Zone Athlete: Case Study |
393 |
|
|
Specific Considerations for Conditions That Predispose to SCD Episodes |
394 |
|
|
Cardiomyopathies and Inflammatory Diseases |
394 |
|
|
Congenital Heart Disease |
395 |
|
|
Aortic Reconstruction: Case Study |
395 |
|
|
Rhythm Disturbances |
396 |
|
|
Supraventricular Rhythm Disturbances |
396 |
|
|
AV Nodal Reentrant Tachycardia |
396 |
|
|
Wolff–Parkinson–White Syndrome |
396 |
|
|
Ventricular Rhythm Disturbances |
397 |
|
|
Nonsustained or Sustained Ventricular Tachycardia |
397 |
|
|
Ventricular Fibrillation |
397 |
|
|
Common Valvular Diseases |
398 |
|
|
Bicuspid Aortic Valve |
398 |
|
|
Aortic Stenosis |
398 |
|
|
Aortic Insufficiency |
398 |
|
|
Mitral Valve Prolapse |
398 |
|
|
Summary |
399 |
|
|
References |
399 |
|
|
b978-0-387-78701_4 |
402 |
|