Cardiovascular Issues and the Athlete

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Cardiovascular Issues and the Athlete

• by
• Ann Cappellari
• Sports Medicine Fellow
• San Jose Medical Center

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Overview

• Cardiovascular Adaptations to Exercise
• Cardiovascular Screening
• Causes of Sudden Death
• Management of Arrhythmias
• Management of Hypertension

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Why do we care?
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Screening for Cardiac Problems

• Personal history
• Family history
• Physical Examination

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Personal History

• Exertional chest pain
• Exertional syncope
• Unexplained shortness of breath
• Fatigue

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Personal History

• Heart murmur
• Increased blood pressure

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Family History

• Premature death
• Premature morbidity from heart disease

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Family History

• What age is a red flag for sudden cardiac death?

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Family History

• Specific knowledge of
• Hypertrophic cardiomyopathy
• Dilated cardiomyopathy
• Long QT syndrome
• Marfans syndrome

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Physical Examination

• Blood pressure
• Heart murmur
• Arterial pulses
• Stigmata of Marfans

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Athletic Heart Syndrome

• Normal Adaptations to Exercise

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Athletic Heart Syndrome

• Endurance training
• Increased left ventricular chamber size

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Athletic Heart Syndrome

• Strength training
• Increased left ventricular mass

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Athletic Heart Syndrome

• Arrhythmia

• How slow is too slow?

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Athletic Heart Syndrome

• Why is there bradycardia?
• Heart is more efficient with each beat
• Greater muscle mass, greater chamber size
• More blood pumped per beat

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Sudden Cardiac Death

• Hypertrophic cardiomyopathy
• Anomalous coronary artery circulation
• Marfans syndrome
• Coarctation of the aorta
• Miscellaneous

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Hypertrophic Cardiomyopathy

• Thickened, non-dilated left ventricle
• 15 mm septal wall
• Autosomal dominant
• Deranged cellular architecture leads to
  conduction problems

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Hypertrophic Cardiomyopathy

• May not be evident until late teens

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Hypertrophic Cardiomyopathy

• Physical exam
• Systolic murmur

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Systolic Murmur

• Accentuated with Valsalva maneuver
• Decreased with squatting

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Hypertrophic Cardiomyopathy

• Chest X-ray
• Cardiomegaly

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Hypertrophic Cardiomyopathy

• What actually causes death?

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Hypertrophic Cardiomyopathy

• Diagnosis
• History
• Physical exam
• EKG
• Echocardiogram

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trans
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Anomalous Coronary Artery Circulation

• Congenital abnormalities of the Arteries
• Single coronary artery
• Smaller arteries
• Common origin of the arteries

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Anomalous Coronary Artery Circulation

• History
• Poor perfusion of the heart with exercise

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Anomalous Coronary Artery Circulation

• Physical exam
• No consistent findings

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Anomalous Coronary Artery Circulation

• Diagnosis
• Autopsy
• Angiography

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Marfans Syndrome

• Connective tissue disorder
• Autosomal dominant trait
• Fibrillin gene

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Marfans Syndrome

• Physical exam findings
• Tall body habitus (wingspan greater than height)
• Hyperextensible joints
• Arachnodactyly

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Marfans Syndrome

• Physical exam findings
• Pectus excavatum
• Scoliosis
• Subluxed lens

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Marfans Syndrome

• What causes sudden death?
• Aortic dissection

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Marfans Syndrome

• Can they compete?
• Avoid contact sports, isometrics, weights,
  exhaustive exercise
• Consider noncompetitive swimming, biking

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Coarctation of the Aorta

• Congenital
• Often a pediatric diagnosis

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Coarctation of the Aorta

• Classic findings
• Radial pulses greater than pedal pulses
• Uneven radial pulses

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Coarctation of the Aorta

• Definitive treatment before allowing participation

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Hypertension

• Definition SBP 140
• DBP 90

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Hypertension

• Risk Factors
• High Na intake
• Excessive EtOH
• Cocaine, deitary supplements
• Anabolic steroids
• Male gender

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Hypertension

• Risk Factors
• Race
• Family history
• Diabetes
• Smoking
• Obesity

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Hypertension

• Exercising with high blood pressure
• SBP can increase to 200-300 mm Hg with
  weightlifting
• Heart muscle remodeling

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Hypertension

• Exercising with high blood pressure
• Inability to shunt blood to skin effectively

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Hypertension

• End organ damage

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Hypertension

• End organ damage
• EKG
• U/A (proteinuria, albuminuria)
• Serum creatinine
• Retinopathy

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Hypertension

• In or Out?

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Miscellaneous Badness

• Myocarditis, pericarditis
• Valvular disease
• Drugs
• Coronary artery disease

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Myocarditis/Pericarditis

• Inflammation of the cardiac muscle or cardiac
  lining
• Fever, chest pain
• Decreased exercise tolerance

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Valvular Disease

• Mitral valve prolapse
• Aortic stenosis

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Drugs

• Cocaine
• PCP
• Amphetamines

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• What is the most common cause of sudden cardiac
  death in athletes 30 years old?

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Coronary Artery Disease

• Exertional chest pain
• Exertional dyspnea
• Nausea
• Diaphoresis
• Referred arm pain

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Review

• History
• Chest pain
• Syncope
• Dyspnea on exertion

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Review

• Family History
• Unexplained young deaths (

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Review

• Physical Exam
• Murmurs
• Blood pressure
• Pulses
• Marfans

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When in doubt, keep them out.
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The End