So when we talk about etiologies, all of us on the sports medicine side are familiar with each of these diagnoses. This is a review article actually from Sanjay Sharma's group in the UK. And I like this because it separates things into bins. So it's, you don't necessarily have to memorize diagnoses so much as different categories. Of course, when you think of structural cardiac pathologies, HCM or hypertrophic cardiomyopathy is a diagnosis we all think of. You think of congenital coronary anomalies, Marfan syndrome, and perhaps ARVC. Which stands for arrhythmogenic right ventricular cardiomyopathy. Some of the more common causes. Acquired cardiac abnormalities. I'm going to highlight specifically the first one, infection myocarditis. So we're not going to talk about COVID-19 today, which is probably to everybody's relief. But I can tell you, I'm sure we've all thought about the fact that unfortunately, COVID-19 is here to stay. And it's going to impact us on the sports medicine side. And clearly integrate itself into how we think about the pre-participation evaluation, number one, symptomatic athletes. And unfortunately, we're going to have to keep a close eye on cases of sudden arrest given the concerns of underlying cardiac injury in athletes with COVID-19. So myocarditis is clearly a highlighted diagnosis that we need to be mindful of. And then, of course, commotional cortis, other toxins, drugs, hypohyperthermia, et cetera. And then your primary inherited arrhythmic syndromes, like long QT syndrome or Wolff-Parkinson-White. So these are the diagnoses that are all running through our head whenever we're evaluating athletes. And so, of course, we know that the pre-participation screen at its core is certainly mandated by the American Heart Association and by the Europeans as well. And I suspect many of us all know that the big difference is the recommendation or lies in the recommendation for a pre-participation ECG, where the Europeans mandate the use of the ECG, whereas here in America, we do not. It's based off that Italian study from Domenico Corrado that I mentioned as to why the Europeans and the Italians kind of led to that recommendation in Europe. It is important to recognize that, yes, the ECG does improve the ability to diagnose various conditions, such as an asymptomatic athlete with Wolff-Parkinson-White pattern. You will recognize the delta wave on the ECG, and that would never be diagnosed based on the physical exam in an athlete who otherwise did have symptoms. Similarly for long QT, and even for diagnoses potentially such as hypertrophic cardiomyopathy, if you can't pick up the heart murmur. We're going to talk a little bit about that controversy as well. But first, I want to spend a good bit of time going through the 14-point American Heart Association history and physical. So we're not going to go through each of these. Everybody probably already knows these, because I'm sure all of us have gone through this at some point, and it's clearly easily referenced and accessible. But I think the key point here is one of the, I think, limitations of the history and physical isn't so much that it's poor, it's a poorly performed 14-point history and physical. And you can do one of these certainly in a short period of time, particularly in an athlete that may have no symptoms with a normal exam. But it really is an art form to do this well, and recognizing that the patients that we're trying to perform this on are primarily young individuals who have low attention spans, are distracted, are trying to get out of there through physicals. We also have to recognize that they're young, and they don't necessarily have the knowledge base that the rest of us do, given that we've been studying all of these symptoms and conditions for our entire medical careers. So I think it's really important that you spend the time. The worst thing to do is to say, hey, do you have any cardiac symptoms? And believe me, I think I've observed some of this in the past. And of course, the athlete is going to say no. Or just say, hey, do you have chest pain when you exercise? Believe it or not, you need to extrapolate it. You need to expand on that a little bit more. Use colloquial terms, a squeezing sensation in your chest, a tightness in the chest. Sometimes they may think of chest pain as like a true sharp, knife-like pain, versus when they're exerting themselves, if there's a pressure, which isn't really an uncomfortable pain. It's a pressure sensation. That actually is what we're really concerned about. So it's outlined in the HMP, but it's really important to get in on these symptoms. Of course, if there's a positive for anything, you want to get more into the weeds, particularly when they say, oh, I'm dizzy when I exercise. You know, many times it's not really a concerning dizziness, but you've got to get into the weeds and go through those symptoms in detail. Palpitations, I guarantee you that most young individuals have no idea what a palpitation really is. So don't ask about, hey, do you have palpitations when you exercise? You want to describe it really at its simplest form. Use terms like racing heartbeat, flutterings in the chest. I mean, all these things that almost sound silly to you, but can really help get to an underlying symptom from the athlete. So it's really important to go through these symptoms in detail. And similarly, for the family history, if you go through this too fast, it'll fly right by their eyes. Meaning, if you have a family history of hypertrophic cardiomyopathy, long QT syndrome, dilated cardiomyopathy, ARVC, they can't process that because they've changed their heart and they've never heard of the conditions. And it's going to be a waste of time. I have certainly had instances, which I promise I'm not making it up, where I'll say hypertrophic cardiomyopathy. Oh, no, I've never heard of that. Is there anybody in your family who was told their heart was abnormally thick at a young age? Oh, yeah. That has happened. So sometimes breaking down the conditions to its simplest form can pick up on a condition. I ask about, do you know anybody in your family who's young who has a pacemaker or a defibrillator in place? Sometimes that can bring up some of these syndromes. Ask about even conditions that aren't on here, like anybody in your family with a problem with their aorta that was diagnosed at a younger age. Ask about strange deaths, drownings, single vehicle car accidents. Occasionally, perhaps you could pick up a long QT syndrome with a drowning. So you really just want to be as detailed as possible. And it's really not to say that the history of physical is perfect. It definitely is not. But at the same time, carefully performed HNP can be quite advantageous.

2nd Edition, CASE 05

2nd Edition

Cardiac

cardiac conditions

hypertrophic cardiomyopathy

myocarditis

ECG screening

athlete evaluation