This post is authored by Renee Sullivan, MD, member of the ACC’s Sports and Exercise Cardiology Section.

I recently presented a case study at the ACC’s Sports Cardiology Summit about a 20 year old athlete with syncope and rhythm disturbance. The patient was previously healthy, exercised and ran competitively his entire life, however, over the last six months he had experienced palpitations and syncope immediately after he would end a four mile run. Although this would not happen with every run, he eventually decided to seek care since he was passing out more frequently.

From what I could tell, the cause of the syncope was not clear and could have been related to neurocardiogenic syncope as it happened right after the run was complete and never happened during the run; but it was also possible that an arrhythmia was to blame.

We decided to issue a holter monitor which the patient would wear while running, and we immediately observed ventricular tachycardia. The patient refused admission but came to the office the next day to undergo an exercise treadmill test.  At 28 minutes, we again noted the patient had ventricular tachycardia but he did not pass out. 

An aggressive EP study was then performed on the patient, but ventricular tachycardia was not inducible. Further, his echocardiogram, cardiac MRI, and CT coronary angiogram were all normal. 

The patient was started on a beta blocker to suppress ventricular tachycardia. He chose to continue participating in sports despite the ventricular tachycardia and did not want an implantable cardioverter-defibrillator. Luckily, the patient is healthy, currently participates in extreme sports and rarely has palpitations.

A number of observations can be learned from this case. When evaluating an athlete, or any patient, it is important to reproduce the physical activity that causes the symptoms to the best of our ability. However, often times the symptoms may not happen in a test situation, and the athlete must be playing the exact sport in order for the symptoms to occur.  This may be due to stress or catecholamines. 

In addition, we are often faced with patients who do not want to be restricted from playing sports and prolong seeking medical advice, which can be detrimental to their health. It’s critical that young athletes understand the warning signs and know when to seek help.

There is a lot to learn from one another within the sports and exercise community, and I hope that by sharing this case, others can learn from our observations. I invite you to leave your own case studies or observations in the comment section below.

For more information about the ACC’s Sports and Exercise Cardiology Council and Section, click here.  

This post is authored by Michael S. Emery, MD, FACC, member of the ACC’s Sports and Exercise Section.

Recently a diverse group of cardiologists, sports medicine physicians, pediatricians, athletic trainers, patient families, representatives of college and professional sports, researchers, military physicians, and others met for the first Sports Cardiology Think Tank, followed by the first Sports Cardiology Summit.

More than 200 participants joined the summit, a lively two-day educational forum that included interactive discussions of case studies; a debate about adding ECGs to screening; presentations about differences in athletes based on sports played, gender, age; and a presentation by the family of a 9-year-old boy who died from anomalous origination of a coronary artery from the opposite sinus after two years of failure to get an accurate diagnosis. It was truly a dynamic meeting, which I was honored to be a part of.

During the summit, I spoke on performance enhancing drugs (PEDs) and their cardiovascular effects and risks. This is a hot topic since there continues to be a lot of buzz in the media about PEDs, especially in baseball and cycling (particularly with the recent news that Lance Armstrong has been stripped of his seven Tour de France titles and has been banned for life).

It is highly probable that this topic is even more prevalent than reported. However, beyond the legal implications and questions of ethics, the question becomes what are cardiovascular effects and risks of using PEDs?

Unfortunately, not a lot is known as studies are typically small, observational studies, or case reports. The most common PEDs are anabolic-androgenic steroids (AAS), often taking multiple as a “stack” at supraphysiological doses for prolonged periods in “cycles.” Others include human growth hormone, erythropoietin (EPO) and blood doping, which all have even less data available. Cardiovascular effects can include systolic dysfunction, diastolic dysfunction, accelerated atherosclerosis, myocardial infarction, arrhythmias, hypertension and dyslipidemia (particularly low HDL).

Over the counter supplements are another diverse group of “performance enhancers” legal in the U.S. but are not controlled by the U.S. Food and Drug Administration (FDA) and may contain a number of different substances with varying names.  Knowing what an athlete may be ingesting with these and what role they may play with regards to any cardiovascular side effects is often difficult.

We as cardiologists also need to be mindful of the use of prescription medications for athletes as some are prohibited from use in competitive sports.

The bottom line is more data is needed but since studies are difficult due to the “black market/underground nature,” it is almost impossible to have a controlled study. This is indeed a conundrum that my colleagues and I are faced with, which we are striving to overcome.

For more information about the ACC’s Sports and Exercise Cardiology Council and Section, click here.  

This post is authored by Silvana M. Lawrence, MD, FACC, member of the ACC’s Sports and Exercise Section.

Although summer has come and gone, fall brings with it the excitement of the start of school and American-loving competitive sports like football. However, with the start of competitive sports also comes the fear of the unexpected event of a young athlete collapsing on the field.

Towards the beginning of fall, cardiologist’s offices become overwhelmed with young athletes needing sports clearance, and many questions surface that were not taught during training nor were considered in the daily practice of pediatric cardiology. Fortunately, parents pay more attention to complaints reported at the time of physical exams at the primary care physician’s office prior to sports participation. However, there is an undulating comfort level to clear young athletes with any positive answers to history questions or unusual findings on a cardiac exam.

To participate in sports in the US, a young athlete must first complete a screening, which includes a history and physical exam currently based on the AHA recommendations. However, those who undergo a screening at their cardiologist’s office will, undoubtedly, receive at least one test, i.e., an ECG, and not infrequently, additional testing that might include an echocardiogram, Holter and/or a stress exercise test.

Several screening programs exist in different parts of the country aiming at early detection of conditions associated with sudden cardiac death. Presently, an ongoing large screening program of high school athletes is occurring in the state of Texas: The Texas Adolescent Athlete Heart Screening Registry – TAAHSRTM. This program has screened over 6,000 athletes to date, ages 14-18 years and utilizing history, 12 lead ECG and limited echocardiogram. Initial analyses of data have demonstrated a referral rate of about 9 percent for abnormalities detected either by ECG or an echocardiogram. We are currently putting together a paper on our findings, which I think will be a good piece of information. I also want to follow these kids longitudinally and see what happens with their natural history.

There is also a multifaceted group of young adults with congenital heart disease, repaired and palliated, that poses challenges. The present Bethesda guidelines have provided guidance for many years. However, many in the field agree it might be time to revise our data and perhaps dare to cautiously, but yet firmly, expand the type of physical activities these patients can (and ought to) engage in.

Challenges are posed daily by the growing population of inactive children that in addition to underlying heart disease, have added risk factors such as obesity, hypertension and abnormal lipid levels. Our inability, to some extent, to better define the level of physical inactivity necessary in order to protect the diseased heart, is hurting us by not promoting physical activity perhaps in the most needed segment of our pediatric population.

Exciting times are ahead of us and I truly believe we are making a difference in kids’ lives. We may not have the perfect model and, in fact, I think we do need to improve our understanding of the process and results/data to reassess the best mode of screening. Regardless, the face of sports and exercise cardiology continues to reach new horizons and, undoubtedly, will contribute to change the world of athletes with a healthy or a diseased heart.  

This post was authored by Christine Lawless, MD, FACC, co-chair of the Sports and Exercise Cardiology Council & Section.

This year leaders from the ACC’s Sports and Exercise Cardiology Council were invited to lead sessions at the International Convention on Science, Education and Medicine in Sport (ICSEMIS) in Glasgow from July 19 – 24. The conference is a collaboration among the International Olympic Committee, International Paralympic Committee, International Federation of Sports Medicine and the International Council of Sport Science and Physical Education. Also known as the “Knowledge Olympics,” the convention occurs ever four years in conjunction with the Olympic Games, and some may joke that is the more important Olympics as there is always much to learn from one another.

Although Glasgow was cold (about 60 degrees) the topics were hot and we had a jam-packed program. Our session, “Return-to-Play (RTP) in Athletes with Cardiac Conditions,” covered innovation in RTP for athletes with cardiac conditions in the U.S., which I led; cardiomyopathy RTP, led by Barry Maron, MD, FACC; RTP with aortopathy and valvular heart disease, led by Paul Thompson, MD, FACC; and sports electrophysiology: RTP with Long QT and implanted devices, led by Michael Ackerman, MD, FACC.

There were also several heavy hitters that presented including Paolo Angelini, MD, from Houston, TX, where he runs a center for coronary anomalies, and gave a talk on the subject. He has a novel method of limited MRI to assess for this condition in middle school children (athlete and nonathlete), and has enrolled over 2500 children in this project. Sanjay Sharma, MD, from the UK, who spoke at ACC.12, gave a presentation on ECGs in black athletes. After his talk he left for London where he is providing medical coverage for endurance events.  Antonio Pelliccia, MD, from Italy, who also spoke at ACC.12, gave a presentation on SCD in athletes and the Italian screening program. Soon after, he also left for London, where he will provide service as Chief Medical Officer for the Italian Olympic team.

We also had the opportunity to network with Stewart Hillis, MD, who was the Scottish football team doctor for many years and received the Order of the British Empire for his work creating the sports medicine curriculum at the university in Glasgow. He shared some wonderful insights with us about cardiovascular screening for young people in the UK and Scotland. Surprisingly, high school athletes are not mandated to undergo preparticipation screening in the UK, thus here in the U.S. we are doing more for our high school athletes by requiring at least a history and physical. He also informed us that Italy was one of the few – if not only- European countries performing mandatory screenings.

Overall it was a great experience and I enjoyed the culture and hospitality of our hosts (I discovered a great goats’ cheese parcels recipe for anyone interested)!  Although the international audience may have different guidelines and opinions on the topic of screening of athletes, we still have much to learn from one another.

View photos from the Knowledge Olympics on ACC’s Facebook page and stay tuned to the ACC in Touch blog for the latest cv news from the Olympic Games. Also be sure to check out my interview in an American Medical News article about the Olympic games.

This post was authored by Dick Kovacs, MD, FACC, former chair of the ACC Board of Governors and co-chair of the Sports and Exercise Cardiology Council and Section.

The 2012 Olympic Games in London kick-off today, and as we all prepare to root for our respective teams, this is a time where the field of Sports and Exercise Cardiology will inevitably be in the spotlight.

TheHeart.org reported, “at least four elite athletes have been felled by sudden cardiac death in recent months ... the media attention these events have garnered has inflamed the controversy over whether better preparticipation screening would have prevented any of the deaths or whether the time has come for nations and health organizations to agree on a universal approach. And although cardiac events at past Olympic Games have been rare, they're not unheard of.”

The International Olympic Committee (IOC) has recommended that all countries screen their athletes to minimize the risk of sudden death. However, as Dr. Bove stated in a previous blog post, both the American College of Cardiology and the American Heart Association agree that the mandatory screening of all young athletes with an ECG is not warranted based on cost (due to the large number of tests that would be required), the low incidence of sudden death among athletes in the U.S., as well as the concern for false positive results.

The next few weeks will be exciting nonetheless watching some of the most talented athletes of our time competing for the gold.

A recently published perspective in the New England Journal of Medicine by David S. Jones, MD, PhD, notes, “One thing is certain: the Olympics will remain an object of medical fascination."

Stay tuned to the ACC in Touch Blog and ACC’s Facebook page for the latest cv news from the Olympic Games! Also next week on the blog Dr. Christine Lawless will be giving an update from the Knowledge Olympics which just wrapped up this week.

Today I had the distinct pleasure and honor of representing the ACC and CardioSmart and carrying the Olympic Torch through Bicester, England. My five minutes of “Olympic fame” were quite a whirlwind. The experience was unique, symbolic and memorable; cheering spectators, taking time to express an involvement in the very spirit that the Olympics embody: dedication, collaboration, and healthy competition in sports.  I was reminded of all the hard work and determination of the amazingly talented athletes who will be competing in a few short weeks. I was proud to carry the Olympic Torch in this symbolic run in the name of heart heath.

I was also reminded of why I was given this honor. As I wrote in a previous blog post, I am one of 22 participants chosen by the Coca-Cola Company to carry the Olympic Flame as part of its Live Positively campaign. Other participants running with me include leaders of national health organizations, former Olympians like Michelle Kwan and Summer Sanders, and young individuals representing charitable organizations. Participants were selected due to their commitment to live positively and make a difference in their communities.

Sports and exercise medicine is always a hot topic around the Olympics, and just last week The Lancet published a series of articles that discussed recognizing exercise as a “fifth vital sign”, one of the key indicators of health used by health professionals, and whether sports and exercise specifically contribute to the health of nations. Other papers addressed issues like the role of technology in improving sports performance; commentaries included training in sports and exercise medicine for medical undergraduates, Olympic winning, the art of medicine, drug cheating at the Olympics, and more. I invite you to peruse this interesting issue.

Be sure to check out more photos from my run on ACC’s Facebook page, and as we gear up for the 2012 Summer Olympics which will kick-off on July 27, stay tuned to ACC’s Facebook page for the latest cv news. I will also be Tweeting live from Bicester: you can follow me at @williamzoghbi.

On a related note, members from the ACC’s Sports and Exercise Cardiology Council will be leading sessions at the International Convention on Science, Education and Medicine in Sport (ICSEMIS) on July 19 – 24. Also known as the “Knowledge Olympics,” ICSEMIS is a global sports and science convention held every four years at the same location as the Olympics. Also, if sport and exercise cardiology is your area of interest, don’t miss ACC’s Sports Cardiology Summit: Protecting the Heart of the American Athlete, which will be held at Heart House in October. You can also join the Sports and Exercise Cardiology Section of the ACC.

Overall the Olympic Torch Relay was a unique, thrilling and memorable experience; a first for the ACC and cardiovascular organizations.

PS, Read more about my run in an article in CultureMap Houston.

This post was authored by former ACC President Alfred Bove, MD, PhD, MACC.

In the news this week, Alexander Dale Oen, a world champion swimmer from Norway died during training camp in Flagstaff, AZ, after suffering a cardiac arrest. He was 26. Oen won the 100 breaststroke at the worlds in Shanghai last July and took silver at the 2008 Beijing Olympics. He was expected to compete in the Olympics in London this summer.

Oen is not the first, nor unfortunately last, young athlete to suffer from sudden cardiac death. A recent policy statement published in March by the American Academy of Pediatrics estimates that 2,000 people under the age of 25 die from sudden cardiac arrest in the U.S. every year.

As we head into Spring training seasons for high schools, colleges and major-league teams, as well as look ahead to the summer Olympics, this latest death will likely add continued fuel to the debate about whether to require EKGs in addition to physical exams for younger athletes participating in high-intensity sports. Both the American College of Cardiology and the American Heart Association agree that the mandatory screening of all young athletes with an ECG is not warranted based on cost (due to the large number of tests that would be required), the low incidence of sudden death among athletes in the United States, as well as the concern for false positive results. However overseas, both the European College of Cardiology and the International Olympic Committee (IOC) recommend resting electrocardiograms for all young athletes before they are allowed to compete.

The Journal of American College of Cardiology last year featured an article titled “Mandatory Electrocardiographic Screening of Athletes to Reduce Their Risk for Sudden Death: Proven Fact or Wishful Thinking?” that suggests the latter. The study analyzed the incidence of sudden death among competitive athletes following the enactment of the 1997 National Sport Law, which mandates screening of all athletes with resting ECG and exercise testing. The study found that there were 24 documented events of sudden death or cardiac arrest events among competitive athletes during the years 1985 through 2009, with 11 occurring before the 1997 legislation and 13 occurring after it. According to the study, the average yearly incidence of sudden death or cardiac arrest events was 2.6 events per 100,000 athlete-years. The study concluded that mandatory ECG screening of athletes had no apparent effect on their risk for cardiac arrest.  The authors suggested that the higher incidence of sudden death found in the Italian studies was not representative of the sudden death risk in the athlete population of most other countries [including the United States] which have a much lower incidence.

What does this mean? Johann von Goethe, a German poet, playwright, novelist, and natural philosopher, said: “Knowing is not enough; we must apply.” As the latest cardiac-related death of an athlete makes headlines, it is our job to take our knowledge and make sure we continue to educate not only each other, but our primary care colleagues as well, about what to look for and the questions to ask when screening young athletes. Most importantly we need to make sure primary care providers know when to refer for EKGs.  Patient education is also key. It’s critical that young athletes understand the warning signs and know when to seek help. Promoting the availability of AED’s at athletic events is also key, serving as a less costly alternative to mandatory ECGs that is proven to save lives if used immediately.

Moving forward, the College’s Sports and Exercise Cardiology Council and Section is an important resource for cardiovascular professionals who work with and or treat athletes. The goal of the section and council is to serve as a conduit for information and action regarding the cardiovascular care of athletes, and support constructive and enhanced interactions with all interested stakeholders. We are also participating in the dialogue regarding public policy around issues specific to the cardiovascular care of athletes and exercising individuals and are looking at enhancing opportunities for multidisciplinary training to improve interpretation cardiac testing in athletes and exercising individuals.

Also earlier this week the Sports and Exercise Cardiology Council worked with The New York Times to get a correction to an article “Should Young Athletes Be Screened for Heart Risk?” Read the article including a comment by Christine Lawless, MD, FACC and Richard Kovacs, MD, FACC here.

Share your thoughts on mandatory testing of athletes below.