Cardiovascular Considerations

Cardiovascular Screening

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Annual preparticipation cardiovascular screening of athletes is a generally accepted practice.1,2,3 The main objective of the screening is to identify risk factors that predispose a previously asymptomatic and apparently healthy athlete to sudden cardiac arrest and death.

History

History is the most important aspect of cardiovascular screening of young athletes. The history has been shown to have the most yield for identifying potential risk factors for adverse cardiac outcome. The key elements of cardiovascular screening history are summarized in Table 14-1.14

Table 14-1. Cardiovascular Screening History

Symptoms

Fatigue

Exercise-related chest pain

Presyncope or syncope during exercise

Dizziness

Heart racing or skipping beats during exercise

Exercise-related shortness of breath

Recent febrile illness

Past history

Heart surgery

Congenital heart disease

Kawasaki disease

Rheumatic fever

Personal history

Known heart murmur

Known high cholesterol or lipid disorder

Systemic hypertension

Diabetes mellitus

Marfan syndrome

Any diagnosed heart disease

Any previous or currently recommended physical activity restrictions

Current use of therapeutic medications, dietary supplements, over-the-counter medications

Current or past history of substance abuse, smoking, or other forms of tobacco use

Family history

Death of close family relatives before age 50 y from a cardiac or unknown cause

Congenital heart disease including Marfan syndrome, cardiomyopathy, long-QT syndrome

Systemic hypertension

Diabetes mellitus

Lipid disorders

Physical Examination

A general physical examination may reveal some important clues to cardiovascular disease, exemplified by the wide ranging clinical features seen in Marfan syndrome (Table 14-2).5 Key elements of cardiovascular examination are summarized in Table 14-3. Heart murmurs are a common finding in children and adolescents and it is important to appropriately distinguish the benign from pathologic murmurs that will indicate need for further evaluation. A simple classification of heart murmurs is presented in Table 14-4, the effects of certain physiologic maneuvers on cardiac auscultatory events are summarized in Table 14-5, and clinical clues that help identify benign heart murmurs are summarized in Table 14-6.4,6

Table 14-2. Criteria for Marfan Syndrome

System	Major Criteria	Minor Criteria	Requirements for System Involvement
Skeletal	Medial displacement of the medial malleolus causing pes planus	Facial appearance (dolichocephaly, down- slanting palpebral fissures, enophthalmos, malar hypoplasia, retrognathia)	2 major or 1 major plus 1 minor criteria
	Pectus carinatum	High-arched palate with crowding teeth
	Pectus excavatum requiring surgery	Joint hypermobility
	Protrusio acetabulae of any degree (ascertained on radiographs)	Pectus excavatum of moderate severity
	Reduced extension of the elbow
	Reduced upper-to-lower segment ratio or arm-span-to-height ratio >1.05
	Wrist and thumb sign
Note: 4 of 8 major criteria for the skeletal system are required to confirm the diagnosis of Marfan syndrome.
Ocular	Ectopia lentis	Abnormally flat cornea (as measured by keratometry)	At least 2 minor criteria
		Hypoplastic iris or hypoplastic ciliary muscle causing decreased miosis
		Increased axial length of globe (as measured by ultrasound)
Cardiovascular	Dilation of the ascending aorta with or without aortic regurgitation and involving at least the sinuses of Valsalva	Mitral valve prolapse with or without mitral valve regurgitation	1 major or 1 minor criterion
	Dissection of the ascending aorta	Dilatation of the main pulmonary artery in the absence of valvular or peripheral pulmonic stenosis or any obvious cause, if patient is younger than 40 y
		Calcification of the mitral annulus (if patient is younger than 40 y)
		Dilation or dissection of the descending thoracic or abdominal aorta, if patient is younger than 50 y
Pulmonary	None	Spontaneous pneumothorax	1 minor criterion
		Apical blebs (ascertained by chest radiograph)
Skin and integument	None	Recurrent incisional hernia Stria atrophicae (stretch marks) not associated with marked weight changes, pregnancy, or repetitive stress	1 minor criterion
Dura mater	Lumbosacral dural ectasia visible on CT scan or MRI	None	1 major criterion
Family/genetic history	Parent, child, or sibling who meets diagnostic criteria independently	None	1 major criterion
	Presence of mutation in fibrillin-1 gene, known to cause the Marfan syndrome
	Presence of a haplotype around fibrillin-1 gene inherited by descendant known to be associated with unequivocally diagnosed
	Marfan syndrome

Table 14-3. Key Elements of Cardiovascular Screening Examination

Heart rate, rhythm, character
Blood pressure
Femoral pulses palpated simultaneously with radial or brachial pulses (delay or diminished in coarctation of aorta)
Heart sounds
Systolic ejection murmur that intensifies with standing or Valsalva maneuver and decrease with squatting suggest hypertrophic cardiomyopathy
Decrescendo diastolic (aortic insufficiency) or holostystolic (mitral insufficiency) murmurs may be noted in Marfan syndrome
Midsystolic click may be noted in mitral valve prolapse

Table 14-4. Classification of Heart Murmurs*

Timing	Class	Description	Characteristic Lesions
Systolic	Ejection	Begins in early systole; may extend to mid or late systole; crescendo-decrescendo pattern; often harsh in quality	Valvular, supravalvular, and subvalvular aortic stenosis; HCM; pulmonic stenosis; aortic or pulmonary artery dilation; malformed but nonobstructive aortic valve; transvalvular flow (e.g., aortic regurgitation, hyperkinetic states, ASD, physiologic flow murmur)
	Holosystolic	Extends throughout systole; relatively uniform in intensity	MR; tricuspid regurgitation; ventricular septal defect
	Late	Variable onset and duration, often preceded by a nonejection click	MVP
Diastolic	Early	Begins with A2 or P2; decrescendo pattern with variable duration; often high-pitched, blowing	Aortic regurgitation
	Mid	Begins after S2, often after an opening snap; low-pitched “rumble” heard best with bell of stethoscope Presystolic accentuation of mid-diastolic murmur	Mitral stenosis; tricuspid stenosis; ↑ flow across-AV valves (e.g., MR, tricuspid regurgitation, ASD)
	Late		Mitral stenosis; tricuspid stenosis
Continuous		Systolic and diastolic components; “machinery” murmurs	Patent ductus aerteriosus; coronary AV fistula; ruptured sinus of Valsalva aneurysm into right atrium or ventricle; mammary soufflé; venous hum

Table 14-5. Effects of Physiologic Maneuvers on Auscultatory Events*

Maneuver	Major Physiologic Effects	Useful Auscultatory Changes
Respiration	↑ Venous return with inspiration	↑ Right heart murmurs and gallops with inspiration; splitting of S2
Valsalva (initial ↑ BP, phase I; followed by ↓ BP; phase 2)	↓ BP, venous return, LV size (phase 2)	↑ HCM
		↓ AS, MR
		MVP click earlier in systole, murmur prolongs
Standing	↓ Venous return	↑ HCM;
		↓ AS, MR; MVP click earlier in systole, murmur prolongs
Squatting	↑ Venous return, systemic vascular resistance, LV size	↑ AS, MR, AI: ↓ HCM; MVP click delayed, murmur shortens
Isometric exercise (e.g., handgrip)	↑ Arterial pressure, cardiac output	↑ MR, AI, MS
		↓ AS, HCM
Post PVC or prolonged	↑ Ventricular filling, contractility	↑ AS; little change in MR
R-R interval
Amyl nitrate	↓ Arterial pressure, LV size	↑ HCM, AS, MS
	↑ Cardiac output	↓ AI, MR, Austin Flint murmur; MVP click earlier in systole, murmur prolongs
Phenylephrine	↑ Arterial pressure, LV size	↑ MR, AI; ↓ AS, HCM; MVP click delayed, murmur shortens
	↓ Cardiac output