Cardiovascular disease in athletes

Hearables: feasibility of recording cardiac rhythms from single in-ear locations

The ear is well positioned to accommodate both brain and vital signs monitoring, via so-called hearable devices. Consequently, ear-based electroencephalography has recently garnered great interest. However, despite the considerable potential of hearable based cardiac monitoring, the biophysics and characteristic cardiac rhythm of ear-based electrocardiography (ECG) are not yet well understood. To this end, we map the cardiac potential on the ear through volume conductor modelling and measurements on multiple subjects. In addition, in order to demonstrate real-world feasibility of in-ear ECG, measurements are conducted throughout a long-time simulated driving task. As a means of evaluation, the correspondence between the cardiac rhythms obtained via the ear-based and standard Lead I measurements, with respect to the shape and timing of the cardiac rhythm, is verified through three measures of similarity: the Pearson correlation, and measures of amplitude and timing deviations. A high correspondence between the cardiac rhythms obtained via the ear-based and Lead I measurements is rigorously confirmed through agreement between simulation and measurement, while the real-world feasibility was conclusively demonstrated through efficacious cardiac rhythm monitoring during prolonged driving. This work opens new avenues for seamless, hearable-based cardiac monitoring that extends beyond heart rate detection to offer cardiac rhythm examination in the community.

Evolving Expectations of the Orthopedic Team Physician: Managing the Sidelines and Landmines

ABSTRACT

The role of orthopedic team physicians has evolved greatly over the past decade having been influenced by advances in sports science and performance, new surgical and biologic technologies, social media, medicolegal liability, marketing, and sexual misconduct cases by some team physicians. The great variety of events and sports that are covered from high school and collegiate to the Olympic and professional levels requires a myriad of skills outside of the traditional medical training curriculum. In the current climate of increasing media scrutiny from a 24-h news cycle it is imperative for orthopedic team physicians, whether operative or nonoperative, to continually adapt to the needs and expectations of athletes who also are patients. This is especially true in the wake of the COVID-19 pandemic. Orthopedic team physicians' responsibilities continue to evolve ensuring their relevance and necessity on the sidelines and in the training room as well as in the operative suite.

Diet-dependent entropic assessment of athletes' lifespan

Life expectancies of the athletes depend on the sports they are doing. The entropic age concept, which was found successful in the previous nutrition studies, will be employed to assess the relation between the athletes' longevity and nutrition. Depending on their caloric needs, diets are designed for each group of athletes based on the most recent guidelines while they are pursuing their careers and for the post-retirement period, and then the metabolic entropy generation was worked out for each group. Their expected lifespans, based on attaining the lifespan entropy limit, were calculated. Thermodynamic assessment appeared to be in agreement with the observations. There may be a significant improvement in the athletes' longevity if they shift to a retirement diet after the age of 50. The expected average longevity for male athletes was 56 years for cyclists, 66 years for weightlifters, 75 years for rugby players and 92 years for golfers. If they should start consuming the retirement diet after 50 years of age, the longevity of the cyclists may increase for 7 years, and those of weightlifters, rugby players and golfers may increase for 22, 30 and 8 years, respectively.

Cholesterol removal from human plasma with biologically modified cryogels

In this study, low molecular weight heparin immobilized P(HEMA) cryogels were fabricated for the removal of LDL-C in hypercholesterolemic human plasma. After characterization studies for P(HEMA) cryogels, effects of the parameters including medium pH, CNBr concentration, heparin concentration and contact time on heparin immobilization were investigated. Blood compatibility and cell adhesion tests were also performed, and platelet and leucocyte loss for P(HEMA)-Hp cryogels were found to be 2.95% and 4.91%, respectively. Maximum adsorption capacity for LDL-C from hypercholesterolemic human plasma was found to be 26.7 mg/g for P(HEMA)-Hp cryogel while it was only 1.67 mg/g for bare P(HEMA) cryogel. The P(HEMA)-Hp cryogels exhibit high desorption ratios up to 96% after 10 adsorption-desorption cycles with no significant decrease in the adsorption capacity. The findings indicated that these reusable P(HEMA)-based cryogels proposed good alternative adsorbents for removal of LDL-C.

The Impact of Previous Athletic Experience on Current Physical Fitness in Former Collegiate Athletes and Noncollegiate Athletes

Background:

Physical activity performed at moderate intensity is associated with reduced risk of mortality, cardiovascular disease, hypertension, and some types of cancers. However, vigorous physical activity during participation in college athletics may increase the risk of injury, which might limit future physical activity levels.

Purpose:

To evaluate differences in current physical fitness levels between former Division I athletes and noncollegiate athletes.

Study Design:

Cross-sectional study.

Level of Evidence:

Level 3.

Methods:

The sample was recruited from a large midwestern university alumni database and consisted of 2 cohorts: (1) former Division I athletes (n = 100; mean age, 53.1 ± 7.4 years) and (2) nonathletes who were active in college (n = 100; age, 51.4 ± 7.3 years). Individuals answered a demographics questionnaire and completed a physical fitness assessment consisting of 7 measures: percent body fat, 1-mile walk, sit-to-stand test, push-up, half sit-up test, sit and reach test, and back scratch test.

Results:

Performance was significantly worse for former Division I athletes compared with nonathletes for percent body fat (mean difference, 7.58%; F_{(1, 198)} = 59.91; P < 0.01), mile time (mean difference, 2.42 minutes; F_{(1, 198)} = 1.74; P = 0.03), sit-to-stand test (mean difference, 4.3 repetitions; F_{(1, 198)} = 6.59; P = 0.01), and push-up test (mean difference, 8.9 repetitions; F_{(1, 198)} = 7.35; P = 0.01).

Conclusion:

Former Division I athletes may be limited because of previous injury, inhibiting their ability to stay active later in life.

Clinical Relevance:

It is imperative that clinicians, coaches, and strength and conditioning specialists understand the possible future repercussions from competing at the Division I level.

ESC Study Group of Sports Cardiology: recommendations for participation in leisure-time physical activity and competitive sports for patients with ischaemic heart disease

BACKGROUND

Evidence for the proper management of ischemic heart disease (IHD) in the general population is well established, but recommendations for physical activity and competitive sports in these patients are scarce. The aim of the present paper was to provide such recommendations to complement existing ESC and international guidelines on rehabilitation and primary/secondary prevention.

DESIGN AND METHODS

Due to the lack of studies in this field, the current recommendations are the result of consensus among experts. Sports are classified into low/moderate/high dynamic and low/moderate/high static, respectively.

RESULTS

Patients with a definitive IHD and higher probability of cardiac events are not eligible for competitive sports (CS) but for individually designed leisure time physical activity (LPA); patients with definitive IHD and lower probability of cardiac events as well as those with no IHD but with a positive exercise test and high risk profile (SCORE > 5%) are eligible for low/moderate static and low dynamic (IA-IIA) sports and individually designed LPA. Patients without IHD and a high risk profile+ a negative exercise-test and those with a low risk profile (SCORE < 5%) are allowed all LPA and competitive sports with a few exceptions.

CONCLUSIONS

Individually designed LPA is possible and encouraged in patients with and without established IHD. Competitive sports may be restricted for patients with IHD, depending on the probability of cardiac events and the demands of the sport according to the current classification.

Current Health-Related Quality of Life in Former National Collegiate Athletic Association Division I Collision Athletes Compared With Contact and Limited-Contact Athletes

CONTEXT

Previous researchers have shown that current health-related quality of life (HRQoL) is lower in former National Collegiate Athletic Association Division I athletes than in nonathletes. However, evidence supports the idea that individuals in collision sports (football) may suffer more serious injuries that may affect them later in life.

OBJECTIVE

To measure HRQoL in former Division I collision, contact, and limited-contact athletes.

DESIGN

Cross-sectional study.

SETTING

Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 374 former Division I athletes between the ages of 40 and 65 years were separated into collision, contact, and limited-contact groups.

INTERVENTION(S)

All individuals completed the Short Form 36 version 2 via a computer.

MAIN OUTCOME MEASURES(S)

The dependent variables were the physical component and mental component summary scores and the physical functioning, physical role functioning, bodily pain, general health, vitality, social role functioning, emotional role functioning, and mental health scales. An initial multivariate analysis of covariance included data from the 2 domains: physical component and mental component summary scores. The second multivariate analysis of covariance included data from the 8 dimensions: physical function, role physical, bodily pain scale, general health, mental health, role emotional, social function, and vitality scales. The α level was set at P < .05 with a covariate of sex.

RESULTS

The responses were significantly lower (worse) for the former collision athletes compared with the contact and limited-contact athletes for the summary scores (F2,370 = 90.09, P < .01) and all 8 scales (F8,364 = 24.33, P < .01). The largest differences were between the collision and limited-contact athletes for the bodily pain and role physical scales, with mean differences of 12.91 and 11.80 points, respectively.

CONCLUSIONS

Competing at the Division I level can be strenuous on an athlete's physical, mental, and social dimensions, which can affect the athlete later in life. Based on these data, collision athletes may sacrifice their future HRQoL compared with contact and limited-contact athletes.

Concept Design for a 1-Lead Wearable/Implantable ECG Front-End: Power Management

Power supply quality and stability are critical for wearable and implantable biomedical applications. For this reason we have designed a reconfigurable switched-capacitor DC-DC converter that, aside from having an extremely small footprint (with an active on-chip area of only 0.04 mm²), uses a novel output voltage control method based upon a combination of adaptive gain and discrete frequency scaling control schemes. This novel DC-DC converter achieves a measured output voltage range of 1.0 to 2.2 V with power delivery up to 7.5 mW with 75% efficiency. In this paper, we present the use of this converter as a power supply for a concept design of a wearable (15 mm × 15 mm) 1-lead ECG front-end sensor device that simultaneously harvests power and communicates with external receivers when exposed to a suitable RF field. Due to voltage range limitations of the fabrication process of the current prototype chip, we focus our analysis solely on the power supply of the ECG front-end whose design is also detailed in this paper. Measurement results show not just that the power supplied is regulated, clean and does not infringe upon the ECG bandwidth, but that there is negligible difference between signals acquired using standard linear power-supplies and when the power is regulated by our power management chip.

Rugby contact and collisions--clinical challenges of a global game

Rugby Union (rugby) is a sport that evolved from and resembles other forms of football but is unique in many respects and presents distinctive clinical challenges. This article discusses those aspects of rugby that are different from other sports and those injuries that have specific significance to the game as a result of it being a global collision sport with an increasing focus on serious injury prevention. Injury screening and intervention programs, neck injuries, rugby's contribution to evolving concussion protocols, contact and travel-related illnesses, and rugby's drug intervention protocols are discussed.

Imaging spectrum of sudden athlete cardiac death

Sudden athlete death (SAD) is a widely publicized and increasingly reported phenomenon. For many, the athlete population epitomize human physical endeavour and achievement and their unexpected death comes with a significant emotional impact on the public. Sudden deaths within this group are often without prior warning. Preceding symptoms of exertional syncope and chest pain do, however, occur and warrant investigation. Similarly, a positive family history of sudden death in a young person or a known family history of a condition associated with SAD necessitates further tests. Screening programmes aimed at detecting those at risk individuals also exist with the aim of reducing fatalities. In this paper we review the topic of SAD and discuss the epidemiology, aetiology, and clinical presentations. We then proceed to discuss each underlying cause, in turn discussing the pathophysiology of each condition. This is followed by a discussion of useful imaging methods with an emphasis on cardiac magnetic resonance and cardiac computed tomography and how these address the various issues raised by the pathophysiology of each entity. We conclude by proposing imaging algorithms for the investigation of patients considered at risk for these conditions and discuss the various issues raised in screening.

An ultra-high input impedance ECG amplifier for long-term monitoring of athletes

We present a new, low-power electrocardiogram (ECG) recording system with an ultra-high input impedance that enables the use of long-lasting, dry electrodes. The system incorporates a low-power Bluetooth module for wireless connectivity and is designed to be suitable for long-term monitoring during daily activities. The new system using dry electrodes was compared with a clinically approved ECG reference system using gelled Ag/AgCl electrodes and performance was found to be equivalent. In addition, the system was used to monitor an athlete during several physical tasks, and a good quality ECG was obtained in all cases, including when the athlete was totally submerged in fresh water.

Cardiovascular screening of adolescent athletes

A preparticipation cardiovascular screening is recommended for all athletes with the aim of identifying conditions that increase the risk for adverse cardiac event, including sudden death. History and physical examination are the mainstay of cardiovascular screening of young athletes. The ability to identify athletes at risk, however, based on history and physical examination alone is low, and inclusion of an electrocardiogram as a screening tool has been suggested to improve the sensitivity of screening. This article provides an overview of key aspects of cardiovascular screening currently recommended in the United States for young athletes.

Electrocardiogram testing during athletic preparticipation physical examinations

CONTEXT

Sudden cardiac death (SCD) is a relatively rare yet unfortunate risk of athletic participation. To reduce the incidence of SCD, electrocardiogram (ECG) use during athletic preparticipation examinations (PPEs) has been proposed to detect underlying cardiac abnormalities.

OBJECTIVE

To estimate the effectiveness of ECG use during athletic PPEs.

DESIGN

Epidemiologic modeling.

POPULATIONS

Public high school athletes.

DATA COLLECTION AND ANALYSIS

Estimates of ECG sensitivity (70%) and specificity (84%) were drawn from the literature, as was the estimate of overall prevalence of cardiac conditions relevant to SCD (0.3%). Participation rate by sex was determined from National Federation of State High School Associations data. Participation by ethnicity was assumed to be proportionate to the public high school attendance rates for grades 9 through 12 (18.4% African American). Population-specific ECG effectiveness (positive predictive value), estimated total costs, cost per year of life saved, and cost to identify 1 additional case were computed. Total annual PPE screening costs reflected a cardiologist's office visit, including echocardiogram for those athletes with a positive ECG screen.

RESULTS

The model predicted that 16% of all athletes would be expected to have a positive ECG, but only 1.3% of athletes with a positive ECG would have a cardiac abnormality capable of causing SCD, including hypertrophic cardiomyopathy, structural defects, and various conduction abnormalities. Total annual cost estimates for ECG screening and follow-up exceeded $126 million. Average cost per year of life saved across groups was $2693, and the cost to identify 1 additional case averaged $100 827. Compared with females, males had both lower cost per year of life saved and lower cost to identify 1 true case. Similarly, black males exhibited lower costs than white males. Across groups, false-positive ECG screening exams accounted for 98.8% of follow-up costs.

CONCLUSIONS

Large-scale, mass ECG testing would be a costly method to identify athletes with cardiac abnormalities. Targeting high-risk populations can increase the effectiveness of the ECG for athletic PPE screening.

Electrocardiograms of collegiate football athletes

BACKGROUND

The prevalence of electrocardiogram (ECG) abnormalities in American collegiate football athletes is virtually unknown.

PURPOSE

The purpose of this study was to characterize the type and frequency of ECG abnormalities in a sample of football athletes entering National Collegiate Athletic Association (NCAA) Division I Football Bowl Subdivision university program.

METHODS

Over a 4-y period, resting and exercise 12-lead ECG recordings were analyzed by a cardiologist from 68 freshmen and 9 transfer football athletes (n=77; 54 African-Americans and 23 Caucasians, aged 18 +/- 1 y, height=1.89 +/- 0.06 m, weight= 104.4 +/- 19.8 kg) as part of their entry physical examination.

RESULTS

A total of 79% of the athletes demonstrated at least 1 abnormal ECG finnding, and significantly more African-America athletes (85%) than Caucasian (65%) athletes. Wolff-Parkinson-White (WPW) syndrome was found in 1 African-American player. Frequencies of various ECG abnormal findings in all athletes were: left ventricular hypertrophy = 64.5%, ST-T wave = 6.5%, interventricular conduction delay = 2.6%, sinus bradycardia = 9.1%, sinus arrhythmia = 15.6%, first-degree atrioventricular (AV) block = 11.7%, left atrial enlargement = 48.1%, early repolarization = 33.8%, and right axis deviation = 20.8%. Average values for the PR (0.17 +/- 0.03 s), QRS (0.08 +/- 0.02 s), and QT intervals (0.38 +/- 0.05 s), P-wave duration (0.10 +/- 0.02 s), and QRS axis (79.1 +/- 18.2 degrees) were normal. The ECG responses to maximal treadmill exercise stress tests were evaluated as normal without ischemia or arrhythmias.

CONCLUSION

Abnormal resting ECG findings are common in a sample of collegiate football athletes, exceeding the rate expected for their age, and are more frequent in African-American athletes as compared with Caucasian athletes.

Sudden death in competitive athletes

Sudden death in athletes is an extremely rare event yet no less tragic for its infrequency. Up to 90% of these deaths are due to underlying cardiovascular diseases and therefore categorized as sudden cardiac death (SCD). The causes of SCD among athletes are strongly correlated with age. In young athletes (<35 years), the leading causes are congenital cardiac diseases, particularly hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and congenital coronary artery anomalies. By contrast, most of deaths in older athletes (<35 years) are due to coronary artery disease. This review focuses on the cardiac causes of SCD and provides a brief summary of the principal noncardiac causes. Current pre-participation screening strategies are also discussed, with particular emphasis on the Italian experience.

Preparticipation medical evaluation in professional sport in the UK: theory or practice?

OBJECTIVE

To determine the level of pre-employment, pre-season, and post-injury medical evaluation of players undertaken within UK professional team sports.

DESIGN

A postal, whole population survey.

SETTING

Elite professional sports teams in England.

POPULATION

Six groups comprising the following clubs: professional football (Premiership, 15 of 20; Championship, 22 of 24), rugby union (Premiership, 9 of 12; Division 1, 11 of 14), rugby league (Super League, 6 of 11) and cricket (County, 12 of 18).

MAIN OUTCOME MEASURES

Number (percentage) of clubs recording players' medical history and undertaking medical examinations of players' cardiovascular, respiratory, neurological, and musculoskeletal systems at pre-employment, pre-season and post-injury.

RESULTS

The overall response to the survey was 74%, with a range from 55% to 92% among groups. Almost 90% of football (Premiership and Championship) and rugby union (Premiership) clubs took a pre-employment history of players' general health, cardiovascular, respiratory, neurological, and musculoskeletal systems, but fewer than 50% of cricket and rugby union (Division 1) clubs recorded a history. The majority of football (Premiership and Championship) and rugby union (Premiership) clubs implemented both cardiovascular and musculoskeletal examinations of players before employment. Fewer than 25% of clubs in any of the groups implemented neurological examinations of players at pre-employment, although 100% of rugby union (Premiership) and rugby league clubs implemented neurological testing during pre-season.

CONCLUSIONS

None of the sports implemented best practice guidelines for the preparticipation evaluation of players at all stages of their employment. Departures from best practice guidelines and differences in practices between clubs within the same sport leave club physicians vulnerable if their players sustain injuries or ill health conditions that could have been identified and avoided through the implementation of a preparticipation examination.

Electrocardiography and the preparticipation physical examination: is it time for routine screening?

The preparticipation physical examination (PPE) is a screening tool endorsed by numerous organizations and used to evaluate young athletes prior to competition for both medical and musculoskeletal conditions that may predispose them to injury. The cardiac portion of the examination, as recommended by the American Heart Association, is detailed specifically to detect signs or symptoms consistent with certain congenital heart conditions that may increase a young athlete's risk of sudden cardiac death (SCD). Much controversy has erupted over the years as to whether this examination has the diagnostic sensitivity to detect these conditions and prevent SCD, and whether additional modalities, such as the 12-lead electrocardiograph (ECG), should be incorporated. Given the rarity of SCD events, the large population of young athletes that would qualify yearly for the examination, and the limitations that an ECG would present, it would not be efficient to add the ECG to the standard PPE on the symptomatic athlete. More efforts should be spent in standardizing the PPE on a national level to further improve its efficiency.

The athlete's electrocardiogram

The electrocardiogram performed in the competitive athlete may manifest abnormal electrocardiographic findings; these findings may indicate either normal variant syndromes as well as true cardiac pathology. The normal variant syndromes include ST-segment and T-wave abnormalities, rhythm disturbances, and intraventricular conduction delay--it must be stressed that these electrocardiographic findings are, in fact, normal variants, not indicative of underlying pathology. Other presentations in these same competitive athletes describe significant cardiac pathology, including syndromes predisposing the patient to sudden cardiac death and other potentially dangerous dysrhythmias and diagnostic of acute coronary syndrome. This article reviews the various findings in this group of patients.

Sudden cardiac death in athletes: a guide for emergency physicians

A conditioned athlete is usually regarded as a member of the healthiest segment of society, and exercise itself is looked upon as a means to improve health. Although extremely uncommon, sudden cardiac death (SCD) in young athletes is a devastating medical event to all involved (patient, family, community, team, and caregivers). Most etiologies of SCD in athletes result in the same final common denominator (cardiac arrest) on presentation to an emergency physician. There are, however, certain historic, physical examination, and electrocardiographic features of many of these disease processes that emergency physicians should have a working knowledge of to try to identify them before they result in SCD. This review examines the clinical presentation, diagnostic techniques, and management options applicable to emergency practitioners.

Role of exercise stress test in master athletes

BACKGROUND

The effectiveness of cardiovascular screening in minimising the risk of athletic field deaths in master athletes is not known.

OBJECTIVE

To evaluate the prevalence and clinical significance of ST segment depression during a stress test in asymptomatic apparently healthy elderly athletes.

METHODS

A total of 113 male subjects aged over 60 were studied (79 trained and 34 sedentary); 88 of them (62 trained and 26 sedentary) were followed up for four years (mean 2.16 years for athletes, 1.26 years for sedentary subjects), with a resting 12 lead electrocardiogram (ECG), symptom limited exercise ECG on a cycle ergometer, echocardiography, and 24 hour ECG Holter monitoring.

RESULTS

A significant ST segment depression at peak exercise was detected in one athlete at the first evaluation. A further case was seen during the follow up period in a previously "negative" athlete. Both were asymptomatic, and single photon emission tomography and/or stress echocardiography were negative for myocardial ischaemia. The athletes remained symptom-free during the period of the study. One athlete died during the follow up for coronary artery disease: he showed polymorphous ventricular tachycardia during both the exercise test and Holter monitoring, but no significant ST segment depression.

CONCLUSIONS

The finding of false positive ST segment depression in elderly athletes, although still not fully understood, may be related to the physiological cardiac remodelling induced by regular training. Thus athletes with exercise induced ST segment depression, with no associated symptoms and/or complex ventricular arrhythmias, and no adverse findings at second level cardiological testing, should be considered free from coronary disease and safe to continue athletic training.

Medicolegal issues in sports medicine

This article reviews medicolegal issues in sports medicine. Nonmusculoskeletal medical conditions discussed include cardiac abnormalities, heat illness, and concussion in the athlete. Musculoskeletal injuries with the greatest potential for litigation, knee dislocation, and cervical spine trauma, are also reviewed. We provide legal case examples and discuss evaluation and treatment strategies to assist the medical team in the care of athletes.

Sudden cardiac death in division I collegiate athletics: analysis of automated external defibrillator utilization in National Collegiate Athletic Association division I athletic programs

OBJECTIVE

To determine current outcomes of automated external defibrillator (AED) interventions in sports medicine programs in National Collegiate Athletic Association (NCAA) division I athletics.

DESIGN

Qualitative scripted telephone interview with all positive responders to prior NCAA division I-wide study on AED utilization and implementation.

SETTING

NCAA division I sports medicine programs. Head athletic trainers were the main data source.

PARTICIPANTS

All positive responders to a previously published study on AED implementation in the NCAA division I sports medicine community. Positive responders were those that indicated that they had used their departmental AEDs in a sudden cardiac death (SCD) scenario.

MAIN OUTCOME MEASUREMENTS

Survival to hospital discharge was the main outcome sought. When available, additional outcomes were time to defibrillation, time to notification of athletic training staff, EMS response time, location of event, and sudden cardiac victim type (i.e., student, coach, fan).

RESULTS

Sixteen departments that previously reported having had an SCD event at their institution responded to this follow-up telephone survey. Twenty percent of AED uses were attributed to student athletes, with 33% of utilizations for athletic department staff and 47% for fans. Defibrillation was actually administered in 53% of AED unit applications. Time to shock was an average of 3.4 minutes, with average EMS response time of 8.2 minutes for those events without EMS on site. Reported survival to hospital discharge in this university athletic department setting for SCD was 0% for students, 75% for staff, 57% for fans, and 61% overall.

CONCLUSIONS

The results of this study demonstrate the need for NCAA division 1 athletic sports medicine programs to examine, and possibly expand, the traditional scope of practice of caring primarily for student athletes to include the larger community of sports participants comprised of athletes, departmental staff, and spectators. Athletic department AED programs were extremely successfully at increasing survival of SCD far above national prehospital standards, mainly in the nonathletic population. Further study is also necessary in the realm of AED placement, maintenance, and training of staff.

Exercise related syncope, when it's not the heart

Syncope or pre-syncope in association with physical exercise may be the first indication of a dangerous underlying cardiovascular condition. Thus, the diagnostic workup of patients presenting with exercise-related syncope must include assessment of the risk for acute cardiac death. When potentially lethal conditions have been ruled out, several hypotensive syndromes that are associated with exercise should be considered. This review aims to give a concise overview of several forms of exercise- related functional hypotensive syndromes causing syncope, including the physiology of post-exercise hypotension. The focus is on underlying mechanisms, clinical considerations, and outlining treatment strategies for these syndromes.

Cardiovascular disorders in the college student

This article provides an overview of diagnosis and treatment of college students with possible congenital or acquired heart problem issues. Preventive cardiac concerns and issues regarding risk factors for atherosclerotic heart disease are discussed. College students with corrected or palliated heart conditions are included because they are an expanding segment of the adult cardiac population. Selected major syndromes with associated cardiac anomalies and complications are included. Finally, reinforcement and review of cardiac diagnosis or management issues occurring in college students (six case scenarios) are included in the appendix.

Automated external defibrillators in National Collegiate Athletic Association Division I Athletics

BACKGROUND

Sudden cardiac death is the leading cause of death in athletes. Evidence on current sudden cardiac death prevention through preparticipation history, physicals, and noninvasive cardiovascular diagnostics has demonstrated a low sensitivity for detection of athletes at high risk of sudden cardiac death. Data are lacking on automated external defibrillator programs specifically initiated to respond to rare dysrhythmia in younger, relatively low-risk populations.

METHODS

Surveys were mailed to the head athletic trainers of all National Collegiate Athletic Association Division I athletics programs listed in the National Athletic Trainers' Association directory. In all, 303 surveys were mailed; 186 departments (61%) responded.

RESULTS

Seventy-two percent (133) of responding National Collegiate Athletic Association Division I athletics programs have access to automated external defibrillator units; 54% (101) own their units. Proven medical benefit (55%), concern for liability (51%), and affordability (29%) ranked highest in frequency of reasons for automated external defibrillator purchase. Unit cost (odds ratio = 1.01; 95% confidence interval, 1.01-1.0), donated units (odds ratio = 1.92; confidence interval, 3.66-1.01), institution size (odds ratio =.0001; confidence interval, 1.3 E-4 to 2.2E-05), and proven medical benefit of automated external defibrillators (odds ratio = 24; confidence interval, 72-8.1) were the most significant predictors of departmental defibrillator ownership. Emergency medical service response time and sudden cardiac death event history were not significantly predictive of departmental defibrillator ownership. The majority of automated external defibrillator interventions occurred on nonathletes.

CONCLUSIONS

Many athletics medicine programs are obtaining automated external defibrillators without apparent criteria for determination of need. Usage and maintenance policies vary widely among departments with unit ownership or access. Programs need to approach the issue of unit acquisition and implementation with knowledge of the surrounding emergency medical service system, geography of their individual sports medicine facilities, numbers and relative risk of their athletes, and budgetary constraints.

Torsades de pointes following cardioversion: case history and literature review

Torsades de pointes (TDP) is a relatively uncommon but potentially fatal cardiac arrhythmia which occurs in patients with long QT syndromes (LQTS). This literature review and case history investigate the causes, symptoms, presentation and treatment of torsades, focusing on drug induced torsades developing after successful cardioversion. In torsades, imbalanced positive ion flows result in early after-depolarisations (EADs) and increased variability in repolarisation rates. These combine to create an unstable re-entrant polymorphic ventricular tachycardia (VT) which can cause patients to suffer symptoms progressing from syncope to ventricular fibrillation (VF) arrest. Typically, torsades has a twisting morphological presentation on rhythm strips due to the irregularity of its re-entry pattern. The arrhythmia is more common in women. Intravenous magnesium is the initial emergency treatment in torsades. The case history illustrates the progressive acquisition of risk factors for drug induced torsades in a patient treated with sotalol following cardioversion. Typical progressive rhythm strip, electrocardiograph (ECG), and QT & corrected QT interval (QTc) interval changes occurring with the arrhythmia are presented.

Preparticipation cardiovascular screening

Regular aerobic exercise provides many health benefits regardless of age, and should be promoted by health care providers to all patients. In older athletes, coronary artery disease is the most common cause of sudden death. There is widespread consensus, however, that the overall health benefits derived from exercise outweigh the risks of participation. Screening should focus on identifying signs and symptoms of underlying cardiovascular disease by obtaining a personal and family history and performing a focused physical examination according to the recommendations of the AHA. Exercise testing is recommended in males older than 40 and females older than 50, and individuals with cardiac risk factors. Cardiovascular PPE screening in young athletes remains a challenge, because potentially fatal abnormalities are uncommon and in some cases are undetectable without sophisticated testing. Most sudden cardiac deaths in athletes are caused by anomalies that are clinically silent, are rare, or are difficult to detect by history and physical examination. Many athletes may not experience symptoms consistent with heart disease or may not report family histories of sudden cardiac death. Important clues to a cardiac abnormality include history of syncope, chest pain, and family history of sudden death. Any underlying condition suspected on the basis of history or physical examination requires further diagnostic evaluation before the athlete can be cleared for activity. Currently there is considerable variability and inconsistency among state requirements for PPEs. A national adoption of a more uniform PPE screening process should be encouraged. The screening process should include the AHA's cardiovascular screening recommendations, as this would assist in closing the gap between screening practices recommended by sports medicine experts and the reality of current screening practices. Although the extent of screening continues to be debated, clinical guidelines for performing PPEs and determining clearance have been established. Without a uniform implementation of the current guidelines, it will not be possible to assess the value of the current cardiovascular screening recommendations in detecting and preventing cardiovascular death in young athletes. Physicians should be aware of the emerging role of genetic testing for cardiovascular diseases in athletes with a family history of heart disease or sudden death. Advances in the diagnosis and understanding of cardiovascular disease may provide better tools for preventing sudden death of young athletes in the future [11].

[Cardiovascular benefits and hazard of physical practice]

The benefits of regular physical activity have been demonstrated in numerous epidemiologic studies in primary and secondary prevention of coronary artery disease. However, even high level physical activity is not an absolute guarantee against complications of coronary artery disease. Sudden death remains a major complication of sports. Beyond 35-40 years of age, coronary artery disease is the main cause of sudden death during physical activity. In normotensive as well as hypertensive subjects, physical activity lowers blood pressure. It also has beneficial effects on body fat and increases HDL-cholesterol. Likewise, physical activity has documented beneficial effects in diabetic patients, for type 1 as well as type 2 diabetes mellitus. Overall, the advantages of regular physical activity clearly exceed the potential risk of sudden death which is usually caused by heavy exertion in otherwise unaware coronary patients.

Cardiac risk factors and participation guidelines for youth sports

Accurate assessment of the cardiac system in pediatric and adolescent youth is important. The hemodynamic demands associated with exercise, training, and sport participation are usually positive and beneficial; however, when an underlying cardiac problem exists, it is imperative that such cardiac problems be identified. Safe sport-related cardiac participation guidelines should be provided for young athletes and their families and coaches. This chapter provides a physician perspective on the recognition and current cardiac management considerations for young athletes participating in both static and dynamic types of sports. The most recent guidelines for hypertension in youth are also provided.

Sudden cardiac death in young athletes. Causes, athlete's heart, and screening guidelines

Sudden cardiac death of a young competitive athlete is a rare but tragic event. Hypertrophic cardiomyopathy and coronary artery anomalies are the most frequent causes. Most cardiovascular abnormalities go unrecognized until the time of death owing to the lack of preceding signs or symptoms suggestive of disease. Physicians responsible for the care of athletes should be familiar with the various causes of sudden cardiac death, the physiologic adaptations seen in so-called athlete's heart, and existing cardiovascular screening guidelines. The preparticipation evaluation, although it has limitations, is the major instrument readily available for prevention of sudden cardiac death. Effort should be made to follow established consensus guidelines.