Sports Cardiology Care of The Athletic Heart From The Clinic To The Sidelines 1st Edition by David Engel, Dermot Phelan ISBN 9783030693848 3030693848
Sports Cardiology Care of The Athletic Heart From The Clinic To The Sidelines 1st Edition by David Engel, Dermot Phelan ISBN 9783030693848 3030693848
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123
Sports Cardiology
David J. Engel • Dermot M. Phelan
Editors
Sports Cardiology
Care of the Athletic Heart from the Clinic
to the Sidelines
Editors
David J. Engel Dermot M. Phelan
Division of Cardiology Sports Cardiology Center
Columbia University Irving Medical Center Hypertrophic Cardiomyopathy Center
New York, NY Atrium Health Sanger Heart &
USA Vascular Institute
Charlotte, NC
USA
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Preface
Participation in organized sports across the globe has markedly increased over the
past decade, and, in parallel, the clinical practice and research activity centered on
the cardiac care for athletes within the field of sports cardiology has expanded expo-
nentially. Recognizing the unique diagnostic and management challenges in opti-
mizing the heart health of athletes and reflective of the increasing importance
assigned to protecting the hearts of athletes, the American College of Cardiology
(ACC) in 2011 launched the ACC Section of Sports and Exercise Cardiology.
A foundation in the growth of sports cardiology has been the development of a
refined and enhanced understanding of the physiological manifestations of exercise
on the heart. This improved characterization of exercise-induced cardiac remodel-
ing, recognizing the relative influence of such modifiers as sport type, duration and
intensity of training, age, gender, race, size, and genetics, has vastly improved our
ability to screen for subclinical cardiac disease and differentiate normal physiology
from pathology. It is essential for healthcare providers who screen and treat athletes
at all skill levels to have a firm grasp of the tenets of sports cardiology and readily
available reference data encompassing the key elements within this growing field.
The cumulative clinical experience gained from caring for athletes training and
competing with existing cardiac conditions has resulted in the rapid evolution of
recommendations guiding sporting participation and the recognition of the impor-
tance of shared decision-making. A contemporaneous challenge has been the devas-
tation wrought by the COVID-19 pandemic. Sport and health organizations now
confront significant challenges designing and implementing safe athlete return to
play (RTP) strategies. In this textbook, we will review the critical issues and data
surrounding concerns of potential cardiac sequelae of COVID-19, and their impact
on athlete screening and RTP plans, as the newest element in the field of sports
cardiology.
Finally, the field of sports cardiology has pushed the practicing cardiologist from
the clinical facilities to the sports training facilities where they must participate in
the acute evaluation and management of athletes in addition to provide guidance on
effective emergence action plans.
v
vi Preface
vii
viii Contents
ix
x Contributors
Thomas Roth, PhD Department of Sleep Medicine, Henry Ford Health System,
Detroit, MI, USA
John J. Ryan, MD Division of Cardiovascular Medicine, Department of Internal
Medicine, University of Utah, Salt Lake City, UT, USA
Elizabeth V. Saarel, MD Division of Pediatric Cardiology, St. Luke’s Health
System, Boise, ID, USA
Nishant P. Shah, MD Department of Cardiovascular Medicine, Cleveland Clinic,
Cleveland, OH, USA
Daichi Shimbo, MD The Columbia Hypertension Center, Columbia University
Irving Medical Center, New York, NY, USA
David Shipon, MD, FACC Thomas Jefferson University Hospital,
Philadelphia, PA, USA
Meeta Singh, MD Department of Sleep Medicine, Thomas Roth Sleep Disorders
Center, Henry Ford Health System, Detroit, MI, USA
Mohita Singh, MD Department of Medicine, Cardiology Division, Cardiac
Electrophysiology, UT Southwestern Medical Center, Dallas, TX, USA
Tamanna K. Singh, MD, FAAC Sports Cardiology Center, Heart, Vascular and
Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
John Symanski, MD Sports Cardiology Center, Hypertrophic Cardiomyopathy
Center, Sanger Heart & Vascular Institute, Atrium Health, Charlotte, NC, USA
Marc P. Waase, MD, PhD Division of Cardiology, Columbia University Irving
Medical Center, New York, NY, USA
Shayna Weinshel, BS, MS Department of Medicine, University of Central Florida,
Orlando, FL, USA
Brad Witbrodt, MD Emory Clinical Cardiovascular Research Institute,
Atlanta, GA, USA
Michael Workings, MD Department of Family Medicine, Henry Ford Health
System, Detroit, MI, USA
Kenneth G. Zahka, MD Department of Pediatric Cardiology, Cardiovascular
Medicine, Cleveland Clinic, Cleveland, OH, USA
Chapter 1
The Cardiovascular History
and Examination
Introduction
Given that the primary goal of the PPE is to promote the health and safety of the
athlete [1], the cardiovascular (CV) screening portion of the PPE is perhaps the
most essential piece of this assessment. The CV component aims to identify and
evaluate symptoms or exam findings that may lead to the diagnosis of underlying
J. DiFiori (*)
Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
e-mail: [email protected]
C. Asplund
Department of Orthopedics and Sports Medicine, Mayo Clinic, Minneapolis, MN, USA
J. C. Puffer
Division of Sports Medicine, Department of Family Medicine, David Geffen School of
Medicine at UCLA, Los Angeles, CA, USA
e-mail: [email protected]
cardiac conditions that could result in cardiac morbidity, sudden cardiac arrest, or
sudden cardiac death. The American College of Cardiology and the American Heart
Association state that “the principal objective of screening is to reduce the cardio-
vascular risks associated with organized sports and enhance the safety of athletic
participation; however, raising the suspicion of a cardiac abnormality on a standard
screening examination is only the first tier of recognition, after which subspecialty
referral for further diagnostic testing is generally necessary” [11].
Consensus statements and recommendations for the PPE include specific details
for the cardiac history and physical examination [1, 11–13]. Despite these published
standards, there remains a lack of consistency in their implementation [7–10].
Further, it is important to understand that there is debate about the ability of the CV
history and physical exam to detect significant CV conditions during PPEs.
However, it is well recognized that no screening algorithm is capable of detecting
all clinically relevant cardiac disorders [2, 12]. These important issues are beyond
the scope of this chapter and are discussed in detail in other sections of this
publication.
With these issues in mind, the goal of this chapter is to delineate the key features
of the CV history and physical examination of the PPE.
medicine. In other situations, it may be ideal for an athlete who has an ongoing
relationship with a personal physician to have that physician perform the screening
examination [1]. This may be the best approach for children and adolescents who
are participating in programs that do not have an identified team physician.
Cardiologists may be used to perform the screening CV history and exam, but they
are more commonly relied upon to evaluate concerning findings. In some cases, a
nurse practitioner or a physician assistant may perform the screening [1]. Regardless
of the certification of the clinician, it is critical that the individual performing the
CV history and exam has had clinical training in this component of the PPE, an
intimate knowledge of the nuances of CV screening in athletes, and the necessary
clinical experience to identify a potential concern in this population.
Once the screening date is set, the athletes (and if minors, their families) should
be notified well in advance. This will allow sufficient time to complete the CV his-
tory (especially if performed online) and obtain any pertinent documents related to
prior screening and/or records involving CV diagnoses and treatment. In cases
where athletes will have the PPE performed by a personal physician or provider, this
provides ample time to arrange the examination.
Finally, the planning should occur with the understanding that the history and/or
physical examination may raise suspicion for the presence of a cardiac condition
that then requires additional evaluation. In such cases, screening events that occur
immediately prior to the planned start of training could result in removal from par-
ticipation while further investigations are performed. To lessen the likelihood of an
athlete needing to be withheld from their training program for sports that have des-
ignated start periods (e.g., high school or collegiate sports), it is recommended that
exams occur several weeks prior to the anticipated start date for that sport. As men-
tioned above, communication with consultants in cardiology and radiology should
take place in advance so that they will be prepared to examine athletes who have had
a concern raised based upon the history and exam.
If the PPE is conducted in a location other than the office of the athlete’s personal
physician, the organizers should arrange a setting that ensures privacy, is comfort-
able for the athletes, and is conducive to maximizing the ability to perform the
examination. For CV screening of groups of athletes from a school, program, or
team, securing the use of patient examination areas in a medical facility is ideal. An
individual exam room is preferred for reasons of privacy and the ability to have
quiet space for auscultation. The use of gymnasiums, auditoriums, locker rooms,
and other non-private areas is not recommended. Attempting to create a level of
separation within a large room by using a “pipe and drape” setup is likewise not
recommended.
In order to conduct a thorough exam, an appropriate amount of time should be
allocated for each athlete being screened. The amount of time needed to conduct an
4 J. DiFiori et al.
exam for an individual athlete, the total number of athletes needing to be screened
in a given time period, and the number of available examination rooms should be
determined in advance. This will indicate the number of examiners needed and the
total time required to perform a complete CV history and exam for a group of
athletes.
Other factors to consider include whether an online questionnaire was completed
in advance or a hard copy was completed on site. Online questionnaires must be
completed on a secure website, and then viewed within an electronic medical record,
or uploaded or printed and scanned to become part of the athlete’s official medical
record. If an online questionnaire or hard copy is to be completed on site, a private
space should be provided for the athlete to complete the document. In either case,
the athlete (or parent/guardian) must sign and date the questionnaire attesting to its
accuracy.
Although uncommon, an athlete (or his parent/guardian) may withhold or mis-
represent important medical information due to a concern that providing such infor-
mation could jeopardize medical clearance for sport participation. Thus, it is
important that the physician confirm that the acknowledgment is signed. In some
cases, an athlete may view the history and exam as an unnecessary burden or “rub-
ber stamp” process prior to the beginning of training. In these circumstances, an
athlete may choose to select negative responses throughout the questionnaire in
order to expedite the screening. This leads to substandard screening that could place
the athlete at risk. In order to recognize if an athlete is not reading and responding
to each question individually, and simply checking the “no column,” it may be help-
ful to embed a question that requires a positive response. An example of such a
question is “have you ever played a competitive sport?” Should the clinician feel
that the athlete is providing inaccurate information, they should proceed to perform
the history using a primary “interview” format, asking each question and clarifying
each response verbally.
A detailed history and physical examination have been the cornerstones of the pre-
participation evaluation of athletes in the United States for decades. However, given
the high degree of variability and lack of standardization of cardiovascular assess-
ment, the American Heart Association (AHA) convened an expert panel in 1996 to
make recommendations for a standardized process for this component of the prepar-
ticipation evaluation [14] with an updated review of the recommendations in 2007
and 2014 [2, 11]. The result of this work was the development of a 14-point evalu-
ation, which has now been widely embraced for the cardiovascular preparticipation
screening of athletes (Table 1.1).
Perhaps the most important component of this 14-point evaluation is the personal
and family history, since athletes with underlying yet undetected cardiovascular
disease may present with warning signs (e.g., syncope or chest pain during exercise)
Other documents randomly have
different content
The helmet Echinites, like the preceding, have given rise to
innumerable siliceous casts, which are found associated with those of
other forms in the Drift, on the ploughed lands, and among the shingle
on the sea-shore; they are often placed as ornaments on the mantel-
shelves of the cottagers. A flint cast of an Ananchyte, in which the
plates were partially separated, is represented Lign. 103, fig. 1. The
shells are sometimes filled with pyrites; and occasionally are found
partially empty, with crystals of calc-spar symmetrically arranged on
the inside of the shell, parallel with the rows of ambulacral pores. Lign.
103, fig. 3, is a remarkable example, in which flint occupies the base
of the shell, while the upper surface is lined with crystals of calcareous
spar.
Our limits will not allow of a more extended notice of the fossil
Echinidæ. The student should consult the Memoirs on the genera, now
in course of publication at the Government School of Mines, by
Professor Edward Forbes; the plates are exquisite, as works of art, and
the descriptions all that can be desired.
Mr. Dixon's work contains three excellent plates of cretaceous
Echinites. Several chalk species are figured in my Foss. South Down.
The numerous coloured figures of fossil sea-urchins in the Pictorial
Atlas of Organic Remains, have already been mentioned.
Geological Distribution of Echinites.—No vestiges of this order of
radiata have been discovered in the Silurian deposits: the earliest
known occurrence of any type is in the Carboniferous formation. The
most ancient Echinidæ, according to the present state of our
knowledge, are the Cidares, in the modified form previously noticed,—
Archæocidaridæ (ante, p. 322.).
In the Trias another type appears, Hemicidaris, which holds an
intermediate place between the Cidarites properly so called and the
Diadema.
In the Oolite, and Jurassic formations, numerous forms are for the
first time met with, constituting the genera Echinus, Clypeus, Disaster,
Holectypus, Diadema, Nucleolites, &c.
The Cretaceous seas swarmed with echini belonging to genera of
which no traces have been found in earlier rocks; viz. Holaster, Salenia,
Micraster, Salerites, Discoidea, Ananchytes, Cassidulus, &c.
In the Tertiary formations, Spatangus, Scutella, Clypeaster, and
other new genera appear, and many of the ancient ones are absent; or
at least have not been observed. Of the genera printed above in italics,
no living species are known.
On collecting and developing fossil ON COLLECTING FOSSIL ECHINODERMAT
It is scarcely more than a hundred and twenty years ago, that the
existence of this numerous order of microzoa was first made known to
naturalists by Beccarius, who detected a considerable number of
species in the sand on the shores of the Adriatic. But the structure of
the animals that secreted these shells is a discovery of comparatively
modern date. The early collectors classed these microscopic bodies
with the shells of true mollusca; and even M. D'Orbigny, whose
elaborate researches justly constitute him a high authority in this
branch of natural history, in his first memoir, in 1825, described the
involuted discoidal forms as Cephalopoda. This error was corrected by
the investigations of M. Dujardin, who in 1835 satisfactorily
demonstrated that the Foraminifera are animals of the most simple
structure, and entirely separated by their organization from the
Mollusca.
But the true nature of this class is so little understood by British
collectors of fossil shells,—of course I mean the uninitiated, and the
amateur naturalist, for whose use these unpretending pages are
designed,—that in order to invest the study of the fossil species with
the interest which a knowledge of the structure and economy of the
living originals can alone impart, I must give a history of the recent
forms somewhat in detail, taking M. D'Orbigny as my chief authority.
[310]
The specimens figured in Lign. 110 are from the limestone that
forms the foundation rock of the Great Pyramid of Egypt, and of which
that structure is in great part composed. Strabo alludes to the
Nummulites of the Pyramids, as lentils which had been scattered about
by the artificers employed on those stupendous monuments, and
become stone.[315] Silicified masses of Nummulites are occasionally
met with; polished slices of such specimens are richly figured by the
sections of the inclosed Foraminifera.
[315] An interesting fact was communicated to me by a friend
who lately descended the Nile; the Nummulitic limestone rocks are
in some parts of the course of the river washed into the stream, and
becoming disintegrated, the Nummulites are set free, and re-
deposited in the recent mud of the Nile.
The Nummulitic limestones are of the Eocene or ancient. Tertiary
epoch, as the labours of Sir Roderick Murchison in the Alps, Apennines,
and Carpathians first established: Nummulites are unknown in the
Secondary formations.[316]
[316] Geol. Journal, vol. v.
NODOSARIA. LITUOL
Nodosaria. Lign. 111, fig. 5.—Straight, elongated cells placed end to
end, separated by constrictions; the last formed cell has a round
central aperture. Several beautiful species abound in the Chalk;
specimens often occur adhering to the surface of the flint nodules.
Nodosariæ are abundant in tertiary deposits. Mr. Walter Mantell
discovered Foraminifera of this genus in the blue clay of Kakaunui, in
New Zealand.
Cristellaria. Lign. 109, fig. 4.—The shell is in the form of a
compressed Nautilus; it has a single aperture, which is situated at the
angle of the keel; the cells are oblique.
This genus comprises seventy fossil species, which occur in the
Lias, Oolite, and Chalk. Living species are abundant in almost every
sea.
Flabellina. Lign. 111, fig. 4a.—In a young state, this shell, like the
preceding, resembles that of a Nautilus, and the cells are oblique; but
in the adult, are of a zigzag (chevron) form. It has a single round
aperture. Fig. 4a shows a young individual, seen in profile; fig. 4b a
lateral view, exhibiting the obliquity of the cells.
Species of Flabellina are often found in cretaceous strata. The
genus is not known in a recent state.
Polystomella.—In its general form this genus resembles the other
nautiloid shells above described, but its structure differs essentially; for
there are several apertures along the side of the shell, as well as the
opening in the last segment. The cells are simple, and each is a single
cavity. The figures and details of structure, given by Professor
Williamson, must be referred to, for an insight into the organization of
this beautiful and complicated type of Foraminifera.[319] One species of
Polystomella is said to occur in the Chalk; I have not detected this
genus in our cretaceous deposits. Recent species swarm in our seas;
and may be easily obtained from the mud and sand on the shores at
Brighton.[320]
[319] Trans. Microscop. Society, vol. ii.
[320] Mr. Poulton has specimens of the shells, and the bodies of
the animals deprived of the shell, mounted for the microscope.
Lituola. Lign. 111, fig. 3a.—In a young state the shell is nautiloid,
as in fig. 3b, 3d; but becomes produced by age, and assumes a
crosier-like form, as in fig. 3a. The cells are filled with a porous
testaceous tissue, as shown in figs. 3b, 3c; which also illustrate the
foraminiferous character of the shells in this class of animals; for both
the external testaceous covering, and the septa of the cells, exhibit
perforations.[321]
[321] The perforations are omitted, by mistake, in the figure of
the adult shell, fig. 3a.
Lign. 112. Spirolinites in Flint.
Chalk. Sussex.
(By the late Marquis of Northampton.)
The specimens are only sections of the shells
Imbedded in flint, and seen as opaque objects with a
lens of moderate power. The small figures denote the
size of the originals.
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