Cardiac evaluation of young athletes: Time for a risk-based approach?

Pre-participation cardiovascular screening (PPCS) is recommended by several scientific and sporting organizations on the premise that early detection of cardiac disease provides a platform for individualized risk assessment and management; which has been proven to lower mortality rates for certain conditions associated with sudden cardiac arrest (SCA) and sudden cardiac death (SCD). What constitutes the most effective strategy for PPCS of young athletes remains a topic of considerable debate. The addition of the electrocardiogram (ECG) to the medical history and physical examination undoubtedly enhances early detection of disease, which meets the primary objective of PPCS. The benefit of enhanced sensitivity must be carefully balanced against the risk of potential harm through increased false-positive findings, costly downstream investigations, and unnecessary restriction/disqualification from competitive sports. To mitigate this risk, it is essential that ECG-based PPCS programs are implemented by institutions with a strong infrastructure and by physicians appropriately trained in modern ECG standards with adequate cardiology resources to guide downstream investigations. While PPCS is compulsory for most competitive athletes, the current debate surrounding ECG-based programs exists in a binary form; whereby ECG screening is mandated for all competitive athletes or none at all. This polarized approach fails to consider individualized patient risk and the available sports cardiology resources. The limitations of a uniform approach are highlighted by evolving data, which suggest that athletes display a differential risk profile for SCA/SCD, which is influenced by age, sex, ethnicity, sporting discipline, and standard of play. Evaluation of the etiology of SCA/SCD within high-risk populations reveals a disproportionately higher prevalence of ECG-detectable conditions. Selective ECG screening using a risk-based approach may, therefore, offer a more cost-effective and feasible approach to PPCS in the setting of limited sports cardiology resources, although this approach is not without important ethical considerations

Pre-Participation Cardiac Screening: consideration for Young Athletes

This article is the first of two focusing on the utility and evidence base for pre-participation cardiac screening in competitive athletic populations. The second article will focus on the diagnostic value of different screening modalities used in the large-scale screening of athletic populations. The current article, however, focuses on the incidence of sudden cardiac death (SCD) in young athletic populations and goes on to consider the effectiveness of cardiac screening programmes for reducing the risk of SCD. Cardiac screening in athletic populations is problematic as it may be difficult to distinguish between physiological adaptations resulting from a specific exercise training stimulus and pathological conditions. Different types of chronic exercise training can induce eccentric or concentric myocardial hypertrophy, which may mimic pathological conditions. The final section discusses some of the practical issues that a clinician may face when needing to advise a young athlete to either stop or modify his/her habitual patterns of physical activity including future exercise considerations

Sudden Cardiac Death in Athletes - What Can be Done?

Sudden death in athletes is a rare event but brings with it an impact that goes beyond sport. There are many causes of sudden death during exercise. While the responsibility of preventing or treating them lays with us physicians, preparticipation screening is largely ineffective and impractical. Definitive, large scale prospective research is required in order to design the most cost-effective system for screening of athletes. In the meanwhile rapid access to defibrillators by trained personnel remains the best possible approach to abort sudden death

Do preparticipation clinical exams reduce morbidity and mortality for athletes?

Though clinical preparticipation exams (PPE) are recommended by experts and required in most states, we found no medium- or better-quality evidence that demonstrates they reduce mortality or morbidity. PPEs detect only a very small percentage of cardiac abnormalities among athletes who subsequently die suddenly (strength of recommendation [SOR]: C, case series study). PPEs are also unable to accurately identify athletes with exercise-induced bronchospasm (SOR: C, small cross-sectional study) and are poorly predictive of which athletes are at increased risk of orthopedic injuries (SOR: C, cross-sectional study)

Part 1: potential dangers of extreme endurance exercise: how much is too much? Part 2: screening of school-age athletes

The question is not whether exercise is or isn’t one of the very best strategies for improving quality of life, cardiovascular (CV) health and longevity—it is. And there is no debate as to whether or not strenuous high-intensity endurance training produces an amazingly efficient, compliant, and powerful pump—it does. The essence of the controversy centers on what exactly is the ideal pattern of long-term physical activity (PA) for conferring robust and enduring CV health, while also optimizing life expectancy. With that goal in mind, this review will focus on the question: “Is more always better when it comes to exercise?” And if a dose–response curve exists for the therapeutic effects of PA, where is the upper threshold at which point further training begins to detract from the health and longevity benefits noted with moderate exercise? The emerging picture from the cumulative data on this hotly debated topic is that moderate exercise appears to be the sweet spot for bestowing lasting CV health and longevity. However, the specific definition of moderate in this context is not clear yet

High School and College Athletes Should Be Required to Undergo Pre-Participation Cardiac Screening Prior to Participation in Competitive Sports

Sudden Cardiac Arrest (SCA) is the leading cause of death in young athletes. Most of these athletes are unaware they have a condition that puts them at risk. In addition it is estimated that approximately 1 in 220,000 young athletes experience Sudden Cardiac Death (SCD) each year, although, these numbers are not truly reliable because there is no national mandatory reporting system in the United States. My paper argues that all high school and college athletes should be required to undergo pre-participation cardiac screening (i.e. an ECG and extensive family health history) as a part of a required physical exam to identify student-athletes at risk of SCD. Studies in Italy, where pre-participation screening is mandatory, and at some US universities in the US where collegiate athletes received cardiovascular screening prior to sports participation suggest that including ECG improved overall sensitivity, mass ECG screening is achievable and cost-effective, and that screening lowered the death rates in the population screened. Some critics believe that the cost of the screening is not cost-effective, but others believe the costs are reasonable; some hospitals in the US now provide student athletes with free ECG screening, or at reduced cost. ECG screening will save lives, and should not be discounted as being too costly. Every parent who has a child participating in school athletics should be informed of the risks, and be given the opportunity to have their child tested. Saving someone’s child is worth the cost of testing. My interest in this topic comes from my family’s personal experience with a student athlete who experienced a cardiac event characterized by shortness of breath and dizziness while playing in a collegiate baseball game. Our son, Neil, was a healthy 21-year-old student athlete who had participated in organized sports since he was seven years old. His event was initially diagnosed as a panic attack, but after he underwent a series of cardiac testing, including an ECG that showed an abnormality, he was diagnosed with Arrhythmogenic Right Ventricular Dysplasia (ARVD), a progressive heart disease. We have no family history to link to Neil’s disease, and we had no idea he was at risk. Today Neil lives with an implantable cardioverter defibrillator (ICD), takes anti-arrhythmic medication, and no longer participates in team sports. Neil is one of the lucky ones who survived, and his survival impelled me to get involved in my community to promote awareness about sudden cardiac arrest, and the importance of CPR training and the availability of automated external defibrillators (AEDs). Our experience also inspired me to research adding pre-participation cardiac screening for young athletes. If such a program had been instituted at his high school or college, Neil’s disease would have been diagnosed and treated, keeping him from being at risk during athletics

Stages of change profiles of offenders : exploring offenders' motivation to work on their offending problems : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Albany, New Zealand

Research has highlighted the importance of the stages of change (SoC) model (Prochaska, DiClemente, & Norcross, 1992) in assessing offenders’ motivation to work on their offending problems and as a guiding framework for selecting interventions. This thesis investigated the stages of change profiles in a group of general male offenders (N = 481) before and after a Short Motivational Programme (SMP), which is a combination of motivational interviewing and cognitive behavioural material. For the first aim, distinct homogenous stage profiles that reflected the stages of change were generated by subjecting offenders’ responses on the University of Rhode Island Change Assessment Scale (URICA; McConnaughy, DiClemente, Prochaska, & Velicer, 1989; McConnaughy, Prochaska, & Velicer, 1983) to hierarchical agglomerative cluster analysis. At pre-SMP, the Ambivalent, Non-Reflective Action, Precontemplation, Preparticipation and Participation profiles were generated. At post-SMP, the same profiles were generated with the exception of the Non-Reflective Action profile. These stage profiles were consistent with profiles elicited in previous studies, and mapped well onto the SoC model. The majority of offenders were in the precontemplation stage (represented by the Ambivalent, Non-Reflective Action and Precontemplation profiles), whereas a smaller proportion were in the preparation (represented by the Preparticipation profile) and action stages (represented by the Participation profile). For the second aim, stage profiles obtained at pre- and post-SMP were then used to investigate stage movement following the SMP, by constructing a stage-transition matrix. There was evidence for offenders with different stage profiles showing different responses to the SMP, whereby a comparatively larger proportion of offenders with the Non-Reflective Action, Preparticipation and Participation profiles appeared to continue working on their offending problems or progressed to a more highly-motivated stage, compared to offenders with the Ambivalent and Precontemplation profiles. These findings indicated that there is a need for a more flexible approach to motivational interviewing to more effectively facilitate offenders’ motivation to work on their offending problems. Men with the Ambivalent and Precontemplation profiles may require further help to resolve their ambivalence towards changing, before cognitive behavioural content is introduced. For the third aim, stage profiles at pre- and post-SMP, and stage movements were examined as predictors of recidivism in three separate logistic regression analyses, controlling for salient demographic and risk variables. Men with profiles representing the precontemplation stage were less likely to reoffend compared to men with the Preparticipation profile. This study also found that men who remained in the precontemplation stage were less likely to reoffend than those who remained in the preparation and action stages. These results suggested that men with the Preparticipation profile (which represents the preparation stage) may still be experiencing some ambivalence towards changing their behaviour, thus, impacting on their readiness to change their offending behaviour. It also raised the question on whether men with the Participation profile (which represents the action stage) may be more externally motivated to change their behaviour resulting in less lasting change upon the completion of their sentences. These findings contributed to a more in-depth understanding of offenders’ stages of change, and demonstrated that these stages have important clinical implications in guiding assessment of offenders’ motivation to work on their offending problems, and tailoring rehabilitation programmes to increase treatment responsivity and improve outcomes

Neurocardiogenic syncope in the intercollegiate athlete : an examination of problems and solutions : an honors thesis (HONRS 499)

Neurocardiogenic Syncope, a condition common in young people, is becoming more recognized in the Athletic Training profession. The purpose of this discussion is to delve into this condition and provide basic knowledge to help the Athletic Trainer manage athletes with this condition. The information will be divided into two sections. First, the examination will describe Neurocardiogenic Syncope, its presentation, anatomical and physiological causes, warning signs and techniques for diagnosis. It will also examine the decreased quality of both daily living and performance due to this condition. The last part of the first section will attempt to summarize numerous treatment options available to the athlete with Neurocardiogenic Syncope. The second section will present a case study of an intercollegiate athlete with this condition and its effect on the athlete's performance and overall well-being. It is hoped that this examination can bring to light a new and challenging condition that is becoming more frequently recognized in the Athletic Training profession and to offer suggestions to make the problem more manageable. It is also my goal that the information in this paper can be used to improve the quality of health care that Athletic Trainers can provide for the athlete with Neurocardiogenic Syncope.Honors CollegeThesis (B.S.

Exercise and hypertrophic cardiomyopathy: Two incompatible entities?

A greater understanding of the pathogenic mechanisms underpinning hypertrophic cardiomyopathy (HCM) has translated to improved medical care and better survival of affected individuals. Historically these patients were considered to be at high risk of sudden cardiac death (SCD) during exercise; therefore, exercise recommendations were highly conservative and promoted a sedentary life style. There is emerging evidence that suggests that exercise in HCM has a favorable effect on cardiovascular remodeling and moderate exercise programs have not raised any safety concerns. Furthermore, individuals with HCM have a similar burden of atherosclerotic risk factors as the general population in whom exercise has been associated with a reduction in myocardial infarction, stroke, and heart failure, especially among those with a high-risk burden. Small studies revealed that athletes who choose to continue with regular competition do not demonstrate adverse outcomes when compared to those who discontinue sport, and active individuals implanted with an implantable cardioverter defibrillator do not have an increased risk of appropriate shocks or other adverse events. The recently published exercise recommendations from the European Association for Preventative Cardiology account for more contemporary evidence and adopt a more liberal stance regarding competitive and high intensity sport in individuals with low-risk HCM. This review addresses the issue of exercise in individuals with HCM, and explores current evidence supporting safety of exercise in HCM, potential caveats, and areas of further research