Case

A fourteen year old boy comes to your office for a physical exam prior to entering high school. He is planning to play soccer. What are the important areas to cover in your history and physical exam? 

Approximately 50 young athletes die suddenly each year. Sudden death in athletes is defined as a cardiac arrest up to 6 hours after initial onset of symptoms in an individual who has not previously been recognized to have cardiovascular disease. It is estimated that 5/100,000 children have an underlying condition that makes them vulnerable to sudden death.

The American Heart Association recommends a pre-participation physical every two years by a healthcare worker who is able to obtain a complete cardiovascular history, physical exam, and recognize heart disease. 

The physical exam should be done in a quiet area and the parent should be present. A thorough history and review of systems is important.

Pre-participation questions:

1. Has there been any fainting or syncope associated with exercise?
2. Has there been any family history of death in members less than 40 years old other than by accident?
3. Any history of chest pain with or without exercise?
4. Any history of shortness of breath?
5. Palpitations?
6. History of rheumatic fever, hypertension, or Kawasaki's disease?
7. Physical exam should include blood pressure, heart rate, palpation of pulses, and chest and heart auscultation

Conditions associated with sudden unexpected death

1. Hypertrophic Cardiomyopathy
1. there is increased cardiac muscle mass without heart dilatation and there is a filling defect. There may be impedance to outflow and the increased muscle mass may act as an arrhythmogenic focus.
2. Symptoms-dyspnea, syncope, angina,seizures
3. may have harsh systolic murmur
4. may have EKG and ECHO changes
2. Coronary artery abnormalities
1. Usually an aberrant origin. Physical exam normal
3. History of Kawasaki's Disease
1. If there have been no coronary artery changes or patient has resolution of coronary artery disease, patient should be cleared for competition.
4. Myocarditis
1. Usually have a history of being ill including CHF
2. Sudden deaths probably related to conduction system inflammation.
5. Marfan's Syndrome
1. Autosomal dominant
2. Pectus deformities, > 95% for height, long spindly fingers, ectopic lens, high palate, kypho scoliosis, inguinal hernias. Should see cardiologist.
6. Mitral Valve Prolapse
1. If there are cardiac symptoms, should see cardiologist
7. Arrhythmias
1. sinus node disturbance
2. WPW
3. Exercise induced ventricular ectopy
4. Prolonged QT -high risk for ventricular arrhythmia (torsades de pointes)
1. Jervell-Lange-Nielsen syndrome associated with congenital hearing loss(auto dom)
2. Romano Ward syndrome (autosomal recessive)
8. Atherosclerotic coronary heart disease 
1. Family history of hyperlipidemias should be discussed

1. Berger S. Dhala A and Friedberg DZ. Sudden Cardiac Death in Infants, Children and Adolescents. Pediatric Clinics of North America. 1999; 46(2):221-234.
2. McCaffrey, FM, Braden, MC, Strong WB. Sudden Cardiac Death in Young Athletes. AJDC Vol 145, February 1991
3. Van Camp, Steven P. Sudden Death. Clinics in Sports Medicine Vol 11 Number 2 April 1992
4. Braunwald Eugend.  Hypertrophic Cardiomyopathy-The Benefits of a Multidisciplinary Approach NEJM Vol. 347 No. 17 pg.1306 October 24, 2002
5. Maron B.J. Sudden Death in Young Athletes. NEJM September 11, 2003 Vol 349 No. 11 pg 1064
6. NishimuraR. Holmes D. Hypertrophic Obstructive Cardiomyopathy NEJM 350:13;1320 March 25, 2004
7. Case Records off the Massachusettes General Hospital.  NEJM August 25, 2005
8. Ellison Alison, et al. Preventing-with the goal of eradicating- sudden cardiac death in children.  Contemporaray Pediatrics October 2005