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Auscultate the chest with patients in the standing position during preparticipation examinations (PPEs)

Auscultate the chest with patients in the standing position during preparticipation examinations (PPEs): Excerpt from Avoiding Common Pediatric Errors

Author: Sonya Burroughs, MD

What to Do - Gather Appropriate Data

Preparticipation sports screening is an essential yet difficult tool used for athletic clearance. This purpose of the screening is to identify those at risk for sudden cardiac death and to enlist restrictions for those with known factors that predispose the athlete to sudden death. Despite its importance, the ability of this screening to identify those at risk varies and is questionable. The thoroughness and expertise of clinicians vary, and this factor understandably affects the screening process and overall findings. Only 3% of trained athletes who experienced sudden cardiac death were previously suspected of having a cardiovascular abnormality during the preparticipation sportsexam. Thankfully, sudden cardiovasculardeathis arare phenomenon, affecting 1 in 200,000 to 300,000 individual student athletes per academic year. The risk for sudden death in young athletes with cardiovascular disease is 2.5 times higher than in nonathletes. In the United States, sudden cardiac death most commonly occurs with basketball and football. Males account for 90% of the cases.

The medical history is the most important aspect of the cardiovascular PPE. It should focus on the presence of symptoms such as: near-syncope, syncope, dizziness, chest pain, chest tightness, and fatigue. Medication history, including questions regarding illicit and performance-enhancing drug use, is extremely important. The history should also elicit information concerning Kawasaki disease, rheumatic fever, myocarditis, arrhythmias, hypertension, congenital heart disease, and heart murmurs. A history of seizures or near-drowning may indicate long QT syndrome. Pertinent findings in the family history include: congenital heart disease, long QT syndrome, Marfan syndrome, and cardiomyopathy.

Table 55.1 Red Flags in the History or Physical Examination
• Syncope or near-syncope on exertion
• Chest pain/discomfort on exertion
• Palpitations at rest
• Excessive shortness of breath or fatigue with activities
• Family history of Marfan syndrome, cardiomyopathy, long QT syndrome, or clinically significant arrhythmias
• Family history of premature, sudden death
• Irregular heart rhythm
• Weak or delayed femoral pulses
• Fixed, split second heart sound
• Any systolic murmur graded 3/6 or greater
• Any diastolic murmur
• Stigmata of Marfan syndrome
• Chest pain in Turner syndrome

The physical exam of the PPE begins with the vital signs. Blood pressure and pulse must be compared with age-specific norms. If hypertension is present (blood pressure >90th percentile for age, height, and sex), a fourextremitybloodpressureiswarranted.Thegeneralexaminationshouldfocus on looking for features suggestive of Marfan syndrome (pectus deformity, arm span greater than height, kyphoscoliosis, and arachnodactyly). When examining the heart, one should focus on heart sounds, and the presence of clicks and murmurs. The chest should be auscultated while the patient is standing and supine. The standing position accentuates the dynamic obstruction murmur of HCM. The abdominal exam should focus on detecting organomegaly, and femoral pulses must be assessed as a screening tool for aortic coarctation. Table 55.1 provides several "red flags" for the preparticipation history and physical exam.

These flags should prompt a pediatric cardiology consultation. Approximately 75% of all sudden deaths are due to cardiovascular disease; HCM is the most common cause.

HCM has an autosomal dominant inheritance pattern, with a prevalence of approximately 0.2% of the general population. It is characterized by an asymmetrically thickened left ventricular wall (>=12 mm). It leads to impaired perfusion of the myocardium because of the thickened wall. Perfusion is worst with elevated heart rates. It is often clinically silent and presents with sudden cardiac death. Features that may raise suspicion for this condition include heart murmur, family history, abnormal electrocardiogram(ECG) tracing,or symptoms ofleft ventricular outflow obstruction. Other cardiac conditions leading to sudden death include congenital coronary artery anomalies, congenital long QT syndrome, Marfan syndrome, and commotio cordis. Table 55.2 provides several absolute contraindications for sports participation.

Table 55.2 Absolute Contraindications to Sports Participation
• Pulmonary vascular disease with cyanosis and large right-to-left shunt
• Severe pulmonary hypertension
• Severe aortic stenosis or regurgitation
• Severe mitral stenosis or regurgitation
• Cardiomyopathies
• Vascular form of Ehlers-Danlos syndrome
• Coronary anomalies of wrong sinus origin
• Catecholaminergic polymorphic ventricular tachycardia
• Acute phase of pericarditis
• Acute phase of myocarditis (at least 6 mo)
• Acute phase of Kawasaki disease (at least 8 wk)
mo, month; wk, week.

Suggested Readings

Cava JR, Danduran MJ, Fedderly RT, et al. Exercise recommendations and risk factors for sudden cardiac death. Pediatr Clin North Am. 2004;51:1401–1420.
Singh A, Silberbach M. Consultation with the specialist: cardiovascular preparticipation sports screening. Pediatr Rev. 2006;27:418–424.

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Book Source Details

• Book Title: Avoiding Common Pediatric Errors
• Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
• Year of Publication: 2008
• Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

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More About This Book: Title: Avoiding Common Pediatric Errors Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7489-6

 » Next page: Do not use chest physiotherapy (CPT) in bronchiolitis, it is not helpful (Avoiding Common Pediatric Errors)

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