Five Simple Rules for Evaluating Cardiac Conditions in Athletes
Within the field of sports cardiology, Dr. Paul D. Thompson, Emeritus Chief of Cardiology at Hartford Hospital, is considered one of the original thought leaders and true 'pioneers' of this sub-specialty within cardiology. After the 2019 Care of the Athletic Heart, Dr. Eugene Chung and the course directors of Athletic Heart, Drs. Matt Martinez and Jonathan Kim, asked Dr. Thompson to summarize some of his most well-known sports cardiology clinical practice philosophies, otherwise known as his "Thompsonisms," for ACC.org. The following are his "Top 5." Enjoy!
- "What brought him/her here?" This is the first question I ask our fellows in sports cardiology clinic. The answer is usually amusing: "His mother" or "He came by car" but what I really want to know is whether or not symptoms prompted the visit. I have far more concern when symptoms prompted the visit. I have much less concern when the visit was prompted by an abnormality found in screening an otherwise healthy athlete. This simple distinction will set the tone as to how aggressive I will be in my evaluation.
- "You had me at hello." That is Tom Cruise's classic line in the 1996 movie Jerry Maguire. Cruise, as Jerry, had returned to his girlfriend, Dorothy Boyd, played by Renee Zellweger, and delivers a soliloquy about how much he loves her and why she should take him back. Zellweger listens a bit, but then tells him, "Shut up. Shut up. You had me at hello."
The same principal applies to evaluating syncope. Whether or not the syncopal episode is important can often be determined in the first few minutes of the history, just after "Hello."
Did the syncope occur right after, or during, exercise? Right after vigorous exercise is usually simply post-exertional collapse. Exercise dilates both the arterial and venous systems of the exercising limbs. That vasodilatation persists after exercise, but the cessation of muscle contraction eliminates the muscles' pumping venous blood back to the central circulation. Consequently, syncope soon after exercise is almost always benign, but syncope actually during exertion is never a good thing and requires a full-press workup.
Was there a prodrome? How did the athlete feel just before passing out? Athletes by virtue of their sinus bradycardia and large venous capacity are prone to vasovagal syncope, which often is preceded by nausea, a feeling of warmth, or other signs. So, the presence of such prodromal symptoms is reassuring. Sudden syncope without a prodrome is worrisome.
How did the athlete feel immediately after the episode? Some confusion as to what happened, and a gradual return of the senses often with hearing returning before vision, suggest vasovagal syncope. Athletes with vasovagal syncope often take some time to come back to normal. In contrast, the athlete who wakes up feeling fine and wants to get back into the game immediately is much more concerning since that suggests cardiac syncope.
Finally, does the athlete, or patient, have a history of cardiac disease? Syncope in someone with prior disease is always more concerning. I once worked in an ER with someone whose first question to almost every patient was, "Have you ever had this before?" If the patient said, "Yes", his reply was, "Well, you got it again." And he was usually right. It's the same with syncope in patients with known heart disease; the underlying heart disease is often the root cause and that is almost always a bad sign since it implies cardiac syncope.
- "The athlete's swoon syndrome" is a term I coined 30 years ago. It refers to a near-syncopal episode with the following clinical scenario:
The patient is usually a young female athlete who is highly successful… in everything, but especially in school and in long distance running. She comes from a family with high expectations for her to succeed. The father often has the highest expectations and dominates the interview with the family. The athlete usually wins her event in dual track or cross country meets, but collapses in conference or state meets when she is not winning. The collapse usually occurs within sight of the finish. The patient is incoherent and only semi-responsive to questions but not really unconscious. The event is dramatic. Often the athlete has gone out to fast, with the race leaders, a technique that worked well in smaller events.
Management is difficult. The athlete is under great pressure to be successful, and it is often easier to have a medical excuse for failure than to admit you cannot meet everyone's expectations. I test these athletes extensively with an ECG, a stress test often with gas exchange measurements, and an echocardiogram. I test largely for reassurance to the family because as in #2 above, I often think I know the diagnosis early on, but I also test to make sure that I am not missing something and because any discussion of the athlete being under too much stress will be adamantly denied, usually by the father, if medical causes are not excluded. It is important during this work-up to avoid "diagnostic creep", which is described below. Treatment includes reassuring the family and patient that there is nothing wrong medically, that this pattern of collapse often represents a physiologic reaction to the stress of high personal expectations, and that the best approach is to make sure the athlete is well rested and not over trained prior to big events and that she starts more slowly in these races.
So, why daughters and not sons? I really don't know and don't think I am a total sexist, but I suspect the sons tell overbearing fathers to "buzz off", whereas the daughters do not. That was certainly the pattern in my family of twin daughters and two sons.
- "Avoid diagnostic creep." Diagnostic creep refers to the situation where no one will take a stand and say, "This athlete is normal and requires absolutely no further work-up." Diagnostic creep usually begins with a screening, borderline ECG, read as abnormal by the computer. The clinician orders an echocardiogram, which has some slight abnormality not related to the ECG abnormality. This leads to a cardiac MR, which also has a borderline abnormality of some sort, but this abnormality is also not related to the ECG or to the echo finding. Nothing is ever absolutely abnormal, and the athlete feels fine, but no one will stop the parade. Someone has to review the history, re-read the tests, and make a decision as to normal or abnormal. That decision has to be definitively provided to the patient and family. Only if there is some definite abnormality should the athlete and family be subjected to later testing because the family has been made to worry and requires reassurance. In my experience, when clinicians creep from one borderline abnormality to another, unrelated, borderline abnormality, the athlete is almost always normal.
- The "I gotta sleep too" rule. People who do not evaluate athletes do not realize the tough decisions we make. The easiest approach to any athlete with heart disease is to tell them, "Go to bed… alone", but the athlete and family want to continue with sports and you as a consultant must make decisions. We can never be certain that our decisions are right and that creates anxiety for the clinician. I decided long ago that if I was not certain what to do and would worry about it, that I would either perform additional testing, send the athlete elsewhere for another opinion, or prohibit participation. I call that approach, not tolerating uncertainty or ambiguity, the "I gotta sleep too" rule.
Keywords: Sports, Athletes, Syncope, Vasovagal, Exercise Test, Vasodilation, Prodromal Symptoms, Bradycardia, Physical Exertion, Syncope, Anxiety, Muscle Contraction, Electrocardiography
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