Shared decision making for participation in elite athletes with cardiovascular conditions. Where are we now?

Sudden Cardiac Death is a leading medical cause of death in athletes of all ages. Recently there has been a shift from an authoritarian approach to that of using a Shared Decision Making (SDM) model in eligibility decisions of athletes with cardiovascular decisions. SDM in elite athletics can be complex and collaboration amongst the athlete, family, physicians, athletic trainers, and institutional stakeholders is critical. SDM acknowledges the complexities of a collaboration between sports cardiologists bringing disease and sport-specific expertise, and team physicians, in complementary fashion to integrate medical knowledge, clinical uncertainty, athlete and family values, and institutional philosophies and risk tolerance.

COVID myocarditis in a collegiate athlete: Timeline and return to play.

Background: Studies in collegiate athletes have demonstrated a prevalence of cardiac involvement between 0.5 and 3 % after SARS-CoV-2 infection. When post-COVID cardiac involvement occurs in athletes, the ideal return to play timeline and many possible long-term sequela or complications are unknown. Case summary: A 20 yo female collegiate athlete tested positive for SARS-CoV-2 and underwent routine cardiac screening prior to her return to play (RTP). Evaluation demonstrated an elevated high-sensitivity troponin-I and an ECG showed some mild T wave changes. She had a normal transthoracic echocardiogram, and her Cardiac magnetic imaging (CMR) met Lake Louise Criteria for acute myocarditis. She was diagnosed with acute myocarditis and restricted from sports. CMR was repeated at 3.5 months after normalization of troponin I HS and demonstrated continued active inflammation. She continued to be restricted from exertion. A third CMR was obtained at 6.5 months and showed resolution of active inflammation but a small area of fibrosis, and the remainder of her cardiac testing was normal. She was allowed to slowly progress back into sport and returned to competition at 9 months and successfully completed her season. Discussion: CMR is not typically repeated prior to RTP after a diagnosis of myocarditis in athletes, but in this case, repeat CMR at 3.5 months initially demonstrated continued active inflammation, and a second repeat CMR at 6.5 months demonstrated abnormal cardiac fibrosis. This may suggest utility in repeating CMR and raises questions about possible long-term implications of cardiac fibrosis once the acute inflammation of myocarditis has resolved.

COVID-19 prevalence and presenting symptoms in a college student population: A retrospective chart review.

Purpose: To describe the clinical presentation and prevalence of COVID-19 in a collegiate population at the time of initial recognition and testing. Methods: A retrospective chart review was performed of all students tested for COVID-19 at the University of Florida Student Health Care Center between March 9th and April 17th, 2020, comprising the first 6 weeks after spring break. Results: Twenty-five of 296 students (8.4%) tested positive for COVID-19. No significant differences were seen between positive and negative students regarding travel history or known exposures. Students who tested positive more commonly experienced fatigue, congestion, nausea, chest pain, anosmia, ageusia, anorexia, abdominal discomfort, and new problems sleeping over the course of illness. Conclusion: Initial symptoms unreliably clinically distinguish COVID-19 from other viral illnesses amongst college students. Providers should continue to have a low threshold for testing, especially as universities have seen large surges in cases related to students returning to campus.

Longitudinal cardiac remodeling in collegiate American football players as assessed by echocardiography during their collegiate career.

BACKGROUND: Studies on the longitudinal effects of intense physical training on cardiac remodeling are limited, especially in American collegiate football players. HYPOTHESIS: College-level American football training will result in remodeling in a pattern consistent of a sport with moderate static and dynamic demands with increases in both wall and chamber sizes. METHODS: We studied 85 American collegiate football players who underwent transthoracic echocardiogram (TTE) for asymptomatic or mild COVID-19-related illness and compared the changes in echo dimensions to their preparticipation screening TTE. Pre- and posttraining variables were compared using a paired t-test for normally distributed variables. RESULTS: Mean age was 19 years ± 1 and 61% of athletes were Black. Mean follow-up between TTEs was 21 ± 13 months. There was an increase in left atrial volume index (26.4 ± 5.5 to 32.8 ± 8.4 mL/m2 , p < .001), LV end diastolic diameter (5.13 ± 0.4 to 5.27 ± 0.4 cm, p = .003), basal RV diameter (3.28 ± 0.7 to 3.83 ± 0.5 cm, p = <.001), LV mass index (86.7 ± 15.3 to 90.1 ± 15.3, p = .015), and aortic root diameter (3.1 ± 0.4 to 3.2 ± 0.3 cm, p = .03) from pre- to posttraining, with a slightly greater magnitude in athletes with >2 years of training. Presence of left atrial enlargement (≥35 mL/m2 ) increased from 2.9% to 29% pre- to postparticipation in athletes with >2 years training. No significant changes in wall thickness, diastolic function, or right ventricular systolic function were observed. CONCLUSION: American football players college-level training was associated with increases in left and right ventricular chamber sizes, left atrial size, and aortic root diameter.

Relationship between arm span to height ratio, aortic root diameter, and systolic blood pressure in collegiate athletes.

Study objective: Sudden cardiac death is the most common cause of non-traumatic death in collegiate athletes. Marfan syndrome poses a risk for sudden cardiac death secondary to aortic root dilation leading to aortic dissection or rupture. Arm span to height ratio (ASHR) > 1.05 has been proposed as a screening tool for Marfan syndrome in pre-participation examinations (PPE) for collegiate athletes but limited data exists on the association between ASHR and aortic root diameter (ARD). This study examines the relationship between ASHR and ARD and assesses for predictors of ARD. Design: Retrospective chart review. Setting: National Collegiate Athletic Association Division I University. Participants: 793 athletes across thirteen sports between 2012 and 2022 evaluated with PPE and screening echocardiogram. Interventions: Not applicable. Main outcome measures: (1) Relationships between ASHR, SBP, BSA, and ARD amongst all athletes as well as stratified by ASHR >1.05 or ≤1.05 using univariate analysis. (2) Predictors of ARD using multivariate analysis using linear regression. Results: 143 athletes (18 %) had ASHRs > 1.05. Athletes with ASHR > 1.05 had higher ARD (2.99 cm) than athletes with ASHR ≤ 1.05 (2.85 cm). Weak correlations were noted between ASHR, ARD, and SBP. Multivariate analysis showed that BSA, male sex, and participation in swimming were predictors of ARD. ASHR was not predictive of ARD in regression analysis. Conclusions: These findings showed a tendency towards higher ARD in athletes with ASHR >1.05 but this observation was not statistically significant in multivariate analysis.

Blood pressure characteristics of collegiate female athletes: A call for more focused attention on young women's health.

Background: There is a paucity of data describing the association between blood pressure (BP) and cardiac remodeling in female collegiate athletes. Methods: This retrospective cohort review describes the BP characteristics and echocardiographic features of female collegiate athletes during preparticipation evaluation. We evaluated data from 329 female athletes at two National Collegiate Athletic Association (NCAA) Division I universities who underwent preparticipation evaluation that included medical history, physical examination, 12-lead electrocardiography, and 2-dimensional transthoracic echocardiography. BP values were divided into categories of normal, elevated, stage 1 and stage 2 hypertension based on 2017 ACC/AHA Guidelines. Left ventricular mass index was calculated and indexed to body surface area and further classified into concentric remodeling, concentric hypertrophy, and eccentric hypertrophy. Results: Normal BP values were noted in 184 (56%) female athletes, 88 (26.7%) had elevated BP and 57 (17.3%) had BP values indicating stage 1 or 2 hypertension. The majority of participants were white (n = 136, 73.9%). There was significantly higher body surface area in female athletes with higher BP values: 1.85 ± 0.18 in the stage 1 and 2 hypertension range, 1.82 ± 0.18 in the elevated BP range versus 1.73 ± 0.16 in the normal BP range (p < 0.001). Conclusions: There was a trend toward higher incidence of concentric and eccentric hypertrophy in athletes with higher than normal BP, however no statistical significance was noted. Elevated BP values were frequent among female collegiate athletes, and there is evidence of cardiac remodeling associated with higher BP values.

Preparticipation Cardiac Evaluation Findings in a Cohort of Collegiate Female Athletes.

Knowledge of cardiovascular adaptations in athletes has predominantly focused on males, with limited data available on females who compromise a substantial percentage of all collegiate athletes. A multicenter retrospective cohort review of preparticipation cardiovascular screening data of 329 National Collegiate Athletic Association Division I female athletes was performed. This included physical exams, electrocardiograms, and echocardiograms. Female athletes in class IB sports had elevated systolic blood pressure (p = 0.01). For electrocardiograms, 7 (2%) had abnormal findings: 100% were white; 6 of 7 (86%) participated in IIC sports. Black athletes had longer PR intervals (p ≤ 0.001), whereas white athletes had longer QTc and QRS durations (p = 0.02 and 0.01, respectively). Athletes in IC and IIC sports had longer QTc intervals (p = 0.01). For echocardiographic parameters, no differences were noted based on race. However, significant differences were noted based on classification of sport: athletes in class IC sports had higher left-atrial volume indexes and E/A ratios. Athletes in class IB and IIC had increased left-ventricular wall thicknesses and aortic root dimensions. In conclusion, among one of the largest cohorts of collegiate female athlete preparticipation cardiac screening data to date, significant differences in various parameters based on classification of sport and race were observed. These categorizations should be considered when interpreting cardiovascular screening in female collegiate athletes to improve screening and guide future research.

Sports Supplements: Pearls and Pitfalls.

Sports supplements can be generally divided into 3 categories: sports foods (foods/drinks containing macronutrients), medical supplements (vitamins/minerals used to treat deficiencies), and ergogenic supplements (used to benefit performance). Supplements are not regulated by the US Food and Drug Administration. They may get to the market and be contaminated with substances banned in sport or dangerous to health; and the contents may not contain what is listed on the label. When choosing to use a supplement, the safest practice is to choose a certified brand, which tests and authenticates label verification, quality, and lack of contaminants and banned substances for sport.

Preparticipation Evaluation.

Although the specific content has been recommended, debated, and extensively reviewed over the past several decades, the preparticipation evaluation (PPE) has become standard of care for athletes as they prepare for organized athletic participation. The PPE seeks to detect conditions that predispose the athlete to injury or limit full participation in certain activities. Of particular interest, underlying cardiovascular and musculoskeletal conditions are sought because they are frequently associated with mortality and morbidity in athletes.

Echocardiographic measurements of left ventricular end-diastolic diameter and interventricular septal diameter in collegiate football athletes at preparticipation evaluation referenced to body surface area.

BACKGROUND: Are borderline echocardiogram structural measurements due to physiological adaptation or pathology in college football players? The normal reference data are very limited in this population. We report left ventricular end-diastolic diameter (LVEDD) and interventricular septal diameter (IVSD) echocardiogram findings in college football athletes. METHODS AND RESULTS: A retrospective cohort review of preparticipation examination transthoracic echocardiogram measurements of LVEDD and IVSD from 375 American collegiate football athletes cleared for participation from the University of Florida in 2012-2017 and University of Georgia in 2010-2015 was performed.LVEDD and IVSD were analysed by field position (lineman, n=137; non-lineman, n=238), race (black, n=216; white, n=158) and body surface area (BSA) for associations. Values were compared with non-athlete norms, and collegiate football athlete-specific reference norm tables were created.Twenty-one (5.6%) athletes had LVEDD and 116 (31%) had IVSD measurements above the reference normal non-athlete values. Univariate analyses indicated that the lineman position and increasing BSA were associated with larger values for LVEDD and IVSD. Black race was associated with larger IVSD values, and white race was associated with larger LVEDD values. Player position correlated strongly with BSA (r>0.7); we created normal reference tables for LVEDD and IVSD, stratified by BSA group classification (low, average and high BSA). Proposed clinical cut-offs for normal and abnormal values are reported for raw echocardiograph metrics and BSA-indexed scores. CONCLUSIONS: A significant number of collegiate football athletes had LVEDD and IVSD values above non-athlete norms. BSA-specific normal values help clinicians interpret results for football athletes.

Echocardiographic measurements of aortic root diameter (ARD) in collegiate football Athletes at pre-participation evaluation.

BACKGROUND: Some remodelling of the aortic root may be expected to occur with exercise but can already vary due to different body sizes, compositions and genetic predispositions. Attributing the cause of borderline aortic root diameter (ARD) values to either physiological or pathological conditions in American college football athletes is difficult as there is very limited normal reference values in this population. Body surface area (BSA) specific norms are thought to be useful in other cardiac measurements of football athletes. METHODS: A retrospective cohort review of pre-participation examination (PPE) transthoracic echocardiogram data from collegiate football athletes was performed. ARD was analysed by field position (linemen, n=137; non-linemen, n=238), race (black, n=216; white, n=158) and BSA for predictive value and associations. Values were compared with non-athlete norms, and collegiate football athlete-specific normal tables were created. RESULTS: Only 2.7% of football athletes had ARD measurements above normal non-athlete reference values and the mean athlete ARD values were lower than non-athlete values. No athletes had an aortic root >40 mm or were disqualified due to underlying cardiac pathology. Univariate analyses indicated linemen position and increasing BSA was associated with larger values for ARD. BSA outperformed race in predicting ARD. Normal tables were created for ARD stratified by BSA group classification (low, average and high BSA). Proposed clinical cut-offs for normal and abnormal values are reported for raw echocardiograph metrics and their BSA indexed scores. CONCLUSIONS: Non-athlete reference values for ARD appear applicable for defining upper limits of normal for most collegiate football athletes. BSA-specific normal values may be helpful in interpreting results for athletes that exceed non-athlete norms.

Foot and Ankle Conditions: Plantar Fasciitis.

Plantar fasciitis is the most common cause of heel pain in adults. It involves painful symptoms occurring along the plantar fascia with or without the presence of a bony heel spur. Heel pain that occurs on standing after a prolonged non-weight-bearing period is a prominent symptom of plantar fasciitis. On physical examination, palpation along the medial plantar calcaneal region reproduces the painful symptoms. Routine imaging studies usually are not necessary but can be used to rule out pathologies or confirm chronic or recalcitrant plantar fasciitis. The presence of a heel spur on x-ray is not thought to be an underlying cause of symptoms and indicates the condition has been present for at least 6 to 12 months. Conservative therapies such as rest, ice massage, nonsteroidal anti-inflammatory drugs, specific plantar fascia stretching exercises, and orthoses are the preferred initial treatments. Injection therapies using a corticosteroid or platelet-rich plasma typically provide short-term relief. If conservative treatment is ineffective, extracorporeal shock wave therapy and surgery may be considered.

Foot and Ankle Conditions: Pes Planus.

Pes planus or pes planovalgus (ie, flatfoot) is a common condition among young children and also is encountered in adults. In children, congenital pes planus typically resolves with age as the foot musculature strengthens. Flexible pes planus is defined as a normal arch during non-weight-bearing activity or tiptoeing, with a flattening arch on standing. In rigid pes planus, the arch remains stiff and collapsed with or without weight bearing. Patients with rigid pes planus should be referred for subspecialist treatment. Patients with flexible pes planus, in the absence of signs of rheumatologic, neuromuscular, genetic, or collagen conditions, should be treated conservatively. Asymptomatic children should be monitored and maintenance of a healthy weight should be encouraged. Surgical intervention for refractory symptomatic pediatric pes planus may be considered but there is little evidence to support it. Several etiologies of acquired pes planus in adults have been identified. The most common is posterior tibial tendon dysfunction. Clinical and x-ray evaluation can assist in staging the condition and guiding treatment decisions.

Foot and Ankle Conditions: Midfoot and Forefoot Conditions.

The midfoot and forefoot are the regions of the foot distal to the talus and calcaneus and are critical to weight bearing and movement. They help support the arch of the foot, provide shock absorption, and convert vertically oriented forces into horizontal forward and propulsive movement. A spectrum of acute, subacute, and chronic conditions in these regions can cause pain and decreased function. A thorough history and physical examination should include foot and leg biomechanics, alignment, and posture in addition to palpation of painful areas. All patients with traumatic or overuse midfoot and forefoot injuries should be evaluated with x-rays, with the need for advanced imaging determined based on initial findings. Appropriate diagnosis and management of Lisfranc joint injuries and navicular and base of the fifth metatarsal stress fractures can prevent adverse outcomes. Management of these injuries commonly includes a period of non-weight-bearing immobilization and referral to an orthopedic surgeon. Turf toe, hallux rigidus, metatarsalgia, and Morton neuroma are common causes of forefoot pain. Treatment should be individualized and may include shoe and orthotic adjustments, injections, and, occasionally, surgical intervention.

Foot and Ankle Conditions: Chronic Lateral Ankle Pain.

Chronic ankle pain is relatively common in family medicine. Sequelae from lateral ankle sprains are the most common cause. Other etiologies include peroneal tendinopathy or subluxation, osteochondral injury, lateral ankle impingement, sinus tarsi syndrome, cuboid syndrome, bony stress injury, and other unusual factors. A thorough history focusing on the mechanism of injury (if traumatic) and the nature of the pain along with a targeted physical examination typically will provide the information needed to make the diagnosis. Imaging might be necessary for diagnosis or confirmation of the diagnosis. Early functional bracing, physical therapy for strengthening, and proprioceptive exercises are the preferred treatments for most patients. Daily pain drugs or full immobilization devices rarely are necessary.