Episode 3 - The Symptomatic Athlete: Strategies for Evaluation and Return to Play

Join experts Dr. Michael Emery from the Cleveland Clinic and Dr. Simon Lee from Nationwide Children's Hospital as they address common clinical scenarios in athletes of all ages - including post-COVID return to play, dizziness and syncope, and chest pain. Pearls in history taking and testing strategies are reviewed. They also address the incidence and treatment of atrial fibrillation in athletes.

Guests: Michael Emery, MD, FACC and Simon Lee, MD, FACC
Host: Kanny Grewal, MD, FACC, President, Ohio-ACC
Reference: 2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults

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Transcript

Kanny 0:04

This is the cardio Ohio podcast, the presentation of the Ohio chapter of the American college of cardiology. This is canny gray wall president of the Ohio chapter and host for today's discussion. Further information about this podcast, including speaker biographies, as well as references are available@ohioacc.org. Where you can also provide feedback and suggestions for future topics. The podcast will also be available for download wherever you access podcasts, and we encourage you to subscribe, to receive updates on future sessions I'd like to welcome everyone to episode three of the cardio Ohio podcast. Thank you for joining us. Today, we're going to talk about a few key topics in the field of sports cardiology, which is a growing area within cardiovascular disease. I'm really happy to have two experts from here in Ohio. Joining me for today's discussion. First from Cleveland, I'd like to welcome Dr. Mike Emory. many of you who've had an interest in the area of sports. Cardiology are very familiar with Dr. Emery's work. He's currently the co-director. Of the sports cardiology center at the Cleveland clinic, he was previously at Indiana university. He's been very active in the sports cardiology council at ACC, and he's spoken at many of our events in the past years. Mike, welcome to our discussion.

Mike 1:38

Great to be here. Thanks for.

Kanny 1:41

I'd also like to welcome Dr. Simon Lee from here in Columbus. He is a pediatric cardiologist at nationwide children's hospital. He's a specialist in advanced cardiac imaging in pediatrics as well. And my understanding is he's the program director of their current program for coronary anomalies as well as Kawasaki's disease. Simon, thanks for joining us.

Simon 2:04

Yep. Excited to be here. Thanks for inviting me.

Kanny 2:08

So we're going to over about 30 minutes, just hit a touch on a few key topics in sports cardiology that I think are of interest to our audience of general cardiologists, advanced practice providers. We even have some fellows and training joining us as well in this program. I'd like to start by addressing, the post COVID patient because even. Case numbers have been dropping, which is excellent news. Finally, after two years of our pandemic, many of us who are in sports cardiology and adult cardiology, have been of course, dealing with quite a few patients who have recovered from infections or maybe having ongoing symptoms post COVID. And there's been some controversy. as we've learned, about the incidence of cardiovascular anomalies in this, group of patients, there's been controversies about the extent of testing needed. So I thought we could start with that recently. The ACC did put out a consensus statement, Post COVID cardiovascular sequelae, and I'd really encourage everyone listening to check that out. it's a very nice document. That's very practical and it covers really, the current knowledge base we have about all various cardiovascular manifestations, during and after COVID infection. But since we're talking mostly about young patients, today in sports cardiology, Mike, I thought I'd just ask you, obviously you see a lot of these patients, we all do right now. initially there was a lot of interest in doing extensive testing, maybe even MRIs in many of these patients, but would you agree with the consensus document that really for asymptomatic, COVID positive patients or those even with mild symptoms that our approach now should be to try to selectively and judiciously use testing and just the minority.

Mike 3:51

Yeah, I would completely agree with that. Based upon our current level of knowledge, you know, I was just sitting here reflecting on the pandemic and realizing that it was just in may of 2020. So not even two years ago that the ACC sports and exercise council put out their first statement about return to play really at the beginning of the pandemic. And it stemmed from. Really just the hospitalized patients. So we're not even talking athletes are asymptomatic or mildly symptomatic, really floridly, symptomatic hospitalized patients in the initial concern about cardiac involvement. And since we knew a little about COVID and its sequela and its consequences at the time we had urged caution and then as that time has gone and it's amazing to see what had happened and just a little over a year, how much data was collected by really having great. Communication and great teamwork across multiple institutions to come to a point where now we've have several thousand athletes screened, evaluated, and really coming to the conclusion that at least in this population, the incidence of myocarditis from COVID-19 is not nearly as high as we were fearful of in the past. Now we need to sort of regain our footing and understand that. probably back off on a lot of the screening that had been recommended in the past that had been done across even major, major, collegiate, institutions.

Kanny 5:21

So given that, given that situation. In terms of, symptoms that you hear about in a patient who either has current or recent COVID infection, what symptoms or other clinical parameters on either a young patient or athlete would warrant you to consider some of the basic testing like EKG echo or proponent levels.

Mike 5:42

So that triad testing is what it's called these days is really reserved now based upon our current level, for those with moderate to severe symptoms of their initial infection. Or they had specific or concerning cardiopulmonary symptoms, meaning, concerning chest pain, not just, you know, chest pain that strikes in the zone from your knees to the top of your head, but concerning chest discomfort, excessive dyspnea on exertion, syncope, palpitations, all those symptoms that would concern us whether you had COVID or not. so that's a good place to start and setting of the triad, testing, the proponent level, an ECG and echocardiogram, and then additional testing on top of that. Most notably cardiac MRI. If one of those abnormal, one of those tests becomes abnormal or they continue to have these concerning cardiopulmonary symptoms, despite that a normal potential triathlon.

Kanny 6:40

Great. So, Simon, would you agree that. C VMR. obviously you and your group here in Columbus were involved in some of the early data on, myocarditus and athletes with, with MRI imaging. But do you agree now that we've learned more about the incidents and so forth that, Mr. Should be more judiciously used

Simon 7:01

yeah, no, I definitely agree with how the guidelines have sort of evolved over time. And one of the big contributors to that I think is just how many, patients we've all seen for clearance, you know, People were referred and a lot of centers, including our own and nationwide children's. We were really trying to keep a select number of physicians, seeing these patients to develop a little bit of familiarity and expertise. And the other thing too, is I think just seeing, you know, emphasizing this gradual return to play, which everyone, in Ohio, at least in the high school athletes, their trainers, everyone has been really, onboard with. And, while the TRIA testing is important, I think that's really been a big key for identifying, kids or, older athletes who, who may have some concerns who may have a concern for some cardiovascular involvement. You know, you have them kind of ramp up, gradually increase their activity. And then if they, if some symptoms develop, I mean, that's kind of been the bigger red flag from my standpoint, at least for the adolescent in high school athletes.

Kanny 8:04

Yeah, I think emphasizing the graded return activity is very important. I'm the, team cardiologist for the Columbus crew. And I work with our sports medicine team here in OhioHealth where there's a lot of high school trainers involved. And I think, I think I've seen that they've gotten on board with that concept as well that, there should be a graded return using the trainer or maybe the team physician, if there is. As a, you know, to help monitor that returned activity. And by doing that, I think most, most kids really do get back to full activity pretty quickly. One other question for you, Simon is, you know, obviously in your experience in pediatric cardiology, you see a lot of pericoronitis in, in the younger population here at Riverside. You know, we use high sensitivity troponin. We have for a couple of years now and. To me, it's pretty impressive. How many patients with either COVID infection, especially in the hospital, of course, who are hospitalized or even other viral syndromes will have mild proponent elevations, but. do you consider that synonymous with myocarditis or should we be relying on additional imaging before we just make that diagnosis based on a true point in level alone?

Simon 9:13

Yeah. You know, I think that's a really interesting question because one of the other things that's really evolved during the pandemic has been how we diagnose mild carditis. And just seeing that there is the spectrum of, you know, I mean, Referencing those guidelines that were just published or that expert consensus document, I should say. they actually lay out, you know, this is probable mild carditis possible and definite myocarditus. And, you know, in, in cases like you're talking about where you do have a little bit of traponin leak. and again, I think high sensitivity troponin is sort of another area where, you know, we're talking about. test that wasn't really developed to look for this. And so, you know, how do we interpret that? Or how do we utilize that information and make a diagnosis for mild carditis or Parry myocarditis or something like that. But, but yeah, I think that's the other interesting thing that's come out of. This is. Spectrum of sort of cardiovascular involvement after infection. And so, on our end, you know, we don't use a high sensitivity troponin. We use just the regular proponent.

Mike 10:15

Yeah. The highest Institute is your opponent has been, interesting and our institution, as well, like any tests, it has to be taken in context of the clinical scenario for which it's, drawn from. And when we look at high sensitivity proponents in particular, you know, things can acutely elevate that such as exercise, acute exercise, especially high intensity exercise can slightly elevate that high sensitivity proponent. So when you look at the guidelines and we were talking about Wyndham measure proponents and people, we recommend, you know, exercise sensation for at least 24 hours prior to that things that, you know, it makes a difference how your lab sets that normal and abnormal level. When you look at the actual 99th percentile recommended by the manufacturer for most ISIS due to opponents, they have different numbers for men and women. So you have to take a lot of this into context and I've noticed the same thing. We, a high sensitivity pops back sort of like gray zone, mild. They have normal. Yeah, the regular proponent T is a hundred percent normal SED rate is normal. CRP is normal. And then I start to take those tests and a little bit more of a different vein than if other things are abnormal.

Kanny 11:22

And just to follow up on that mic, when obviously only a minority of these COVID positive athletes are going to end up with a true clinical myocarditus. But when you do see that that's a pretty high situation, right. In terms of return to play and, and they do need a longer period of, athletic avoidance. If they have a true clinical marker.

Mike 11:42

Yeah, we definitely believe that, you know, acute myocarditis increases your risk of sudden cardiac arrest and sudden cardiac death, right? That's the most fearsome abnormality. And we're trying to prevent that sort of ongoing inflammation, in the setting of high intensity, in that high adrenergic stage is certainly a cause of concern. There are athletes, however that have mild case of mild carditis that ignore it and do fine. So we're trying to find the needle in the haystack. Certainly, if you've been identified with acute myocarditis, current guidelines is a restriction for three to six months, depending upon how severe that initial case is and how soon you recover.

Kanny 12:22

Well, thank you. I think, obviously our understanding of. Cardiovascular manifestations and complications of code is probably going to continue evolving. hopefully this is not a topic we have to keep revisiting because it's, because of the clinical volume. But, we've also learned that to really expect anything with this pandemic that we can count on. I do want to get into a few other topics related to, athletes and young patients. since we have both of you here. so Mike, I know you run the, the sports cardiologist center there. You obviously see a lot of symptomatic athletes, probably both high school, college, and young adults as well. And you Simon as well. I think, I do notice that amongst general cardiologists, sometimes there's a level of kind of trepidation, when, when a teenager comes in, with symptoms, in terms of, who needs testing, who needs to, restrict sports. Of course, there's always such an urgency with young athletes because they're coaches, parents, and the athletes themselves want to get back to activity right away. So, Mike, in terms of symptoms like syncope or lightheadedness, when you see a young athlete who presents with dizziness, syncope, or even just lightheadedness, what are some of the, historical features that might give you some clues as to when, it may be a benign cause versus a potentially more, structural cause that warrants investigation.

Mike 13:42

And this is a pretty common referral to us in sports cardiology. And I think part of that is that you, as you said, there's a fear there that they don't want to miss something. but when you talk about, you know, syncope, lightheadedness, dizziness, palpitations, just like in any patient, the history is the key here. It may be even more prominent in a young athlete. When do you get syncope and lightheaded? And what do you mean by. So for instance, particularly in endurance sports, there's a phenomenon called exercise associated collapsed sounds ominous. It's actually benign. So that's an important and key part of that history associated with sudden collapse at the end of a race. And not as you're sort of crossing the finish line, but you've finished. You crossed the finish line. And you stopped suddenly and you collapsed. So you have to be careful and take that history very thoroughly because that's considered exercise associated collapse, which is really the loss of the muscle pump from Southern cessation of activity. So as you're running. Your muscles contracting against your veins in your legs, provides a big chunk of that Palmer or that venous return back up to your heart. So you can get it to your brain. And when you stop suddenly and you lose that muscle pump, you lose that venous return to your heart and hit. Flooded here your brain and you have sudden collapse that should be very easily ascertained from a history and really doesn't need any further workup as long as you've taken the history correctly. So this is such a big deal that for those of you who run marathons, half marathons, five Ks, you know, when you get to the finish line, you don't just get to stop at the finish line and get your metal, your water and your. You got to walk through the shoot, right? And at the end of that shoot is where you'll start to get your water and then you'd get your metal and then you get your banana. So that's designed very specifically to avoid everyone collapsing at the finish line from exercise associated collapse. So what are other features of the history that would make you more worrisome? If you collapsed while you're exerting yourself, that's a red. If you have associated chest pain or palpitations with it, why don't you collapse? Then that's a red flag. If you have a family history of cardiovascular disease, particularly unexplained, sudden death or other cardiomyopathy's or channelopathies or some kind of apathy, and that's a risk factor, and that should be taken seriously. Other things in the history that maybe should make you not think so seriously, meaning orthostatic symptoms. So this is a common referral, a young competitive athlete who gets the Swoon because they stood up to. Not related to exertion, but they nearly passed out when they stood up too fast. Well, unfortunately, or fortunately, that piece of cardiovascular adaptation that makes you a good athlete. I E a very compliant heart that can handle large increases in volume with minimal changes in pressure. So you can create a large stroke volumes and cardiac output to run and be competitive or cycle, and be competitive. So what makes you good athlete makes you more prone to exercise, to orthostatic symptoms. That's not pots, that's not inappropriate sinus tachycardia, that's simple physiology. And we shouldn't overreact to that. The other thing we see not uncommonly is something called the athlete swim. So this was an interesting phenomenon with the phrase coined by Dr. Paul Thompson, who I consider the godfather of modern sports cardiology. Whereas that athlete who only seems to. Look, woozy and dizzy as the, as they're crossing the finish line. So they're doing great, the whole race, and it's always in a race. It seems like they get within a few yards, a few hundred yards of finish line. They start to kick that in. towards the end and then they sort of swerved across the finish line and then collapsed right. Accurate. So this is, you know, partly exercise associated collapse, but they're swooning across the finish line. That's probably benign. you should make sure it's not benign cause they are feeling sort of bad while they're exercising. But the interesting part about this. We really don't find any pathology associated with this. And it always seems to happen in races. You ask them and it never seems to happen when the training sessions, for whatever reason, them pushing the heart at the end of the race just makes them feel poorly. cause we all feel poorly. If we push that proverbial red, red line too far, you get nauseous and lightheaded.

Kanny 18:23

Very interesting. Yeah. I have seen examples of that too. So in the subset of these athletes who might have one of these red flags say exertional symptoms, can you just briefly go through like the sequence of testing you may consider, to fully exclude a structural problem?

Mike 18:40

So, yeah, you're gonna want to exclude some structural problem or electrical problem. That's the other thing that would be. A common cause that isn't going to show up on an echo for instance, but you're going to start with an ECG looking for things like, you know, WPW or pre-excitation, you're going to look for a long QT, anything that would set you off on ARVC. You're going to get an echo to look for structural heart disease. And then it's going to kind of diverge from there on what your pre-test probability is. If you find something abnormal, looking on an echo and you need to make sure what you're looking at is. Athletic remodeling and you don't go down the diagnostic treat pathway, but if something looks really concerning, then at cardiac MRI is going to be. there's going to be, excuse me, it's going to be, potentially of high yield here, to make sure you're not missing something on the echo or something small, that isn't a have more consequences when you get a better look and a better imaging study. coronary CT angiogram. If the history is consistent with, Anomalous coronaries, which can be the touristy unpredictable in terms of their symptoms and often associated with chest pain, but notoriously unpredictable, and then any electrical studies. So that could be an ILR. If you were concerned about recurrent symptoms and an order, an exercise stress test audited. Hi on your list of things you're going to do. because some things may only pop out on a stress test looking for things like QT prolongation, that's inappropriate or inappropriate long in recovery, or whether they have PVCs induce suggestive of cardiopulmonary era. Catecholamine energetic, polymorphic VT. So I'm going to always start with an ECG and echo and probably almost always some form of stress. I'm not looking for ischemic heart disease and most of these patients. So they usually don't require imaging. They usually require ECG and trying to reproduce their center.

Kanny 20:28

So Simon, you see teenagers who present with some of the lightheadedness and other syndromes, is, is your experience been similar on the younger patients who are maybe, middle school or high school age in terms of a likelihood of structural problems and how you would go about, approach to diagnostic to.

Simon 20:45

Yeah. You know, sometimes it can be even more challenging in younger athletes just because chest pain is just such a common complaint. And so like Mike was saying, I think history is really where you have to start, you really have to get. A very clear sense of when is this happening? How often is it happening? you know, is it, associated with, peak exertion? Is it happening at rest and exertion? You know, some of those red flags that Mike talked about it, those are the things that you really have to try to get. And I will say that even though it is relatively common in pediatric patients, you do sort of get a flavor of. Sort of idiopathic chest pain or benign chest pain. And so when there is a story that pops up, that's a little atypical or doesn't quite sound like the other cases that you've heard, those are the times where we do go for testing. And on echo, we very specifically look for anomalous, coronary artery origins, or any evidence or suggestion of hypertrophic cardiomyopathy, or just atypical or asymmetric. but left ventricular hypertrophy. And so those are definitely kind of a similar approach. And I think we just have to keep, in pediatrics anyway, we just try to emphasize the history like Mike is saying, because one of the most common things that we get in our general pediatric cardiology clinics is chest pain.

Mike 22:06

One thing I wanted to come back and emphasize. But I think is important for the cardiologist to start recognizing more is that pulmonary and respiratory symptoms can often significantly overlapped with concerning cardiac symptoms. Things like exercise, induced, Bronco, constriction, exercise, induced, laryngeal obstruction, dysfunctional breathing are all very common in young. More common than true underlying cardiac pathology, but it's something that we as cardiologists unfortunately have often ignored or not then taken the next step that refer on to pulmonary or speech pathology to investigate these further as causes of their symptoms.

Kanny 22:44

Simon, you briefly touched on coronary anomalies and chest pain in the athlete. I just want to kind of clarify, like what in the history might prompt you to consider doing either an echo or even a CT angiogram in a, in a young athlete because of your clinical suspicion for, an anomaly versus, the more benign causes.

Mike 23:05

Yeah.

Simon 23:05

So definitely a exertional syncope and not sort of that post exertional syncope or the athletes wound like Mike was talking about, but really, you know, when you're competing very high, intense activity and you're kicking it up to that next gear, and then all of a sudden you get this, you concerning history of chest pain or syncope, those are the kinds of patients that were typically wondering, you know, is there something else going on? Patients who have family history of cardiomyopathy or just, so my uncle passed away when they were 25, they were in the military and we don't really know exactly why, but I think they were marching, you know, something concerning and that history, those are the times we go for echocardiography. And one of the, one of the advantages from our standpoint from a pediatric standpoint is. Yeah. Typically we have very excellent, echocardiographic windows. And I would say the majority of time we can evaluate the coronary origins very well by echo. and let's say it's an anomalous, right? Coronary from the left sinus. And you have a patient who may or may not have significant symptoms or maybe is asymptomatic and it was incidentally diagnosed, you know, then I think that's when we start to talk about advanced imaging. So, what we do, we always get a CT coronary angiography, just to look, to see some of the risk factors, you know, is there an intramural course? How long is it? Is there any hypoplasia of that inter arterial intramural section? Is that a right dominant versus a left dominant coronary system? you know, what does that osteo morphology look like? You know, we can do 3d, 3d rendering to try to see this. It looked like a very concerning, very narrow or slit, like ostium, or is it more of a oval around kind of ostium? And then from there we like to do. Provocative ischemic testing. And so we'll either do sort of a W2 mean stress echo, or, we've been working with our colleagues at OSU who have the ability to do exercise, stress, profusion, MRI, or nuclear studies, so we, we like to try to get a comprehensive evaluation.

Kanny 25:10

That's that's helpful to know. So I guess I can summarize in our last few minutes here, as we wind down, it sounds like, both Mike and assignment that you're both saying that, that, you know, history is always going to be the key to distinguish in these, everyday causes from potentially more pathologic ones. And then judicious use of. the imaging with an emphasis on stress tests and maybe to reproduce symptoms and then perhaps judicious use of more advanced anatomic imaging to confirm a diagnosis. So I think that's a great template for our audience to follow. and our last couple minutes, I did want to just touch on one other topic. Mike, I understand you're speaking this weekend at the ACC meeting, and you're going to talk a little bit about the controversy of. ablation for atrial fibrillation and athletes. can you just in our last couple minutes kinda touch on, what is the extent of, of atrial arrhythmias in both recreational and competitive athletes? Number one, and then number two, how does the clinical presentation differ from the everyday a AFib at, all of us see, as almost a pandemic and adult cardiology.

Mike 26:18

Sure. So, you know, a AFib in athletes has been, controversial for a little while, mostly because it was the question initially of do athletes have a higher incidence of atrial fibrillation. And I think that now we're coming to the conclusion that lifelong endurance athletes have some elevated incidents of atrial fibrillation, maybe anywhere from two to five times the incidence of a fit. It doesn't mean that all those endurance athletes were going to get a fib far from it. What constitutes long-term endurance exercise that we don't know is that one marathon a year for 20 years is that four marathons a year for 20 years is going to be probably something more susceptible and something more genetic predisposition on top of adding these to it. The good news is most of them thankfully are low risk for thromboembolic events. So that takes part of that discussion about anticoagulation. away from you in terms of whether you're going to recommend the cyclist with the CHADS-VASc of zero has to be on, DOACs or warfarin. But that is a matter of what to do with it. Some of them are symptomatic with exercise. A lot of them are more symptomatic at breasts than they are with exercise, but a lot of'em don't want it there. They don't respond well to medical therapy. They don't like beta blockers. They don't like calcium channel blockers. We get hesitant about antiarrhythmics particularly the one CS without concomitant David nodal blocking agents in these athletes. In addition, I get nervous about antiarrhythmics. When you send out an athlete going to do a long endurance event and their potassium or magnesium is a little off their core temperatures off their volume status is a little. And how can you potentially increase their risk of a pro arrhythmic event from your antiarrhythmic event? So then that brings up, well then should we, these all go for ablation, right? We like to ablations these. they seem to be pretty successful, but what does success mean for an athlete for eighth of ablation athletes want to gone and they want a higher probability. That's going to be gone. If you start looking at some of the data, even in athletes, which is more limited, they still often require more than one ablation. A lot of them still don't get completely off medications and probably that the most controversial and hardest to deal with is when you look at the data for even athletes at undergo ablation on average, their resting heart rate is about 10 to 15 beats per minute higher after their ablation than it was before their ablation. And. Those of you that take care of athletes know that these athletes, where they're a resting heart rate, like a badge of honor, I resting heart rate is so and so, so that is the largest complaint I get post ablation from an athlete is my resting heart rate higher. so there's still a lot to be done to understanding really then the success and what defining success means and ablating and ATM. and an athlete. in addition to what improvement in their quality of life has been some of the data now being published shows that, you know, a lot of the general population has improvement in their quality of life, but I'm not so sure that that quality of life questionnaire and the general population is the same quality of life questionnaire that an athlete experience in AFib would, mark as being important.

Kanny 29:38

Well, that's an interesting perspective because I do agree that it's an extremely unique group of patients, very different than what we are used to dealing with an adult cardiology in general. I wish we had some more time to address a few other topics, but I think we've covered a lot in 30 minutes. I know we're going to continue to have sports cardiology topics that are Ohio meetings, there's a lot of information that will keep coming out and we'll do our best to get that to our audience. I'd really like to thank you both for taking the time to chat with us today and help spread some knowledge about sports cardiology.

Mike 30:14

Great. Thanks for having me.

Simon 30:15

Thanks for having.

30:19

Thank you for joining today's podcast. For more information about the speakers or the topics, please go to Ohio acc.org,