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Ask the Experts: Pre-participation Heart Screening for Adult Endurance Athletes

March 1, 2013 By Larry Creswell, MD 2 Comments

 

It’s the time of year when many endurance athletes are considering their medical and health preparations for the upcoming season, whatever their sport.  One important consideration is pre-participation screening for heart problems.  I get inquiries like:

Should I see the doctor before training?

I’m concerned about the heart risks.  Should I get my heart checked out?

Do I need an EKG?  An echocardioam?

These are all good questions.  But the answers really do depend upon an athlete’s circumstance.  There’s no one-size-fits-all prescription here.

I thought I’d gather a group of experts to give you their opinions about 4 fictitious athlete scenarios.  You’ll get to see how these experts approach the athletes’ situation and how they’d handle the issue of pre-participation screening for each.  None of these fictitious athletes will match your own situation, but you can learn from these scenarios so that you’re better able to have a conversation with your doctor about how to make plans that are suited for your circumstances.

The Experts

John M. Mandrola, MD, is a cardiologist in Louisville, Kentucky who specializes in electrophysiology, the field of cardiology that focuses on the prevention, diagnosis, and treatment of arrhythmias.  He is an avid cyclist and occasional triathlete.  Follow Dr. Mandrola on Twitter at @drjohnm and read his blog about medicine and cyling at www.drjohnm.org.

Jonathan A. Drezner, MD, is a member of the Family Medicine faculty at the University of Washington, with a clinical focus in sports medicine.  He also serves as Team Physician for the University’s Department of Intercollegiate Athletics.  Dr. Drezner has an international reputation in the areas of automatic external defibrillators (AEDs) in sports settings; emergency preparedness for sports-related sudden cardiac death; and pre-participation screening in young competitive athletes.  Dr. Drezner is the current President of the American Medical Society for Sports Medicine.  He is also active with charitable organizations that promote awareness for heart conditions that affect young athletes, including Parent Heart Watch, the Sudden Cardiac Arrest Association, and Heart Screen America.

James G. Beckerman, MD, is a cardiologist in Portland, Oregon who focuses on preventive and sports cardiology.  He serves as Team Cardiologist for the Portland Timbers soccer team and as Medical Director for the Play Smart Youth Heart Screenings Program.  Follow Dr. Beckerman on Twitter at @jamesbeckerman.

Philip F. Skiba, DO, is the Program Director for Sports Medicine at Lutheran General Hospital, in Chicagoland and Acting Program Director for Sport and Exercise Medicine at The University of Exeter, UK.  He is the CEO of PhysFarm Training Systems and has coached a number of world-class triathletes.

The Assignment

I asked each of the experts to comment on the 4 athlete scenarios, with the following instructions:

What would you recommend for the athlete if he/she contacted you about pre-participation health screening–if YOU were going to be the athlete’s doctor?  Please discuss your approach in light of the history provided by the patient in a short telephone conversation.  Assume that the athlete has typical employer-based health insurance, with $1000 annual deductible, and no special wellness benefits.  Would you schedule an office visit for history and physical examination?  If so, what would be your focus?  Would you plan any diagnostic testing–chest x-ray, blood tests, EKG, echocardiogram, stress test, etc.?  If the answer is “maybe,” discuss how you (and the athlete) would decide.

The experts’ responses are listed with each scenario.

Scenario #1

24-year-old woman wants to join her girlfriends in training for her first 5k run.  She is slightly overweight, but sees this as an opportunity to lose weight.  She has no chronic medical problems and has no family history of heart disease.  She sees a primary care physician annually and reports that her last physical examination was 8 months ago.  She takes an oral contraceptive.

Dr. Mandrola:  I would do nothing.

Dr. Drezner:  I would encourage her to start her training program, and offer a more comprehensive heart screen that would include an ECG.  The risk of sudden cardiac death in young athletes is lower in females than males, but I would still offer a screen.  Most young athletes with a pathologic heart condition have no symptoms.  An ECG helps to identify silent diseases that place athletes at risk of sudden cardiac death.

Dr. Beckerman:  No diagnostic testing.  I would counsel her that it is possible that she will not experience significant weight loss from the 5k training, but would emphasize the health benefits–short and long term.

Dr. Skiba:  If I were the primary care physiciansh e sees annually, I would clear her for participation, with the caveat that she should immediately contact me for any strange symptoms, and I would carefully delineate signes or symptoms that should trigger concern.  If I were not her primary care physician, I would not clear her without the pre-participation history and physical exam I provide to all athletes.

Scenario #2

35-year-old man is a former high school track athlete, is currently a recreational runner, and now wants to begin structured training for his first-ever marathon.  He is a former smoker, having quit at age 28 after smoking 1 pack per day for 8 years.  His last complete physical examination was during high school.  He injured his ankle a year ago, prompting an ER visit where he learned it was sprained.  At that visit, his blood pressure was high.  About 8 months ago, along with his wife, he visited a health fair where he had his cholesterol tested.  The cholesterol and LDL were elevated.  His mother has high blood pressure.  He currently takes a fish oil supplement.

Dr. Mandrola:  I would recommend a complete physical exam, including an ECG and stress ECG.  Even if they were normal, I would advise him to begin training very slowly and consider delaying his marathon a year or two.  This will allow him to embark on such a lofty goal when he is fitter and likely with a better blood pressure.  This last caveat comes from personal experience.  It took me 3 years to successfully run a marathon, as each attempt was felled by an over-training related injury.

Dr. Drezner:  This patient has multiple risk factors for atherosclerotic coronary heart disease–the usual culprit in adults over 30 years old that causes heart attacks or sudden cardiac arrest.  I would strongly encourage this patient to come in for an evaluation, counseling and treatment of his high blood pressure and high cholesterol, and discussion of an exercise stress test.  An exercise stress test is the best way to look for coronary artery disease and recommended for adults with cardiovascular risk factors who are starting a new or more intensive training program.

Dr. Beckerman:  If he has normal blood pressure today, I would not recommend any diagnostic testing.  I would recommend some dietary changes and would recheck his lipids in 3 months.  Warrants a full cardiac exam to focus on blood pressure, murmurs, abdominal bruit if BP elevated.

Dr. Skiba:  I would provide the patient with a preparticipation history and physical exam.  As exercise is effective treatment for both hypertension and hypercholesterolemia, my advice would depend upon the level of elevationand,  whether he required urgent treatment or whether a trial of exercise would be appropriate.

Scenario #3

44-year old woman is currently a competitive masters swimmer who wants to take up triathlon in the upcoming season.  She has no chronic medical problems.  There is a remote history of goiter for which she had subtotal thyroidectomy.  She has two healthy children.  Her mother and sister have high blood pressure.  She takes a daily multivitamin with iron.  She reports that she “blacked out” 3 years ago at the conclusion of a swim workout, but had no specific medical evaluation or treatment.  She occasionally has bothersome palpitations.  Her last complete physical examination was 3 years ago.

Dr. Mandrola:  I would recommend a history and physical with an ECG.  If the ECG and exam were completely normal, I would stop.  If the QT was borderline or the palpitations struck me as ominous, I would likely add a Holter monitor and treadmill.  The Holter to look for AF [atrial fibrillation] or other arrhythmia and the treadmill to look for exercise induced arrhythmia or abnormal QT response.

Dr. Drezner:  This patient needs an evaluation to check her blood pressure, ECG and stress test, and perhaps a 24 hour Holter monitor.  Passing out is not normal.  Although it is usually benign when it occurs after exercise (not during), everybody who passes out should have at least one ECG.  Her age suggests a stress test is also indicated for exercise related passing out.  She also has palpitations which may indicate the presence of an arrhythmia.  Extended ECG monitoring (ie, 24 hours) can sometimes capture an abnormal heart rhythm if present.

Dr. Beckerman:  I would check an ECG.  If palpitations are nonexertional, I would consider a Holter monitor or event monitor based on frequency.  If palpitations exertional, consider exercise treadmill test.  Check TSH.  Warrants a full cardiac exam with a focus on murmurs.

Dr. Skiba:  This is an athlete who deserves a thorough workup.  Syncope during or at the end of a swim workout could be the result of shallow water blackout (depending on what she was trying to do during that last bit of swimming), or could be the sign of something more sinister (i.e., an arrhythmia).  The chances that an isolated syncopal episode 3 years ago were a sign of some cardiac issue that has not presented itself again is admittedly somewhat remote, however in the setting of continued palpitations I am more suspicious.  She should at least get at EKG, with possible addition of an echocardiogram and/or Holter monitoring depending on where the workup goes.

Scenario #4

56-year-old man, currently a triathlete, wants to begin structured training in preparation for his first-ever Ironman triathlon.  He is particularly concerned about his heart risk because a friend, and fellow triathlete, recently died after a heart attack.  He is a former smoker, having quit at age 38 after smoking 1 pack per day for 15 years.  He currently takes an ACE inhibitor for high blood pressure and a daily aspirin.  His father died at age 52 of a heart attack.  Although he visits annually with his primary care provider, his last complete physical examination was 4 years ago.  He feels that he is about 20 pounds overweight.

Dr. Mandrola:  I would do a history and physical, blood sugar, lipid panel, ECG and stress test.  If these were normal, I would stop.  I can’t believe I’m saying this, but given his medium risk, a coronary CT scan might help here.  In the presence of coronary calcium, I would recommend statin therapy and strongly explain the risk of doing long-distance marathon/triathlons.

Dr. Drezner:  This patient has multiple risk factors for coronary heart disease, including his past history of smoking, high blood pressure, and his father’s history.  A family history of early heart attacks should be taken seriously, as genetics often dictate one’s risk and the timing of potential events.  Combined with his other risk factors, his family history places him at high risk for heart disease.  Before he enters a vigorous exercise program, I would want to screen for coronary artery disease.  A CT scan for coronary calcium scoring can detect calcium deposits in atherosclerotic plaques and provide some assessment of risk.  A stress test, or in this case a stress echocardiogram, will show if there is an obstructive lesion that limits blood flow to the heart during exercise.

Dr. Beckerman:  Full physical exam.  Check ECG.  If normal, exercise treadmill test.  If abnormal, stress echocardiogram.  Check Chem 7 [serum electrolytes] and CBC [complete blood count].  Recommend screening colonoscopy.

Dr. Skiba:  This is another patient who requires more careful monitoring.  In addition to a pre-participation history and physical exam, I would be concerned with how well the patient’s blood pressure was controlled, as well as how his lipid panel looked.  By strict interpretation of guidelines, he may not require testing because e is seemingly not symptomatic.  However, in roughly half of people the first sign of cardiac pathology is death.  I would therefore very carefully question him with respect to symptoms he might be ignoring or “brushing off.”  Given that he is hypertensive, he has a long smoking history, and a strong family history, my inclination would be to stress test him, especially if he is not (or has not) been training vigorously.

Filed Under: Athletes & preventive care Tagged With: athlete, experts, heart, pre-participation screening, preventive care

Five Questions for Your Doctor

December 6, 2012 By Larry Creswell, MD 1 Comment

At my column this month at Endurance Corner I write about 5 questions athletes ought to be asking the doctor at their next visit.

I’ve written three other articles that address the value of a periodic check-up, how to find a good doctor, and how to deal with the cost of preventive care:

Spring Check-Up

How to Find a Doctor (For Athletes)

Six Tips for Athletes to Reduce the Cost of Preventive Care

Filed Under: Athletes & preventive care, Endurance Corner articles Tagged With: athlete, doctor, preventive care

How to Find a Doctor (for Athletes)

September 20, 2011 By Larry Creswell, MD 3 Comments

I’ve received a couple questions this past week about “how to find a doctor.” In my area. One who understands athletes. One who will take me seriously. And so forth.
I’ve said on many occasions that adult athletes would be well served by having a primary care physician–one that they could visit annually for a physical examination and then rely upon when health issues arise. Some ideal charateristics of that doctor might be:
1. Located in your community or not too far away.
2. An athlete himself or herself….or at least “athlete-friendly” and “athlete-knowledgable.”
3. Accessible….at the office, but also potentially by phone or email.
4. A good listener.
5. Responsive to your needs.
6. Understandable, especially when explaining medical issues to you.
7. Familiar with medical specialists in your community, if their services are needed.
But how do you find that person? Here are some suggestions:
1. Ask you athlete friends who they see (and like). This is your best bet. Find a fellow cyclist or runner who happens to be a physician….and ask him/her who they’d recommend.
2. If you’ve seen some sort of healthcare professional recently, such as a physical therapist, chiropracter, or orthopedic surgeon, ask who they might recommend.
3. Call your local medical society and ask for a recommendation. Explain what you’re looking for. They should be able to help.
4. If you live near a medical school, call the school’s sports medicine department and ask who they might recommend.
Those are my best ideas. Maybe the readers can offer some other suggestions. If so, please leave a comment below.

Filed Under: Athletes & preventive care Tagged With: athlete, doctor, preventive care, resource

In the Medical News: Sports-Related Sudden Death in the General Population

July 29, 2011 By Larry Creswell, MD Leave a Comment

In a scientific article published online earlier this week by Circulation, Eloi Marijon and colleagues at the Paris Cardiovascular Center reported on “Sports-Related Sudden Death in the General Population.”

In recent years there has been a focus on sudden cardiac death (SCD) that occurs in young athletes who are participants in organized and/or competitive sports. There has been much less attention paid to SCD that occurs in athletes (of all ages) who are not part of organized or competitive sports–those who are undertaking so-called recreational sporting activities. The investigators have studied the issue of SCD in this second, much larger group of athletes.

This large, observational study examined the experience in France between 2005 and 2010. The experience included 169,742,000 age specific person-years of follow-up. The investigators considered 2 separate groups:

1. Young athletes, ages 10-35, who were competitive athletes, and

2. Athletes, ages 10-75, who were participants in recreational sporting activities (cycling, jogging, soccer, hiking, swimming, basketball, and others).

Overall, the incidence of SCD was 4.6 per million population per year (860 events total). While a small number of SCD events (50) were observed in the first group, approximately 94% of the SCD events occurred in the group of recreational athletes. If the same statistics were applied to the United States population, we might expect upwards of 4250 cases of SCD among recreational athletes each year.

In the group of recreational athletes with SCD, only 11.7% had a known history of cardiovascular disease or had more than 1 classic risk factor for coronary heart disease. The majority of victims in this group were regular exercisers.

The exact cause of death among the victims was determined for only a minority (24.7%) of the group. If a cause of death was identified, it was cardiac-related in 98%.

The vast majority (93%) of SCD events were witnessed, but bystander CPR was provided in only one third of cases. Survival among the athletes with SCD was very much dependent upon prompt CPR and defibrillation.

SUMMARY

The frequency of SCD among recreational athletes is probably much higher than previously thought. This issue deserves and probably will receive additional investigation. The information provided by this report should prompt or renew discussion about the availability of CPR and defibrillation (AED’s) at venues where recreational athletes participate in their sports.

Filed Under: Sports-related sudden cardiac death Tagged With: athlete, heart, preventive care, sudden cardiac death

Six Tips for Athletes to Reduce the Cost of Preventive Medical Care

June 7, 2011 By Larry Creswell, MD 1 Comment

 

Readers here at the blog will know that I’ve recommended that adult athletes have a doctor….and that they visit the doctor annually. This sort of medical care falls under the category of preventive care or wellness care. You’ll also know that I’ve recommended cardiac screening evaluations that might include an ECG or echocardiogram.

When I talk to athletes about this issue, it seems that one of the most common barriers is the cost. No doubt, medical care is expensive. Moreover, many young adult athletes have medical insurance plans with high deductibles….or no medical insurance coverage at all.

My friend and professional triathlete, Jusitn Daerr, recently wrote an article entitled, “I’m Young, I’m Fit, What Could Happen?” at EnduranceCorner about his experience with a new-patient office visit and cardiac screening evaluation. I’d encourage you to read his piece. His situation and thoughts are typical for young adult athletes.

Today, I thought I’d offer 6 tips for athletes to help reduce the expense of preventive medical care:


1. Know the price (as best you can)

It may actually be difficult to know (ahead of time) the cost of medical services you might need, but it’s worth your effort to try to find out. Your doctor’s office can readily tell you the typical charges for a new patient or established patient visit. Keep in mind that a follow-up visit often costs much less because the doctor doesn’t need to spend as much time getting to know you after the initial visit. You might feel reluctant talking to the doctor about the costs of any visit, but he/she will probably be very happy to answer questions that you might have.

Your doctor or his/her office staff should also be able to find for you the costs for any laboratory or other diagnostic testing that is recommended. It’s important to realize that your doctor may establish the fee schedule if the test is done in his/her office, but won’t have any part in setting the charges if the test(s) are performed at a hospital or other facility. Nevertheless, the doctor’s staff can help you track down the costs of most any test that is recommended.

Your doctor and his/her office staff can also provide some “local knowledge” about options for where to go for a particular test. Since each facility will have a different fee schedule, it can pay off to do some research about the charges at different facilities that offer the test(s) that you need. Don’t be afraid to ask.

2. Time your medical care to your advantage

By its very nature, preventive care is not urgent or emergent. Office visits and laboratory or other diagnostic testing can be scheduled at your convenience. You should take advantage of that opportunity.

Many athletes will have a medical insurance plan with an annual deductibe….a dollar amount that you must pay fully out of pocket before the “real” insurance coverage kicks in. In recent years, it has become common for plans to have deductible amounts of $500 to $1000 or more. Since preventive care often costs far less than this amount, the cost of that preventive care is often totally out-of-pocket.

If you are somebody who has various medical expenses throughout the year (that add up over time), be sure to schedule your preventive care at a time during the year when you will get the best insurance coverage. This could mean delaying that care until later in the year, once your annual deductible is already met. By doing this, you might enjoy considerable cost savings for your preventive care needs.

3. Find health fairs that offer needed services

Local health fairs are a great oportunity to find some of the preventive services you need….either FREE or at a greatly reduced price. But you have to be willing to do some homework to find these health fairs….and work with your doctor to plan for using the health fairs to get needed test(s).

Justin Daerr brought to my attention a great offering in the Colorado front range area. There is a multi-city, continuing health fair sponsored by 9News. Examples of services that can be obtained at a tremendous cost saings include: blood chemistry (blood tests), blood counts (blood test), blood pressure, bone health screening, breast exam, eye health screening, diabetes screening (fingerstick), hearing tests, lung function test, pap smear, sleep apnea screening, and many others. With a variety of offerings, you could choose WHEN and WHERE to get any needed screening tests….and the results could be forwarded to your doctor for review.

This is just one example. Your doctor’s office can often help you to locate suitable offerings in your area. Keep in mind, too, that in February, during Heart Month, many health organizations sponsor health fairs that are very specific to the heart and cardiovascular systems. It’s often possible to find fairs that offer free ECG’s, heart exams, and exams/testing for peripheral arterial disease of the extremities and neck. It’s not usunual to be able to get $100’s to $1000+ of free services if you plan ahead.

4. Use your HSA if you have a high-deductible medical insurance plan

By law, individuals with high-deductible medical insurance plans may contribute pre-tax dollars (up to $3,050 for an individual in 2011) to a Health Savings Account (HSA) that can then be used to pay for necessary medical expenses. By planning ahead for your preventive care needs, you could make the necessary contribution to your HSA and pay for your preventive care with pre-tax dollars (getting you a “discount” of whatever your tax rate would ordinarily be).

Since preventive care can typically be an out-of-pocket expense, the use of your HSA for this purpose is a no-brainer.


5. Use your employer-based flexible spending account if it’s available

Many large employers offer a flexible spending account as part of their benefits package. Like an HSA, the flexible spending account allows for contribution to the account of pre-tax dollars that are deducted from your paycheck each pay period. The money accumulates in your account until you spend it on qualified expenses. Virtually all preventive medical care and any diagnostic testing recommended by your doctor would be eligible.

Unlike the HSA, however, money in the flexible spending account “goes away” if it is not spent by the end of each calendar year (plus, perhaps a small grace period). As a result, it requires special attention and forethought on your part to make an appropriate contribution choice….and then to spend the money before the end of the year. Even with these burdens, though, the flexible spending account is a terrific way to pay for your preventive care needs with pre-tax dollars (getting you a “discount” of whatever your tax rate might be).

6. Take advantage of wellness benefits of your insurance plan

Lastly, be aware that many employer-based health insurance plans offer some sort of wellness benefit. With the newly passed health care reform package, these wellness benefits will be more and more common in insurance plans, going forward.

As an example, I’ll share some of the details of the wellness benefit offered through my own personal employer-based Blue Cross insurance plan. If I enroll (by answering an online questionnaire at the start of the year), I can get up to $1000 in covered wellness services without paying a cent out-of-pocket. The plan prescribes the eligible, covered services by age group for the plan’s participants.

I hope that these 6 suggestions are helpful. A little bit of knowledge can help an athlete get the most for their health care dollar!

Filed Under: Athletes & preventive care Tagged With: athlete, cardiac screening, cost, insurance, preventive care

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