Cardiovascular Health of the Athlete and Infectious Disease Update

Cardiovascular Health of the Athlete and Infectious Disease Update Amy E. Stromwall, M.D. SJSU Athletic Trainers April 7th, 2005 Overview • Cardiovascular Adaptations to Exercise • Cardiovascular Screening • Causes of Sudden Death • Management of Arrhythmias • Management of Hypertension Family History • Premature death • Premature morbidity from heart disease Family History • Specific knowledge of: – Hypertrophic cardiomyopathy – Dilated cardiomyopathy – Long QT syndrome – Marfan’s syndrome Physical Examination • • • • Blood pressure Heart murmur Arterial pulses Stigmata of Marfan’s Athletic Heart Syndrome • Normal Adaptations to Exercise Athletic Heart Syndrome • Endurance training – Increased left ventricular chamber size Athletic Heart Syndrome • Strength training – Increased left ventricular mass Athletic Heart Syndrome • Arrhythmia •How slow is too slow? Athletic Heart Syndrome • Why is there bradycardia? – Heart is more efficient with each beat – Greater muscle mass, greater chamber size – More blood pumped per beat Let’s talk about sudden death And I don’t mean overtime Cardiac Arrest • 400,000 people suffer out-ofhospital arrest annually • Leading cause of death in young athletes • Leading cause of death in the U.S. Sudden Cardiac Death Causes: • Hypertrophic cardiomyopathy • Anomalous coronary artery circulation • Marfan’s syndrome • Coarctation of the aorta • Miscellaneous Hank Gathers (d. 1990) If you watch the tape. • • • • • • He goes down and nobody moves Then everybody surrounds him But does nothing An AED sat on the bench He stumbles, falls again Then he seizes It’s horrifying • • • • • • He is motionless His mother is standing there No one checks for a pulse No one performs CPR No oxygen No paramedics Now we know better Causes of Sudden Cardiac Death • Hypertrophic cardiomyopathy – Formerly known as IHSS • Sickle Cell trait – Do we screen? • Congenital arrhythmias • Illicit drug use Automated External Defibrillators • 91 % of Division I universities have them • Institutions have an average of 4 devices • Placement at public sporting events is a growing trend “Is the expense of AED’s at Division I Universities worthwhile?” • Looked at prevalence, past utilization, and costs • 35 cases of AED use (77% in nonathletes) • Resuscitation rate was 71% • 5 arrests were in athletes, none resuscitated • Average cost per AED was $2500 • Cost per life resuscitated was $49,000 • Estimated cost per life-year gained was $10,000 to $22,000 • Concluded that AED’s were favorable You need an action plan. And you need to practice it. I need 4 volunteers. Questions you need to ask: • Where is your AED? – Who, if anyone, has used it? – What is its battery life? – Does it have the correct pads? • Do you have access to oxygen? • Do you have ambulance support? – Is it BLS or ALS capable? More Questions: • Who does crowd control? – Athletes – Parents/Family – Fans – Media • After event chaos – Media – Documentation You have to practice it. • Your eyes are on the game • Look for altered behavior • Delegate jobs – AED, pulses – Airway – CPR – Coordinate with EMS More Practice • What about away games? • Discussion with team • After-event decompression Take Home Points • Cardiac arrest is leading cause of death in young athletes • It is still rare • AEDs are useful • Have an action plan and practice it Let’s talk about the other causes… Hypertrophic Cardiomyopathy • Thickened, non-dilated left ventricle – >15 mm septal wall • Autosomal dominant • Deranged cellular architecture leads to conduction problems Hypertrophic Cardiomyopathy • May not be evident until late teens Hypertrophic Cardiomyopathy • Physical exam – Systolic murmur Systolic Murmur • Accentuated with Valsalva maneuver • Decreased with squatting Hypertrophic Cardiomyopathy • Chest X-ray • Cardiomegaly Hypertrophic Cardiomyopathy • What actually causes death? Hypertrophic Cardiomyopathy • Diagnosis – History – Physical exam – EKG – Echocardiogram Anomalous Coronary Artery Circulation • Congenital abnormalities of the Arteries – Single coronary artery – Smaller arteries – Common origin of the arteries Anomalous Coronary Artery Circulation • History – Poor perfusion of the heart with exercise Anomalous Coronary Artery Circulation • Physical exam – No consistent findings Anomalous Coronary Artery Circulation • Diagnosis – Autopsy – Angiography Marfan’s Syndrome • Connective tissue disorder • Autosomal dominant trait • Fibrillin gene Marfan’s Syndrome • Physical exam findings – Tall body habitus (wingspan greater than height) – Hyperextending joints – Arachnodactyly Marfan’s Syndrome • Physical exam findings – Pectus excavatum – Scoliosis – Subluxed lens Marfan’s Syndrome • What causes sudden death? • Aortic dissection Marfan’s Syndrome • Can they compete? – Avoid contact sports, isometrics, weights, exhaustive exercise – Consider noncompetitive swimming, biking Coarctation of the Aorta • Congenital • Often a pediatric diagnosis Coarctation of the Aorta • Classic findings – Radial pulses greater than pedal pulses – Uneven radial pulses Coarctation of the Aorta • Definitive treatment before allowing participation Cardiac Screening • Family history of heart problems • Family history of sudden cardiac death before age 50 • Easy tiring, legs before arms, can’t keep up with teammates • Dizzy • Chest pain, shortness of breath, palpitations, drug use • Ever been disqualified by a physician before? Why is hypertension such a big deal? What are the numbers you are looking for? 140/90 Hypertension • Risk Factors – Race – Family history – Diabetes – Smoking – Obesity Hypertension • Risk Factors – High Na intake – Excessive EtOH – Cocaine, deitary supplements – Anabolic steroids – Male gender Hypertension • Exercising with high blood pressure – SBP can increase to 200-300 mm Hg with weightlifting – Heart muscle remodeling Hypertension • Exercising with high blood pressure – Inability to shunt blood to skin effectively Hypertension • End organ damage Hypertension • End organ damage – EKG – U/A (proteinuria, albuminuria) – Serum creatinine – Retinopathy Hypertension • In or Out? Drugs • • • • Cocaine PCP Amphetamines OTC cold Coronary Artery Disease • • • • • Exertional chest pain Exertional dyspnea Nausea Diaphoresis Referred arm pain Review • History – Chest pain – Syncope – Dyspnea on exertion Review • Family History – Unexplained young deaths (<35 yo) Review • Physical Exam – Murmurs – Blood pressure – Pulses – Marfan’s When in doubt, keep them out. Let’s switch gears. MRSA infections • • • • • What are they? Why are they such a big deal? Who here has seen them? Who is getting them? What are we going to do about them? Methicillin Resistant Staphlococcus Aureus • A community acquired bacteria that is running rampant • Now occuring in healthy, young, active people • Easily spread • If you don’t treat it…it can get ugly, and be fatal Why should you care? • Because your athletes, and even yourself could be affected • The infections are spread person to person – Whirlpools – Shared towels, soaps – Equipment (weights, pads) – Artificial turf What do they look like? • Starts out as “no big deal” • Abrasions, turf burn, a “spider bite” • But different… • Skin is red, hot, and looks angry • There can be an abcess, or pustules • And they hurt Case 2 “This thing hurts” Photo “This thing is nasty and smelly.” What is it? What do you do? MRSA • The infections progress rapidly, within 24 - 48 hours • You choose different antibiotics than a typical cellulitis • And they need to scrub with an anti-bacterial soap (Lever 2000) • They may need to be drained • Then… There are carriers. • Close contacts (household, team mates) • Need bactroban ointment inside their noses • Twice a day for 7 - 10 days • And you need to be hypervigilant with your treatment areas Oooooh…scary. Kazakova SV, et al. A Clone of MRSA Among Professional Football Players, NEJM. 2005; 352(5): 468-75. • CDC descended onto the St. Louis Rams practice facility • 9% of the players had MRSA infections at turf abrasion sites • No MRSA found in nasal or enviromental samples • MSSA recovered from whirlpools, taping gel, and 42 % of the noses of players and staff Kazakova, et al. • Abcesses of the same clone of bacteria were then isolated from a competing team (49ers), suggesting game transmission • CDC initiated a collaboration with the NCAA in developing guidelines for prevention and control MRSA…”targeted for athletic trainers” What else? • 130,000 people are hospitalized with MRSA each year… • “It’s an emerging epidemic”, says Dr. Gonzalo Ballon-Landa, president of Infectious Disease Association of California • 50% of staph infections seen in CA hospitals are MRSA • All it takes is a small opening in the skin for MRSA to finds its way into the bloodstream Like this… • Athlete has a cut or an abrasion…you bandage it • He/She practices, comes into the locker room or shower…. • Throws bandage on the ground • Someone with bare feet steps on it • Now it’s shared What do you do? • Wash hands regularly…and often. Go with anti-bacterial option • Cover ALL wounds, even small ones. Throw old band-aids away • Monitor any abnormality in the skin closely • Don’t share towels, or gear. Wipe down all equipment and weight machines Back to Case 2 The Abrasion • Cover it! • Educate them on taking care of band-aids…and their disposal • Wound checks every day • Emphasize not sharing towels, and cleaning all surfaces The Abscess • It will be drained • And cultured • And antibiotics given…likely Septra, or Rifampin/Clindamycin • Use Lever 2000 soap • Bactroban nasal ointment for household/close contacts Case 3 “I don’t feel too hot.” • 19 year old female complains of a fever • Achy, runny nose, cough • Roommate has the same thing • Looks miserable… – Temp = 101.2, HR = 110 What do you do with her? What temperature is a “fever”? 100.5 and above In general • Mild to moderate exercise may enhance the immune system • If you overdue it…you can put it down • Fevers will decrease strength, aerobic power, endurance, coordination, and concentration…. All of this can lead to injury Effect of fever on physiology • Increased cardiopulmonary effort with reduction in peak exercise capacity • Abnormal temperature regulation • Abnormal lung function • Early muscle fatigue • Just sucks mentally General Recommendations • Avoid strenous conditioning and competition during febrile state (100.4) • Symptoms above the neck: go at 50% for a few mintues, increase the intensity if they clear • Symptoms below the neck: no training What could the fever be from? • • • • • • • • A cold…URI Mononucleosis Pneumonia Meningitis Gastroenteritis Pharyngitis/Strep Bladder infection STD Upper Respiratory Tract Infections • Fever, chills, aches, sore throat, fatigue, cough • Bugs: rhinovirus, adenovirus, coxsackie…VIRUS • Treat: rest, fluids, antipyretics…watch over the counter meds… • Big can of suck it up Pharyngitis Pharyngitis • Signs & Sx: fever, sore throat, swollen/ exudative tonsils, anterior cervical LAN • Group A beta-hemolytic Strep • Rapid Strep tests 85-90% accurate • Throat Culture 95% accurate • Tx: PCN, E-Mycin, or Clinda; fluids, rest, analgesics • Return once afebrile & on antibiotics Infectious Mononucleosis Infectious Mononucleosis • 90% of people EBV + by age 30 • Oral transmission • “Classic Syndrome” is headache, fever, anorexia, giant lymph nodes, malaise, aches, sore throat • What do you have to worry about? Big fat spleen It likes to bleed. And bleed. And that is bad. Splenic Rupture • Usually will occur on days 4 - 21 of illness • It can occur with very minor trauma…even day to day things • Left upper quadrant pain, low BP, high HR • Prompt surgical referral Infectious Mononucleosis Treatment • • • • Symptomatic care Stool softeners? Corticosteroids? When can they play? – Afebrile, symptoms resolved – Get an US if any questions – Start with gradual non-contact activity and slowly progress – Most well in 4-6 weeks, some 3-6 months Pharyngitis vs Mononucleosis • • • • Exudative tonsillitis Lymphadenopathy Myalgias Lab tests Pneumonia • Symptoms: fever, chills, cough, short of breath, fatigue, chest pain • Can be viral or bacterial • Diagnosis confirmed with CXR • Treat with fluids, rest, antibiotics • Return: when afebrile, symptoms resolved The pukes and the runs • SUPER contagious…you ate poop • Symptoms: nausea, vomiting, diarrhea, cramps, fever • Causes: TONS of viral, bacterial, parasitic • Treatment: supportive • Who needs an IV? Archives Ped Adol Med, 5/2004 • Enteral versus IV rehydration in adolescents in gastroenteritis • 16 randomized controlled trial, 11 countries • Looked at weight gain, a decrease in diarrhea • Go by mouth! The Unmentionables HIV, Hepatitis B and C, other STDs Bottom Line • They’re all on the rise… • Prevention and education are key • Transmission: – HIV, Hepatitis B and C: Blood borne – HIV, Hepatitis C: Sexual activities • Body fluids: blood, semen, vaginal secretions, breast milk, amniotic fluid Bottom Line • Other fluids: tears, sweat, urine, sputum, saliva, vomit… • Unless they have blood in them • Transmission in sports is very very very low • Use universal precautions Some questions for you… • How often do athletes report STD symptoms to you? • What is your referral system…is it the student health center? • Do you have a reporting system? Immunizations • Tetanus: Booster every 10 years, or give if has wound and > 5 years since last booster. • Influenza: annually if supplies adequate, no contraindications, lasts 1 yr in healthy people, 25-50% sore @ site, 1% fever & myalgias. • Measles and Pertussis: outbreaks recurring! See guidelines. • Hepatitis B: no clear recommendation for athletes Skin Quiz Name it. Impetigo Drug eruption Chicken Pox Hives Cold sore…Herpes Athlete’s Foot/Tinea Pedis Take Home Points • Counsel your athletes • Avoid overtraining and chronic fatigue • Keep immunizations up to date • Avoid ill people…rashes too • WASH YOUR HANDS Any Questions?