Exercise evaluation and sports participation in heart disease — formative SAQs

SAQ 1 (10 marks)

A 15-year-old competitive cross-country runner is brought to your clinic before the school athletics season. She collapsed during a race three days ago, mid-effort, with no prodrome, and recovered within a minute. Her father died suddenly at 41 with no cause identified at autopsy. Her coach is pressuring for a clearance so she can run in the regional finals next week. Her resting 12-lead ECG shows a QTc of 470 milliseconds. [12] [2]

1. Give your immediate clinical decision regarding clearance, the significance of the exertional syncope and family history, and the further investigations required before any return to sport. (4) [12] [13]
2. Describe the role of the 12-lead ECG in preparticipation screening, the athlete-specific interpretation that applies, and the single piece of evidence that most supports adding the ECG to history and examination. (3) [2] [13]
3. Outline how you would counsel the athlete and her family, including the tiered clearance framework, the venue safety requirements, and the principle of the greatest safe activity. (3) [9] [11]

Model answer — SAQ 1

(1) Immediate decision and significance (4). The clearance must not be signed. Syncope occurring DURING exertion, with no prodrome, combined with a family history of sudden unexplained death before 50, is a red-flag combination that halts clearance and mandates urgent cardiology referral. Vasovagal syncope has a prodrome of warmth, nausea, and visual disturbance and occurs on standing or after effort, never mid-race — so her rapid recovery does not make this benign. A QTc of 470 milliseconds in a 15-year-old female is borderline-prolonged and, in the setting of exertional syncope and a positive family history, warrants full investigation. The further workup is echocardiography to define structure, Holter monitoring for paroxysmal arrhythmia, and an exercise stress test (with QT adaptation and CPVT surveillance) to unmask an exercise-provoked arrhythmia, because the resting ECG and echocardiogram may be normal in the child who collapses on the field. [12] [8]

(2) Role of the ECG in screening (3). The 12-lead ECG is the single most powerful test in the symptomatic athlete, but it must be interpreted with athlete-specific criteria, because athletic training produces benign changes — early repolarisation, isolated voltage criteria for left-ventricular hypertrophy, and right precordial T-wave inversion in some athletes — that overlap with disease. The International Recommendations for ECG Interpretation in Athletes were built to reduce false positives without missing disease. The single most cited evidence supporting the ECG beyond history and examination is the Italian Veneto study, which showed an approximate 89% reduction in sudden cardiac death among competitive athletes after the introduction of mandatory ECG-inclusive screening, mostly through earlier detection of cardiomyopathies and channelopathies. [2] [13]

(3) Counselling, tiers, and venue safety (3). Frame the decision in three tiers — cleared, individualised, or disqualified — matched to the lesion, the sport's Mitchell grid load, and the athlete's symptoms and family history. Stress that the goal is the greatest safe activity, not a blanket ban: most children with heart disease can and should exercise, and restriction, where needed, is competitive-specific and intensity-matched. Because no screen is perfect, every venue must have a written emergency action plan and an accessible automated external defibrillator, and trained staff to use it, since defibrillation within three to five minutes is the biggest determinant of survival in athlete cardiac arrest. Reassure that even a disqualifying diagnosis permits leisure activity within limits, and address the psychosocial cost honestly. [9] [11]

SAQ 2 (10 marks)

A 14-year-old boy presents for a sports clearance to play school rugby. At age 4 he had a ventricular septal defect closed surgically. His current echocardiogram shows no residual shunt, normal biventricular function, and no pulmonary hypertension. He is asymptomatic with no exertional symptoms and a clean family history. A second child in your clinic is a 16-year-old with known bicuspid aortic valve (normal function, aortic root z-score 1.4) who wants to play competitive basketball. [4] [11]

1. For the first child, state the eligibility tier and the reasoning, and explain why unnecessary restriction is itself a harm. (3) [4] [11]
2. For the second child, give the eligibility tier, the reasoning about sport type, and the surveillance required through growth. (4) [4] [6]
3. Contrast these two with a third athlete — a 16-year-old with hypertrophic cardiomyopathy who feels well and whose echo is stable — and explain the difference in approach. (3) [3]

Model answer — SAQ 2

(1) Repaired VSD (3). This child sits in the cleared tier. A repaired simple lesion — a closed ventricular septal defect with no residual shunt, normal biventricular function, and no pulmonary hypertension on current echocardiography — combined with a clean exertional history and family history, clears the athlete for all sport. Unnecessary restriction of a successfully repaired simple lesion is a recognised harm: it removes the cardiovascular, metabolic, mental-health, and social benefits of exercise and stigmatises the cardiac child. The modern approach is the greatest safe activity, not a blanket ban. [4] [11]

(2) Bicuspid aortic valve (4). This athlete sits in the individualised tier. A bicuspid aortic valve with normal function and a normal-sized aortic root (z-score 1.4) clears him for most sport, but high-static and collision activity is restricted because the pressure load threatens both the valve and the aorta. Basketball is a high-dynamic, moderate-to-high static sport; he can usually play non-elite basketball but collision variants and heavy strength training are avoided. The surveillance is serial echocardiography through growth, because the aortic root grows with body size and a root that grows disproportionately to body size tips the decision toward greater restriction. [4] [6]

(3) Hypertrophic cardiomyopathy (3). This athlete sits in the disqualified tier, and the approach is fundamentally different. Hypertrophic cardiomyopathy is excluded from competitive sport regardless of symptomatic status, because the risk of sudden cardiac death during exertion is substantially elevated and not abolished by treatment or a defibrillator — being asymptomatic and having a stable echo do not change this. The contrast with the first two is that clearance and individualisation are lesion-and-symptom matched, but certain high-risk diagnoses carry a blanket competitive disqualification. The disqualified athlete is still encouraged toward leisure activity within the lesion's limits, and is enrolled in lifelong surveillance, disease-specific treatment, and psychosocial support. [3] [8]