Pre-participation sports evaluation — formative SAQs

SAQ 1 (10 marks) — The fifteen-year-old basketball player who blacked out on the court

Stem: A fifteen-year-old boy presents for a pre-participation sports evaluation before the basketball season. He mentions that he blacked out briefly during a sprint at training last month, recovering fully within a minute. He has no chest pain. His father's brother died suddenly at forty-one. On examination his heart sounds are normal and his blood pressure is 118 over 72. Outline your cardiovascular screen, your interpretation of the red flags, and your immediate management and clearance decision. [1] [5]

Model answer

The cardiovascular screen and the 14 elements (3 marks). I take the AHA 14-element cardiovascular history and perform the four physical examination elements. The history divides into seven personal items, three family items, and the examination. The seven personal items cover exertional chest pain, unexplained syncope or near-syncope, excessive dyspnea or fatigue with exercise, a prior heart murmur, an elevated blood pressure, a prior restriction from sport, and prior cardiac testing. The three family items cover a sudden death before fifty in a relative, disability from heart disease in a close relative under fifty, and a known familial cardiomyopathy or channelopathy. The examination listens to the heart supine and standing, palpates the femoral pulses, seeks the stigmata of Marfan syndrome, and measures the brachial blood pressure in both arms. [1]

The red flags in this athlete (3 marks). This athlete has two red flags. The first is the exertional syncope — a blackout during a sprint is syncope on exertion, and exertional syncope is sudden cardiac death until proven otherwise, because it is the presenting symptom of hypertrophic cardiomyopathy, a coronary artery anomaly, or an ion channelopathy. The second is the paternal uncle's sudden death at forty-one, which is a positive family history of premature sudden death before fifty. Either flag alone would demand a work-up; the two together make a dangerous cardiac condition the leading diagnosis until excluded. [5] [1]

Immediate management and the clearance decision (4 marks). I do not clear this athlete. I restrict him from sport pending an urgent cardiology referral, a twelve-lead electrocardiogram, and an echocardiogram, and I arrange a Holter monitor or an exercise test as the cardiologist directs. He is placed in the restricted-pending-evaluation clearance category, and the return-to-sport decision waits for the work-up. I would not clear him and review later, because the next exertional event may be the fatal one. I also confirm that the school and the club hold a written emergency action plan with access to an automated external defibrillator, because the defibrillator protects every athlete when the screen misses. [3] [1]

SAQ 2 (10 marks) — The sixteen-year-old runner with an elevated blood pressure

Stem: A sixteen-year-old cross-country runner attends for her pre-participation evaluation. She is asymptomatic, her 14-element cardiovascular history is negative, and her heart sounds are normal. Her blood pressure is 132 over 84 on the first reading in the right arm, sitting. Discuss the correct interpretation of the blood pressure, the staging by the AAP guideline, and the clearance decision. [7]

Model answer

Interpretation of the first reading (3 marks). A single elevated blood pressure is not enough to stage the athlete. I repeat the measurement after the athlete has rested for five minutes, with the correct cuff size and the arm supported at heart level, and I confirm the reading in the other arm. A blood pressure that was elevated with anxiety or an incorrect technique often normalises on the repeat. If the reading persists, I stage it by the AAP clinical practice guideline, which defines the thresholds for children and adolescents by age, sex and height percentile, with the absolute thresholds applying to those aged thirteen and over. [7]

Staging by the AAP guideline (4 marks). For an adolescent aged thirteen and over, the guideline defines an elevated blood pressure as a systolic from 120 up to 130 or a diastolic under 80 up to 80, stage 1 hypertension as a systolic from 130 up to 140 or a diastolic from 80 up to 90, and stage 2 hypertension as a systolic of 140 or more or a diastolic of 90 or more. This athlete's reading of 132 over 84 sits in the stage 1 range for her age. I would confirm it on repeat readings — the guideline requires elevated readings on three separate occasions before a diagnosis of hypertension is confirmed — and I would screen for end-organ effects and secondary causes where the reading persists. [7]

The clearance decision (3 marks). The 14-element cardiovascular history is otherwise negative, and the rest of the examination is normal, so the cardiac screen does not by itself restrict her. The elevated blood pressure does, however, make this a conditional clearance rather than an unconditional one. An athlete with confirmed stage 1 hypertension and no end-organ disease may be cleared for sport once the blood pressure is controlled and followed up, whereas stage 2 hypertension or hypertension with end-organ effects restricts the athlete pending the work-up and the management. The clearance therefore reflects the confirmed staging, and I arrange the follow-up to confirm the reading before the season and to manage it if it persists. [7] [3]