Exercise evaluation and sports participation in heart disease — branching viva

Branch 1 — The immediate decision (3 minutes)

Examiner: The coach wants this signed today. What do you do, and why? [2]

Candidate: I do not sign the clearance. Syncope that occurs DURING exertion, with no prodrome, combined with a family history of sudden unexplained death before 50, is a red-flag combination that halts clearance. Her rapid recovery does not make this benign — vasovagal syncope has a prodrome of warmth, nausea, and visual disturbance and occurs on standing or after effort, never mid-race. I would arrange a 12-lead ECG (already done, borderline), echocardiography, Holter monitoring, and an exercise stress test to look for exercise-provoked arrhythmia, because the resting ECG and echocardiogram may be normal in the child who collapses on the field. I would refer urgently to paediatric cardiology before any return to sport. [12] [13]

Branch 2 — The classification tool

Examiner: If the workup confirms a diagnosis and you must advise on sport, how do you decide what she may do? [1]

Candidate: I use the Mitchell classification of sport, which crosses dynamic intensity (percent maximal oxygen uptake) with static intensity (percent maximal voluntary contraction) into a three-by-three grid of nine cells, from billiards at the lowest-load corner to boxing, cycling, and rowing at the highest. I pair the cardiac lesion and its severity with the load of the intended sport, and I sort eligibility into three tiers — cleared, individualised, or disqualified — rather than applying a blanket ban. A low-risk lesion may enter almost any cell, a moderate lesion is matched to an acceptable cell, and a high-risk lesion is excluded from competitive sport regardless of cell. [1]

Branch 3 — The channelopathy angle

Examiner: Her QTc is 470. If genetics confirms long-QT type 1, what is her tier and what is the rationale? [8]

Candidate: Symptomatic long-QT syndrome is a channelopathy that disqualifies from competitive sport, because the risk of an arrhythmic event during adrenergic stress is substantially elevated. The QTc of 470 is borderline in a 15-year-old female, but the exertional syncope and the family history make this high-probability, and an exercise test showing failure of QT shortening, or a genetic confirmation of KCNQ1, would settle it. She remains encouraged toward leisure activity within limits, on beta-blocker therapy, with surveillance and cascade screening of relatives. I would emphasise that the resting ECG may be normal and exercise is the trigger — that is why the symptom drives the decision. [8] [10]

Branch 4 — The repaired-lesion contrast

Examiner: Contrast her with a 14-year-old who had a ventricular septal defect closed at age 4, with a clean current echo. Different tier? [4]

Candidate: Yes — that child is cleared. A repaired simple lesion with no residual shunt, normal function, and no pulmonary hypertension, plus a clean exertional history, places the athlete in the cleared tier for all sport. The contrast makes the principle explicit: clearance and individualisation are lesion-and-symptom matched, but a normal repaired lesion is not restricted, and unnecessary restriction is itself a harm because it removes the benefits of exercise and stigmatises the cardiac child. [4] [11]

Branch 5 — Venue safety

Examiner: The coach argues the school has no defibrillator. Why does that matter to your decision? [9]

Candidate: Every venue where children compete must have a written emergency action plan and an accessible automated external defibrillator, and trained staff to use it. Defibrillation within three to five minutes is the single biggest determinant of survival in athlete sudden cardiac arrest, and survival falls by roughly ten per cent for every minute of delay to shock in a shockable rhythm. No preparticipation screen is perfect, so the venue response is the secondary line of defence behind screening. I would not sign clearances for a venue that lacks an emergency action plan and an AED, and I would advocate for their provision as part of my role. [9] [13]