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Online Health Chat Transcripts: Cardiac Conditions&Concerns in the Student Athlete with Richard Sterba MD

February 19, 2009

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Introduction

Cleveland_Clinic_Host: Today's live chat with Dr. Richard Sterba is about heart conditions that could affect student athletes. Every year, nearly 200 teenage athletes in this country suffer sudden cardiac death during a game or while training. Dr. Richard Sterba speaks out on how to best prevent these tragedies. Cleveland Clinic pediatric cardiologists believe that the best practice is for pediatricians and family physicians to use national or published screening guidelines. Any patient with abnormal or suspicious findings should then be referred to a pediatric cardiologist for further investigation. Dr. Sterba is available to answer your questions.

Richard Sterba, MD, has been a Staff Physician at Cleveland Clinic for more than 25 years. He is board-certified in pediatrics and pediatric cardiology. He trained in electrophysiology at Duke University Medical Center and he is a member of both the Pediatric and Cardiovascular Institutes at Cleveland Clinic.

Dr. Sterba’s clinical areas of expertise include arrhythmia management, adult congenital heart disease, cardiac problems in athletes, pediatric syncope and pediatric cardiology. He has a special interest in the use of cardiac ablation to treat supraventricular tachycardia, especially in patients with Wolff-Parkinson-White syndrome.

Dr. Sterba has been named one of the ‘Best Doctors in Cleveland’ the last three years. He evaluates patients at the Cleveland Clinic Main Campus, and at the Wooster and Lorain campuses.

Cleveland_Clinic_Host: For more information regarding pediatric cardiology at Cleveland Clinic Pediatric Institute and Children’s Hospital, please visit us on our website: www.clevelandclinic.org/kids or call us locally 216.444.KIDS (4-5437) or toll free 800.223.2273 ext 4KIDS (4-5437).


Overview

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Richard Sterba, MD. We are thrilled to have Dr. Sterba here today for this chat.

We will begin with some general questions about cardiac conditions and how it can affect young athletes. But first, let me ask you a question, Dr. Sterba. Why are you interested in this topic?

Speaker_-_Dr__Richard_Sterba: Whenever we read about a young athlete dying on the field we wonder "Could my child be next?" "How could this happen?" "Who didn't correctly diagnose this potentially fatal condition?" Let's face it, this is the kind of news that sells papers and make people watch TV and read the Internet. IT IS NEWSWORTHY!!

No, none of my family has been personally affected but I have had patients that have been affected. I am not out on a soapbox to change how we evaluate high school athletes. Facts are facts. Sudden death is rare in high school and collegiate athletes- perhaps 1 in 500,000. The incidence of sudden death may not necessarily be increasing as there are many more athletes participating in school sports. Just consider the females that weren't afforded this opportunity years ago.

I like to play sports. All my children have played sports at the high school level and three played in college. I was a coach and I am a pediatric cardiologist. I get asked questions from primary care physicians, parents and the media. They need direction, answers to their questions and to have their fears relieved. There is some new data out there concerning SCD in young athletes but a mass screening approach for a large scale research study would be costly and very difficult to implement. Some European countries push more cardiac testing, especially in Italy but their numbers are so much smaller.


Sudden Cardiac Death

Cleveland_Clinic_Host: Dr. Sterba, can you tell us what exactly is Sudden Cardiac Death (SCD) which may occur in a young athlete?

Speaker_-_Dr__Richard_Sterba: We use the term Sudden Cardiac Death (SCD) when an athlete dies while participating or shortly after coming off the field. SCD occurs because the heart muscle does not receive enough oxygen while the athlete is performing. The athlete develops an arrhythmia that leads to inadequate heart function.

The usual cause of SCD is Ventricular Fibrillation (V-Fib.) V-Fib is the same arrhythmia that causes SCD in adults with coronary artery disease. This arrhythmia can be treated with the use of an AED (automated external defibrillator.)

lars: Are there any other medical conditions that can increase an athlete’s chance of heart problems?

Speaker_-_Dr__Richard_Sterba: Obesity and hypertension are two conditions that can increase the risk of cardiac problems in an athlete. But most commonly the cause of death is an unrecognized congenital heart defect and very rarely an underlying arrhythmia syndrome.

carpoolqueen: Which sport(s) are greater risks for students, as related to heart problems?

Speaker_-_Dr__Richard_Sterba: Statistically, basketball and football have demonstrated a greater risk but soccer is growing. These sports are demanding but some teens with significant heart defects die while sitting, reading or watching TV.


Incidence of Sudden Cardiac Death in Young Athletes

sarahtan: Are kids having more episodes of sudden cardiac death related to athletics than possibly 20 years ago? It seems like there is often something in the media these days.

Speaker_-_Dr__Richard_Sterba: It is not more common than 20 yrs ago, but it is NEWSWORTHY. Look at Ohio this year, pretty quiet, but North Carolina has had at least 5 deaths since the fall!!

To put it into perspective, remember there are more athletes than 20 years ago and better news reporting!!


Causes

sarahtan: Is the problem weather related? Meaning – does this only occur in extremely hot weather, lots of athletic gear, not enough water, etc?

Speaker_-_Dr__Richard_Sterba: Heat can cause heat related illnesses but is a very uncommon cause of death. Coaches are taught to use a "wet" thermometer that considers both humidity and temperature. If that number goes above certain levels, more rest periods and increased fluid intake is mandated. Football practice may be without pads.

Also remember that larger players or obese players may be more susceptible to heat-illnesses.

brandnew: It makes me nervous to hear in the news about athletes that die on the playing field or in practice. Are there rules you should think about regarding temperature outside and sports, or what to drink during practice?

Speaker_-_Dr__Richard_Sterba: It is recommended with high humidity & high temperatures; they wear lighter equipment such as football jerseys, no pads, no helmets, etc.

Shorter practice times and the time of day practice or games occur is also important. In the early morning and late evening the temperatures are less and therefore better for practice times.

It is important that adequate water must be provided. Water is a good choice for fluids.


Warning Signs

cranker: Are there symptoms an athlete would have to alert them to possibility of sudden death?

Speaker_-_Dr__Richard_Sterba: Chest pain with exercise, syncope (dizziness) with exercise and any new symptoms related to exercise intolerance. These are questions that asked on a Pre-Participation Evaluation.

paula: Are there warning signs that I as a parent, or a coach, can look for in an athlete either during or right after play, that would indicate a problem and that some action should be taken to prevent further, more serious problems?

Speaker_-_Dr__Richard_Sterba: Warning signs may include: fainting during or after participation, extreme shortness of breath, an athlete performing worse as the season goes along. Chest pain may be a warning sign although this symptom may be difficult to assess.


Sports Physicals: Pre-Participation Evaluations (PPE)

sammieh: At what age/school level should screenings start, and to what extent?

Speaker_-_Dr__Richard_Sterba: Screening is mandated for all high school sports. One health document you may find interesting from Cleveland Clinic is: Pre-Participation Physicals for Sports

bamagirl: My son plays basketball for his high school. Other than the mandatory sports physical, do you recommend any further testing?

Speaker_-_Dr__Richard_Sterba: Required yearly testing is the way to go. BUT get your exam performed by your child’s health care provider. Mass screening for sports participation misses an opportunity for good medical care such as immunizations and counseling that teens may need.

newtonm: Should everyone who is playing sports, particularly high intensity sports, have an EKG?

Speaker_-_Dr__Richard_Sterba: No it is not required. In Europe an electrocardiogram is required for 'elite' athletes. The International Olympic Committee also requires it.

A Pre-Participation Evaluation (PPE) is required in Ohio and in most other states in order to participate in any school sport. A PPE involves a personal history, a thorough family history, and a physical exam.

harrisburg: If I, as a parent, want to have my 17 year old child further tested before his soccer season starts, what tests should I suggest and is it covered by insurance?

Speaker_-_Dr__Richard_Sterba: This is a tough question. As I stated earlier in the chat, in Europe the testing would be at least an ECG (electrocardiogram). This simple test would identify many cases of hypertrophic cardiomyopathy but may miss coronary anomalies.

An echocardiogram would diagnose most structural defects associated with SCD (sudden cardiac death.) I don't know if insurance would pay for that at $2000-5000 for a study.

Prevention

timsmom: Are there exercise guidelines that should be taken into account to get into shape for athletics?

Speaker_-_Dr__Richard_Sterba: 40 minutes+ of aerobics 3-7 per week.

newtonm: Is weight training OK for younger athletes? Does it help with cardiovascular health or does only aerobic exercise do that?

Speaker_-_Dr__Richard_Sterba: Aerobic exercise is better for overall cardiovascular health. Weight training is acceptable for high school age athletes. They can be sport specific exercises and guided by a trainer at their school.

Younger than age 12, weight training is generally not recommended.

timsmom: What are the recommended dietary guidelines for student athletes?

Speaker_-_Dr__Richard_Sterba: There is excellent information about this topic, but it is beyond the scope of this chat. My suggestion would be to start by looking at the Cleveland Clinic Health Information web site. An excellent document to begin with is: Nutrition for Athletic Performance.

concernedparent: If my 16 year old son is at an elevated risk for problems, but has been cleared by his doctor to play football (which is all he wants to do). What precautions can he take, other than regular check ups? For example, drink more water; take more frequent breaks, etc.?

Speaker_-_Dr__Richard_Sterba: It is difficult to answer this question without knowing the defect or the cause of the elevated risk for problems that you mention. Yearly exams are definitely recommended.

It is important to know that the athlete needs to get into shape and prepare for the competitive season prior to being on the field with the team. Again, diet and fluids are important and can not be emphasized enough.

wellerb: I've heard about the Cleveland Clinic's sports/fitness programs for golf and soccer. Is there one for teen basketball players and would this type of conditioning program (whether done by the Clinic or another institution) help prevent the problems we are discussing?

Speaker_-_Dr__Richard_Sterba: The sports and fitness programs are targeted for fitness. You can get more information at the Cleveland Clinic Sports Health web site. There are several programs offered including a Jump Right program geared toward basketball.

To answer your other question regarding cardiac problems in athletes and the level of fitness, I would say that it is the underlying heart condition that puts the athlete at risk and not the level of training. Meaning - any athlete at risk could also experience symptoms when sedentary.


Adequate Fluid Intake

dragonep: My son plays hockey and I noticed that some of the kids drink high energy drinks prior to play - sometimes more than one. I have told my son not to drink them because I would think it would not be safe prior to playing a game. I don't think he does - but do you have any knowledge about those drinks and what they do? Wouldn't your heart rate speed up? I would like to hear the real truth from an expert.

Speaker_-_Dr__Richard_Sterba: You can drink anything as long it does not a stimulant such as caffeine. Any drink that has caffeine in it is considered a stimulant drink and many of the energy drinks contain a high amount of caffeine. Any electrolyte drink is okay. Water is the cheapest alternative and there have been no studies that have indicated that electrolyte drinks improve performance.


School Athletic Programs and Emergency Procedures

marciaandy: Are school athletic programs required to have emergency medical protocols in place, and as a parent, do I have a right to find out what it is?

Speaker_-_Dr__Richard_Sterba: Schools should have some plan but I don't know if this is required by the state or every state. Some states don't even require physical exams before participation! Ask your school and get active if your school doesn't have a plan!!

persnickity: Is it necessary for athletic programs to have defibrillators available, even at the high school level?

Speaker_-_Dr__Richard_Sterba: Yes, having an AED (automatic external defibrillator) is a great idea. An AED may protect the fans (adults with higher risk for SCD - sudden cardiac death) more than the players. Survival is best related to time of shock (defibrillation)- the shorter the interval, the better the outcome!!

BUT the question is: how do have enough AED's for all the practice facilities a single high school that may be having simultaneous events?

onefortheroad: Are coaches trained to take care of their student athletes in case of a problem? My son has played football from 8 years old. He is now 16. I have been at games where ambulances have been called in to take a player away - never for a cardiac emergency though. But if there was a cardiac emergency, as you have said - speed is of the essence, especially in the use of defibrillators. Are the coaches capable of handling this or is some other type of medical personnel supposed to be at hand?

Speaker_-_Dr__Richard_Sterba: Both coaches and athletic trainers are instructed in the use of AED's. It is actually an easy device to use. Coaches and athletic trainers are also required to participate in continuing education programs that deal with problems that are commonly seen in the high school athlete. Seizures, heat related illness, orthopedic injuries and cardiac problems are addressed in these seminars.


Wolff-Parkinson-White and other Heart Arrhythmias

stine: I have a nephew that was diagnosed with WPW. What exactly is that and how treatable is it? I feel bad for him - he is only 15. He plays basketball. I wonder if he will be able to keep playing if he is treated.

Speaker_-_Dr__Richard_Sterba: WPW (Wolff-Parkinson-White Syndrome) is congenital, electrical abnormality in the heart. There are two electrical connections (instead of one) between the atrium and ventricle chambers. Most patients with WPW can have SVT (Supra Ventricular Tachycardia) SVT is a non-life threatening rapid heart rhythm.

It is important that any individual diagnosed with WPW be cleared by a pediatric cardiologist prior to participating in any sports. He may need an electrophysiologic study like a heart catheterization to assess the properties of that extra (electrical) pathway. It can be treated with medications or ablated (destroyed) with a catheterization.

These kids are usually able to participate in sports with medications and definitely are able to play sports after a successful ablation.

suddenlynow: My son is 17 and has WPW - I would like him to go to a great hospital for an ablation and I have heard Cleveland Clinic is very good but we live in Wisconsin. How would we arrange to come there? Can we send you things ahead of time or do we need to make multiple trips? The weather is not so good and I would like my family to make as few trips as possible? Also - do you know how long the recovery is for an ablation?

Speaker_-_Dr__Richard_Sterba: There are a few ways to obtain an evaluation at the Cleveland Clinic.

For more information regarding pediatric cardiology at Cleveland Clinic Pediatric Institute and Children’s Hospital, please visit us on our website www.clevelandclinic.org/kids or call us locally 216.444.KIDS (4-5437) or toll free 800.223.2273 ext 4-KIDS (4-5437).

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.

Speaker_-_Dr__Richard_Sterba: In a situation like yours, it is nice to receive the medical records prior to appointment. A visit can be scheduled where the evaluation can be completed one day, and if an ablation is a recommended treatment option, it can be done another day.

pandora: I have heard that everyone has a skipped heart beat now and then. My daughter is 12 and she says she feels a skip in her chest every so often? Is that normal for a child too? Should she be checked?

Speaker_-_Dr__Richard_Sterba: Approximately 10-15% of teenagers experience skipped heart beats. This is a type of an arrhythmia and considered generally benign. I would suggest discussing that symptom with your child's pediatrician.

zeus: My son is 7 and he was diagnosed with SVT. Are there some drugs that are safer in children than others? Do they cause harm if he needs to be on them for a long time? Do you ever grow out of this?

Speaker_-_Dr__Richard_Sterba: Children at age 7 usually will not grow out of SVT. Some infants with SVT will lose the problem as they get older.

There are a number of drugs that are safe in children. Most do not have long term side effects. For children who are taking daily medications for years, a heart catheterization and ablation is another option for treatment.


Treatment: Ablation

Cleveland_Clinic_Host: Dr. Sterba, can you discuss what an ablation is?

Speaker_-_Dr__Richard_Sterba: An ablation is a type of cardiac catheterization where catheters the thickness of a piece of spaghetti are introduced into a vein and advanced into the heart.

With these catheters, we study the electrical system of the heart and attempt to induce the tachycardia that has been documented when the patient is having symptoms of palpitations. Tachycardia in teenagers are usually cause by extra electrical connections in the heart.

At Cleveland Clinic, we use intra-cardiac 3 dimensional mapping system to find the location of these extra pathways. Once located, we can usually permanently destroy them either with thermal (heat) or cryo (cold) energy.

When successful, athletes can return to all normal activities without medications. The risk of the procedure is very low. The chance of a successful outcome is very high.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Sterba is now over. Thank you again Dr. Sterba, for taking the time to answer our questions today.

Speaker_-_Dr__Richard_Sterba: With the increasing incidence of obesity in the general population, we cannot suggest that people do not exercise. Children should always be encouraged to do aerobic activities. The goal should be 20-40 minutes almost daily. Lifestyle changes, diet and exercise need to be encouraged by parents who can teach their children by example. Thank you – this has been a great forum.

Reviewed: 02/09

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.