Is a Referral to Sports Cardiology Right for Your Patient?

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart Vascular and Thoracic Institute at Cleveland Clinic.

Tamanna Singh, MD:

Hi everybody, my name is Dr. Tamanna Singh, I'm one of our co-directors for the Sports Cardiology Center here at main campus for Cleveland Clinic.

Michael Emery, MD:

And I'm Dr. Michael Emery. I'm also co-director of the Sports Cardiology Center.

Tamanna Singh, MD:

And we're here to talk to you a little bit about what our center can offer to your patients.

Michael Emery, MD:

Question we often get asked, Tamanna, is what is sports cardiology?

Tamanna Singh, MD:

Sports cardiology is actually a very exciting field. It's very specific. We tend to see a lot of active individuals ranging from those who might be recreational athletes, high school, collegiate athletes, all the way to the professional ranks. We see individuals for pre-participation cardiovascular evaluation, and that's something that we oftentimes do just around here within Cleveland, seeing a lot of our local high school and collegiate folks. And we also do management of individuals who have cardiovascular diseases and illnesses. Things that probably come quickly to mind are run of the mill cardiovascular disease, any sort of channelopathies or cardiomyopathies, individuals who may have aortic disease. And like I mentioned, we see people all the way up through master's athlete range above 40 years and onward.

Michael Emery, MD:

Yeah. And we do a lot of symptom evaluation too. And I think the key differentiator for us when we see an athletic person and not necessarily a professional athlete, but an athletic person with symptoms during exercise, we try really hard to understand the physiology of what could be creating their symptoms and recreate that. We want to treat them like an athlete. We don't want to necessarily treat them like a 65 year old who's never gotten off the couch. We want to try to recreate those symptoms either in the lab or in the field with active monitoring that's appropriate for them.

Tamanna Singh, MD:

And I think Mike, what you're alluding to is one of the specialties of our particular niche and having patients come to be evaluated by us, is that we do have a cardiopulmonary exercise testing lab, which allows for us to, "recreate or simulate" exercise situations where patients may have symptoms. For instance, we could have individuals bike with us. We can have individuals run with us and we can try to recreate a specific scenario where they say, "You know what doc, I've got chest pain at this level of exertion," or "palpitations," or "I feel lightheaded," and whatnot. I think those are some really, I think, helpful ways we can provide our primary care providers with an outlet to have us see any sorts of patients. Again, really of any probably active level, it doesn't have to be a competitive athlete, but someone who's really looking to have a more nuanced, more focused lens in terms of their symptomatology or management of a cardiovascular issue.

Michael Emery, MD:

Yeah. In piggybacking on that, we use a lot of that same testing then to help athletes with known cardiovascular disease, particularly aortopathies, coronary disease, valvular disease, get back to the exercise that they want to do. We don't want them to be afraid of exercise. Exercise is good. And a lot of them want to do more than just moderate intensity, brisk walking. They want to be a little bit more competitive, although they may not be signing up to win medals, but they want to go out and do a little bit more, so we're trying to use the testing that we can, particularly the cardiopulmonary exercise testing, to give them some good exercise and very specific exercise prescriptions that can help them get back to where they want to be.

Tamanna Singh, MD:

And Mike, do you mind just talking a little bit about what cardiopulmonary exercise testing is?

Michael Emery, MD:

Yeah. Cardiopulmonary exercise testing is sort of a medical phrase for a VO2 max test. Many of you may have heard of that. It's where you wear a mask and we collect the gases that you expire to get a VO2 max, which is typically what's thrown around on the websites by people. But we get a lot more in-depth information about that, about pulmonary disease or contributions, cardiovascular disease and contributions. And then we can use those zones that we can delineate, like anaerobic thresholds, to provide more specific exercise prescription in different zones for different training levels.

Tamanna Singh, MD:

Oftentimes we have recreational or competitive or active individuals come to us and say, "Doc, you know what? This is a heart problem that I have," for instance, hypertrophic cardiomyopathy, "And I've been told that I really should not exercise, or I should really keep my exercise light in intensity." Cardiopulmonary exercise testing allows for us to actually take a look at their heart rate zones, see whether or not they do develop any sort of premature ventricular contractions or non-sustained ventricular tachycardia at a specific heart rate. And we can actually use that information to create their own exercise plan. And that allows for us to give them the tools to exercise safely while they also get that mental health benefit of being able to do something that they really enjoy.

Tamanna Singh, MD:

And Mike, you even talked about kind of the caliber of our athletes. Yes, they're not all professional athletes and I don't think we both do this field to take care of the pros specifically, but a lot of individuals, as they get older, love to run the long distances or bike the long distances, or get into strength training and things like CrossFit and have your weightlifting. And I think, we need to do our due diligence and advocating and really encouraging our older individuals to stay active so that they can maintain the appropriate muscle mass and the endurance to stave off any sort of cardiovascular risk. What do you think?

Michael Emery, MD:

Yeah. I totally agree. That's a lot of the patients we see is about sort of rendering a second opinion on what's appropriate exercise for them. And it can be difficult because unless you really understand the physiology of exercise and I think Dr. Singh and I bring a lot of personal experience into this, with what we do, to understand sort of what weightlifting means and what something really weighs. And we are not very good at giving you a weight to lift, we give you a general range, because things are different from person to person. What's heavy for one person may not be heavy for another person. What's intense for another person may not be so intense for another person. We want to be very specific about trying to give that athlete information that they can really use.

Tamanna Singh, MD:

And we're also really helpful when it comes to managing individuals who may be coming for cardiovascular surgery. We see a lot of individuals who may have valvular disease, despite their activity level, who may have issues, like I've mentioned, with cardiomyopathies that need to be surgically managed, or perhaps even cardiovascular disease coming in for bypass surgery or aortic disease coming in for aortic repair. And we are here to provide the tools with respect to how they can return to exercise after their surgery. And I think that's probably one of the biggest highlights and gratifying experiences for me, being able to tell our athlete patients, "You don't have to put your running shoes up," or, "You don't have to rack up your weights anymore, there are ways to again, be able to kind of recreate what you were able to do preoperatively, safely in a postoperative setting."

Michael Emery, MD:

I want to turn the page a little bit and talk about the other big part of what we see and that's what we call exercise induced cardiac remodeling or the athlete's heart. Dr. Singh, why don't you tell us a little bit about your perspective on the athlete's heart and how we as sports cardiologists, can help in that avenue?

Tamanna Singh, MD:

Sure. We have a lot of evidence to date now that shows that specific forms of exercise, whether it be endurance sports, so things like long distance running or long distance cycling or rowing and skiing, as well as activities like heavier strength work, strength training, and heavier weightlifting. Again, recognizing that there's a lot of overlap among sports. These types of exercises do cause appropriate physiologic changes to the heart muscle. You may have heard of terms like athlete's heart or four chamber enlargement consistent with athlete's heart. Oftentimes we can recognize these physiologically appropriate changes in the heart muscle. And we're able to provide a recommendation that essentially supports that this is not an abnormality. We see a lot of individuals coming in sometimes for second and third opinions saying, "I was told that my heart is abnormal," but we at least have the expertise to say that these appropriate physiological changes and how the heart looks, how it's working, how thick it is, how large it is, that it's appropriate for that patient's amount level, intensity and type of activity.

Michael Emery, MD:

Yeah. And I think one of the things I often talk about patients and other providers is that an athlete's heart is not a diagnosis. It's normal. It's a normal physiological finding that we would expect. Now, in some regards, though, if you take what we see on an imaging study in isolation, without the perspective of what may have got them there, it can look in isolation like a dilated cardiomyopathy or hypertrophic cardiomyopathy. But then you have to put it into context of that athlete, watch their physiological state. What would we expect from their sport to differentiate, what is exercise induced cardiac remodeling, which I think often is a better term than athlete's heart, from a pathological substrate. But that can take some nuance to figure out-

Tamanna Singh, MD:

And that's-

Michael Emery, MD:

We certainly don't want to label someone with a normal cardiac remodeled heart from being an athlete, as having a disease. And we don't want to miss someone that has a disease and call it, "Oh, this is just an athlete's heart," and then they're putting themselves at risk, potentially.

Tamanna Singh, MD:

How often would you say you've seen patients come to see you who say, "I was told that I can't play my sport anymore because my heart is abnormal," but it's actually not?

Michael Emery, MD:

More than we like.

Tamanna Singh, MD:

Exactly.

Michael Emery, MD:

Yeah.

Tamanna Singh, MD:

Exactly. And I think that's where having a Sports Cardiology Center, dedicated individuals who practice this field along with the support of many of our colleagues within kind of all the cardiovascular and surgical specialties really makes us, I think, a really incredible tool here for a lot of our primary care providers, our sports medicine physicians, even our trainers and our coaches. I think it's really important to emphasize that we are here to support individuals who want to be active, who want to stay active in however capacity, whatever capacity we can. And also emphasizing that we have that knowledge, that understanding of sport-related change, what is normal and what is abnormal. If I were one of our wonderful primary care providers, what kinds of patients would I be able to send you Mike, to the Sports Cardiology Center?

Michael Emery, MD:

So from primary care, I think a lot of it ends up being symptom driven in an athletic patient or screening driven when you have screened a young athlete in particular, and now this screening doesn't come back completely, "normal," and you don't know, is this remodeling, is this something I should be worried about? That's from a primary care physician standpoint, I think that's a lot of predominantly what we see. But then, why don't you also then comment on why other cardiologists send those patients too.

Tamanna Singh, MD:

Yeah, no, that's an excellent question. We actually see a lot of patients who are either already diagnosed with a cardiovascular abnormality and they're looking for specialized exercise recommendations. We also see patients who are pre/post-surgical, again, looking more so for exercise recommendations. We oftentimes get asked by our colleagues, how to manage patients, whether or not there should be a restriction on sport or no restriction on sport. And even questions about surgical management, is this individual who may have some cardiovascular abnormality, but not that symptomatic, is that someone who really needs to go to surgery or not to surgery. And I think the jury's out with respect to surgical management of a lot of common things like valvular disease in terms of, does athletic performance get compromised? Does it improve? Does it stay the same? But we're definitely used as tools around here for those types of scenarios. Tell me a little bit about EKG screening and what we're doing about that.

Michael Emery, MD:

EKG screening in young athletes is controversial still. It's mostly controversial because what we're trying to do when we screen young athletes, is find the needle in the haystack of that one rare athlete who may be at increased risk for sudden cardiac death, which is a devastating outcome, obviously. Thankfully, it's rare. And the EKG has the potential to pick those out a little bit more, but there are a lot of findings on a young athlete's ECG that we would call normal and consistent with cardiac remodeling from exercise, that in a typical training program where you learn to read ECGs or a standard ECG machine that you have in your office per se, would come out abnormal. In fact, the initial criteria from 2010, that started to delineate what's normal and abnormal on an athlete ECG, had a false positive rate approaching 40%. Now that false positive rate is much lower, but you really have to know what you're looking for. In our hands, experts in this who read thousands of athlete ECGs a year, we can keep that false positive rate pretty low and make it a pretty useful tool, but you have to be careful whose you're employing to do these things.

Tamanna Singh, MD:

And I think that's an excellent point. We all are trained to read EKGs, but we all are not trained on how to read athlete-specific EKGs. And I think that's one incredible service that we do offer within our Center. We did just pilot, a EKG screening program for our surrounding colleges. We definitely do it for our high school athletes as well. And essentially anyone who's coming in, either with an issue or just for basic cardiovascular screening for sports participation. But we do encourage our primary care providers as well as our sports medicine physicians, to utilize us in those situations, particularly when questions about EKGs come up.

Tamanna Singh, MD:

Well, I think we probably have mentioned a lot of our strengths as the Sports Cardiology Center. I think for being one of the biggest things I'd like to make sure I emphasize is that we are here to help you. And like we've mentioned, we have individuals who do exercise across the spectrum and in my mind, anyone can be or will be, or is an athlete. And I think if we can answer some of your questions or help with the management of your patients, please do reach out to us. Mike, how can they reach out?

Michael Emery, MD:

Certainly they can email us directly, if you have access to our emails. We have a website on the Cleveland Clinic website dedicated to our Sports Cardiology Center with dedicated phone number, a dedicated email to our Sports Cardiology Center, and then a second opinion option button under our profile pictures.

Tamanna Singh, MD:

Great. Thanks so much.

Michael Emery, MD:

Thank you.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard, subscribe wherever you get your podcasts or listen at clevelandclinic.org/cardiacconsultpodcast.