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Playing sports is one major way kids can learn important life skills while staying healthy and strong. However, when a child is diagnosed with a heart condition, parents might wonder if it’s still safe for them to play. Pediatric cardiologist, Dr. Akash Patel, discusses what to know about student athletes and heart safety, the importance of pre-participation cardiac screenings and important precautions to take on and off the field.

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Heart Safety and Student Athletes with Akash Patel, MD

Podcast Transcript

Speaker 1: There's so much health advice out there, lots of different voices and opinions. But who can you trust? Trust the experts, the world's brightest medical minds, our very own Cleveland Clinic experts. We ask them tough, intimate health questions. So you get the answers you need. This is the Health Essentials Podcast brought to you by Cleveland Clinic and Cleveland Clinic Children's. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.

Annie Zaleski: Hello, and thank you for joining us for this episode of the Health Essentials Podcast. I'm your host, Annie Zaleski. And today, we're talking about heart safety in kids playing sports, with pediatric cardiologist, Dr. Akash Patel.

Exercise is one of the best things people of any age can do to stay healthy and strong. For kids, playing sports can also be a helpful way to learn about perseverance and how to work as part of a team. However, some student athletes may be playing sports while living with a health condition, such as a heart condition. What do parents need to know to ensure that kids stay safe? Dr. Patel is here to discuss cardiac screenings for student athletes, what parents need to know about kids living with heart conditions playing sports and safety precautions to take. Dr. Patel, thank you so much for being here.

Dr. Akash Patel: Thanks for having me.

Annie Zaleski: So, I'd like to start off the podcast by having you tell us a little bit about your work here at the Cleveland Clinic. What kind of research and clinical work do you do?

Dr. Akash Patel: Well, thanks for asking, Annie. So, I'm a pediatric cardiologist who specializes in pediatric electrophysiology, which relates to managing children with abnormal heart rhythms, or what we call arrhythmias, both children and adults with adult congenital heart disease who have the same conditions, and then other patients, pediatric patients who may have conditions that may pose risk to having arrhythmias or sudden cardiac arrest. I currently am the director of Pediatric and Congenital Electrophysiology here at the Clinic and work with a team of colleagues and care providers to manage these patients.

So, in terms of research, so, most of my research focuses on clinical research, with focus on how to improve and reduce radiation for EP procedures, how to diagnose, manage and the care of children with abnormal heart rhythm conditions, pacemakers or defibrillators — both in the inpatient, outpatient and procedural settings — and to work on sort of multicenter collaborations, to leverage expertise across the country, to treat these often uncommon and rare conditions.

Annie Zaleski: That's amazing. That must be just such interesting work. I mean, I'm going to work every day. There's supposed to be something new to discover and things like that.

Dr. Akash Patel: Yeah, no, I think working with a broad range of ages of patients from kids that have normal hearts to, with minor symptoms, to the very complex, and caring for patients in all venues really creates both a very interesting and exciting job, but also provides us the opportunity to care for our patients in different care settings, especially at moments when they need us the most. And often what we do can also be curative, meaning that some of the conditions that we treat can actually fix or solve the problem, which is always gratifying to see a patient fix their problem, and then ultimately say goodbye, which is very gratifying.

Annie Zaleski: So, in your work then, I guess, let's kind of set the stage for the podcast and talk about what are the most common heart conditions you typically see in kids?

Dr. Akash Patel: Yeah, so it comes in a few flavors. So, as it pertains to today's discussion, we see children who may just present with cardiac symptoms, typically syncope or passing out, palpitations or racing or rapid heartbeat, chest pain or shortness of breath with exertion. So, it could be just symptoms that drive patients to come see us. And then we also see patients who have known or we diagnosed them to have abnormal heartbeats or arrhythmias. We see patients who have had congenital heart disease who develop abnormal heart rhythms that need medical management or device therapy like pacemakers or defibrillators. And so we see a broad range of diagnoses, but those are the typical, most common scenarios. And then of the rare conditions, we do see patients who have cardiomyopathies that may have arrhythmias, inherited arrhythmia disorders, which are problems in which children can look otherwise well, but can have a predisposition having life-threatening arrhythmias as sort of unique to our practice.

Annie Zaleski: So, it sounds like the condition, depending on what it is, could be congenital, it might develop at a certain age or it seems like it could vary from person to person.

Dr. Akash Patel: Yeah. So, some of the things that we see can include fetuses who have an abnormal heart rhythm that are just being seen by their obstetrician to a child who at any age or young adult presents with symptoms that prompts an evaluation to patients who have had known cardiac surgery, and then at some point in their life, as they're being followed by their physicians or care providers or themselves manifest symptoms. You get involved to sort of address issues that may come up. So to your point, yeah, it can be at any age at any time. And it may not be something that they were born with, but can be acquired or develop over time.

Annie Zaleski: So, kind of given the complexity and the fact that it can kind of vary, in general, what sort of advice do you have if parents want to know can kids play sports if they have a heart condition? Is it safe?

Dr. Akash Patel: Yeah. So, it's a great question. I think for many things, sports, and for many kids, sports is a very important part of childhood. There's a lot of benefits in terms of social, emotional development, teamwork and just pure joy. And so our job is to make sure that kids can play sports safely. There are unique circumstances where we would like kids to avoid playing certain types of sports or may tailor the sporting environment to be the safest as possible. But ultimately, the goal is that most kids can play sports safely, but the goal is to identify those patients or children who may be at risk for having a concerning cardiac event on the sporting field. And clearly to identify that before that happens is always the best scenario.

Annie Zaleski: Well, that's what I was going to ask is that how do the rules might change around playing sports if a kid lives with a hard condition? Do they need to stay away from certain sports? Can they only compete in maybe track and field certain events? How does that usually work?

Dr. Akash Patel: Yeah, so it usually depends on the condition that they have. So, if they have just symptoms and they've undergone an evaluation that has shown that there's no concerns, then they're often allowed to play any sports. If they have a cardiac disease such as cardiomyopathy, hypertrophic cardiomyopathy being the most concerning, then, we may restrict sports because we know that in those patients who play sports, they're at increased risk of having a cardiac arrest during activity. Now, not all kids with that diagnosis may be the same. So, there are circumstances where they may be able to play certain types of sports or certain levels of activity.

Patients who have inherited arrhythmias, which for a long time, we restricted them from playing sports. One of the conditions would be long QT syndrome. We've learned that if we create a proper safety net for kids, that often can allow us to be more liberal, especially if there's shared decision making with the child, the parents, the school or the team and the physicians to create an environment where they're on the appropriate medication, the care providers or the trainers, or the parents know how to give CPR. And clearly we feel that their condition based on an individual assessment poses low risk. So, it really is unique to each child and each condition and there's many different types of conditions, but for the most part, most kids can play sports safely even with cardiac disease.

Annie Zaleski: Well, I would imagine that one of the things that's most helpful to figure out what parents and kids to make the best decision would be a pre-participation cardiac screening. So, when kids are gearing up to play sports then, what health information is important to share with schools?

Dr. Akash Patel: Yeah, it's great. I think one of the things that has come out is the pre-participation screening form that has been developed by the American Heart Association really tries to identify either symptoms from a personal history standpoint, family history that children may have inherited conditions, cardiac conditions that may pose risk or the child themselves may have abnormal findings on a physical exam and sort of looks at those factors to really help us tease out who needs further evaluation before they can be cleared for sports. And really, conditions that we look for are those that can cause either sudden cardiac death or arrest, which can happen in anywhere between one in 50,000 to one in 300,000. So, it's very uncommon, but clearly, when those events happen, they're tragic, they clearly can be on the media, so create a lot of media attention, but often can be very impactful clearly to the family and to the community of students in school and other families.

And so the job with that pre-participation screen is to really get honest answers and to get in a baseline assessment of a child to say, “Yes, there's nothing wrong with this kid that I feel OK, they can go play sports,” or there's something that isn't quite a hundred percent normal, and so now I need to think about any additional testing or potentially referring to a cardiologist to get further evaluation to make sure that the screening test has not identified a condition of concern.

Annie Zaleski: Now, is a cardiac screening, is that included with the physical or is that something separate? What is kind of the difference between the two and how are they kind of related?

Dr. Akash Patel: So, great question. I think from a pre-participation cardiac screening, it's really focused on heart conditions that can be elicited based on the survey. So, sort of to break it down a little bit, so in terms of personal history, things that parents and children should look for are, are they having symptoms during exertion like chest pain, any chest discomfort, feeling of racing or rapid heartbeat or palpitations? Do they feel dizzy or lightheaded or do they pass out during sporting activities? Have they had a previous abnormal cardiac exam? Do they have high blood pressure? Have they ever had a pre-participation screen before that was abnormal? And have they undergone any cardiac testing that again would've raised suspicion? And this should be done on an annual basis because clearly as you described, some of those symptoms may not occur one year, but may develop the following year. So it should be done on a yearly basis.

In terms of family history, things that we're looking for are really around early onset history of sudden cardiac death or arrest, usually under the age of 50 and more concerning when it's under age of 35 and particularly if it's happened with activity. Is there family history of heart disease under the age of 50? Is there a history of inherited conditions like cardiomyopathies, which are basically enlarged or thick hearts or abnormal heart function? Is there a history of inherited cardiomyopathies or connective tissue disorders like Marfan syndrome? And so, you sort of go through that questionnaire because again, family's histories may also change on a year basis.

And then the last part is the exam, right? So, if they have a murmur on exam, that's atypical. If they have high blood pressure, if they have abnormal femoral racing pulses in their leg, or if they have characteristic features of a syndrome, like Marfan, that can be associated with cardiac disease, these are the components that really are part of a pre-participation cardiac screening.

When we think about a sports physical, it's really around, and many places will incorporate parts or all of this, but then it's really around other conditions that are important for athletes. So, these are things that primary care providers will often provide, which is, are there any musculoskeletal problems, right? So, predisposition to ankle injuries or knee injuries or things like that. Are there previous history of concussions or head trauma that's become much more prevalent and obvious now as we've learned more about sports like soccer and football, where repetitive hitting of the head can even at low impact can cause those things and clearly having some sense of cognition or headaches or other concerns that an athlete may have, clearly emotional social, emotional factors, or they have good nutrition. Do they have any mental health problems?

So, all of that generally falls in sort of a more global sports physical where they want to make sure from head to toe, not only is the heart OK, but everything else is OK. And then by taking a good inventory with questions just to make sure that there's any other conditions that may predispose them to having either other injuries related to sports or struggles with sports. And so, that's how I would differ the cardiac screening vs. a sports physical, which sort of would incorporate all or parts of that.

Annie Zaleski: Well, it seems like to really get a complete picture of what kind of a student athlete's health is, you almost need both because they're very complementary.

Dr. Akash Patel: Yeah. I think especially in this day and age, there are a lot of positives that happen with sports, but we know that as kids get older, in general, we think about pre-participation screening in middle and high school. And so as the competition gets more intense, so does the stress and the mental health aspects. We see famous athletes take breaks from their sporting events because of that. And I think those are really important aspects of making sure a child is both healthy from a heart standpoint, but also healthy from a mind and body standpoint so that they can enjoy sports and be safe. So yeah, it should be a really holistic global process that they undertake when they get evaluated.

Annie Zaleski: So, are there particular sports that are more crucial to have cardiac screening?

Dr. Akash Patel: That's a great question. I think as we've learned a lot of the events that we see in terms of young athletes having around just the typical college sports or — sorry, high school and middle school sports — that we see, and part of that is because those are the most common sports people play. Part of it is because those sports can be very intense. And so, generally, when we think about when events happen, it's usually the typical top three, soccer, football and basketball, in terms of that. But any sport in reality can cause events to happen. When people have actually looked at this and seen over thousands of patients who've had events, it runs a laundry list of sporting sports you could think of from field hockey, to hockey, to swimming and beyond. And so most things I would confine to really what are the competitive sports that kids can play both at the middle school and high school level because those are the ones that are going to be the most strenuous enduring or — sorry, most strenuous — and can cause issues.

But really, anybody who's going to play competitive sports should get a screen regardless of how intense one may perceive it because there are kids who play, I would say, for instance, like some sports that may be leisure type of sports, tennis, for instance, where you think, well, that's not really hard. But you see how competitive tennis athletes will train, right? They condition with running, when they're playing a grueling match, right. That's probably maybe more intense a sport than saying you're the kicker on the football team, but your "sport" is being a football player. So, it really is anything where your heart rate gets up and you're really pushing yourself and breaking a sweat I would classify as an activity that warrants some degree of evaluation.

Annie Zaleski: So, you mentioned middle school and high school, especially sports. Would younger kids than that have a cardiac screening if maybe they're ... obviously, there's competitive hockey and some kids swim. Is there a specific age you should start having these?

Dr. Akash Patel: Yeah, generally we recommend middle and high school. So, I think about an average sixth grader is around 12 years of age would be sort of when screening should happen. Most events will happen because some of these conditions will not occur at younger ages. So, you're talking about sort of teenagers, young adults. So, I think that's generally, where you're going to be the most likely. But clearly, if you have a child, is I guess, super talented and maybe nine or 10, and may express symptoms to their pediatrician or primary care provider or to a parent, then those kids should get evaluated. But they're not required to play sports in Ohio to have a pre-participation screen done. But I think under 12, I would say if the kid has symptoms or you're concerned, then clearly get evaluated. But clearly over 12, and if you're playing competitive sports, then I would say, it's a must.

Annie Zaleski: Well, you mentioned symptoms. And that was I think one of the questions that people ask. If a kid has a screening, what is kind of the sign that a cardiologist visit would be necessary or they might want to see their pediatrician? What are some of the major red flags maybe?

Dr. Akash Patel: Yeah, great question. Something WE highlighted on, but really it's around symptoms during exertion. When we talk about exertion, think about as exercise or sports. So, chest pain being one or chest discomfort that would be of concern. Some kids can have musculoskeletal pain or, if they're really pushing themselves really hard, get winded and sort of feel chest discomfort. But again, if it's significant pain, it doesn't resolve with just resting or rehydrating, those would be things of concern. Clearly, passing out is a big red flag. So, an athlete who is sort of running on the field and collapses suddenly, clearly that's going to prompt concern, but even an athlete who sort of feels like they're about to pass out should get evaluated. Now, a lot of that can be right in a hot summer day in Cleveland and the coach is making them run and it's a hundred degrees outside and maybe just the typical potentials of heat exhaustion or heat stroke and in rare cases or dehydration.

So, context matters in terms of when those symptoms happen. But if they don't abate with the typical sort of rehydrating and resting and really don't fit the degree of exertion and then they have these events, then they should definitely get screened.

Finding a rapid heartbeat. Clearly, your heart rate will increase with exercise. All kids do that, but if it feels like it's just beating too fast or even if they rest and the heart continues to beat very fast or regular, that would raise concern. And then one that's often hard to tease out, but we always ask is, with activity, do they seem to tire easily or do they have shortness of breath? And that's why it's hard important to get evaluate because that could easily be something like exercise-induced asthma — which is not a cardiac condition that could be due to deconditioning, but that may be due to heart signs or symptoms from a heart may that may not be working well or a heart that is abnormal — that just makes it hard for blood to leave the heart and result in those types of symptoms.

So, when we think about fatigue or exertional symptoms, is it something that seems to be progressive? Is it something that is new? Is it something that they used to be the fastest kid on the team, and now they're taking breaks every five minutes or asking the coach to take a pause or a breather and sort of right out of character. And so those all are sort of I would say the biggest red flag symptoms are really, again, chest pain, rapid heartbeat that is unexpected, and passing out really are the ones that would prompt the most concern for a child or a parent.

Annie Zaleski: In light of all that, then, who is doing these cardiac screenings the? Would it be at a school? Would there be a doctor on site? What does that look like? And where do these almost happen?

Dr. Akash Patel: Yeah. So oftentimes, cardiac screening sports physicals really can happen in a variety of venues. Usually, the initial screens are been done by primary care providers, whether that's a family medicine doctor, pediatrician, nurse practitioner, PA. Sometimes, they're done by athletic trainers and things like that. But usually it's some care provider because part of the exam, part of it requires getting an exam. The venues can be different. So, there are most people just take their kids to the pediatrician or primary care provider's office. There are times where schools will have sort of a provider come to their school and then screen the kids. And so that may be based on your school and you can reach out to whether your school does that or your county does that. But those are usually the two venues that someone either comes to school and screens the athletes for the student athletes who are playing sports that year, or that you take your form that school needs and take that to the primary care provider's office. And then they sort of do the initial pass.

And then usually if those then, whoever does that initial screen, if there's something that then becomes abnormal or raises concern based on history, exam, family history, then that then would prompt referral to then a cardiologist if it's really cardiac symptoms, sports medicine doctors, if you're really worried about sort of musculoskeletal or concussion related issues. So there are subspecialists that sort of would then take the next step and evaluate anything that the screen is abnormal for.

One of the things that does happen that sometimes pediatricians may do or primary care doctor may do as part of their screen if something flags as abnormal is that patients can get an electrocardiogram or EKG. That is not universally done as part of the screen. But if there's something that would raise suspicion, it's basically a test that can look at your heart rhythm to make sure there's no issues with your heartbeat, but also can show signs or subtle findings that may suggest underlying cardiac conditions that would prompt evaluation. And clearly, if you see a cardiologist, that often is a test that will get done, and potentially some small portion of patients may need an ultrasound of their heart or echocardiogram if they have some abnormal findings that would prompt getting a picture of their heart.

Annie Zaleski: So, if an athlete and a kid has a diagnosed heart condition, how would this cardiac screening and/or their physical look different then from someone who's maybe has really no family history?

Dr. Akash Patel: Yeah, that's a great question. In the patients who have known cardiac disease, often we work with the primary care providers to do that because often the families are asking us, and the primary care provider is asking us, what can this child do who's got a known cardiac condition? And that's where we often will then prescribe specific things in terms of what sports they can play, how they should play, how they should limit themselves, any sort of safety net that they need around playing sports and then work with the primary care provider. Because clearly we're focused on the heart to say these are the things from the heart standpoint that would allow us to allow the child to go back into sports. And then for them to say, are there any other non-cardiac things that would elicit either participation or evaluation, or in rare cases, disqualification from sports?

So, usually if they have a known cardiac condition, they're working with their cardiologist to develop sort of a sports clearance form and the requirements that are needed, and that we work to communicate with the primary care provider and the school to make sure that student athletes really are safe to play. Clearly, we want as many of our cardiac patients to have a normal childhood, which often includes sports participation.

Annie Zaleski: What are some common restrictions that doctors tend to give? What are some common or familiar things that how can you modify sports to make them safer for people?

Dr. Akash Patel: Yeah. So, I think it falls into a few categories. So, I think one is just how does a child keep themselves in the healthiest state possible during sports? So, one is making sure that they're well hydrated, right? So, they drink water or there's a variety of different sort of electrolyte replenishing fluids that can be offered during activities. And so making sure that they maintain good hydration before, during and after sports to minimize the risk of any symptoms, including passing out. Clearly, they have a regular diet again to make sure they have enough energy to participate in the sports that they're going to play. So, that's part of it.

In terms of the tailoring a sport, generally kids who have had cardiac conditions and maybe even had cardiac surgery don't in particular need any sort of protective gear or anything in addition to what normally would happen for the sports that they're playing. Patients who have pacemaker or defibrillators, these are children who may have certain devices, which are a small portion of the patients. We generally tell them to avoid contact sports, sports in which there can be a direct blow to the equipment that's implanted underneath the skin and the abdomen and chest just to minimize any risk of damage to that. So, that may sort of change the sports that they can play.

But then individually, within the sport, usually the goal is once we say they can play a sport, we let them try to play any component of that sport, if at all possible. So, don't really get into the minutia. Hopefully, for most patients I'm saying, you can be a catcher, but you can't be a first baseman or you can't be a catcher. It's sort of, are you heart healthy enough to play baseball and create that environment?

Annie Zaleski: Well, you mentioned that so much the clinical screening, if someone is, they might have signs or symptoms during exertion then, would those warning signs be the same if they're actually playing sport, might there be different ones that might show up if there's potentially a problem?

Dr. Akash Patel: Generally, those would be the same ones. So, right. So, those are the ones that, so, sometimes, when we say, are they having symptoms during sports, we often broaden that out because clearly, it could be during a competitive game, but they may just have that symptom while they're practicing. Or they may have that symptom while they're playing around with their friends in the backyard or family members and when they're active. So, the symptoms that I've mentioned, anytime that they are exerting themselves really, really playing or having activity where their heart's getting up and they're running around, those would all prompt the need for at least some discussion and possibly evaluation.

Annie Zaleski: Oh, and that's good then, because I think that's probably one of the things that parents are most concerned about that. What are the signs? If someone is running around or if someone is playing their sport, what do I need to look out for? What do I need to worry about? And so that's good to know that it's like, hey, it's broader. It's not necessarily sports specific.

Dr. Akash Patel: Yeah. And I would say one of the most important things, is we all have children who are either are very vocal and will tell you a lot, and we have some kids who don't express their symptoms or things. And so I think the most important thing is that they understand that you should have an open line of communication with your child and whether it's you or their primary care provider, but someone who they're going to actually disclose their symptoms because kids want to play sports and they don't want to do anything that's going to jeopardize their ability to play sports.

And I think a lot of times, by reassuring them that most of the time, when you express those symptoms, we just want to make sure you're safe and that most kids will be able to play sports. But in the setting where we do find something, then the goal is to make it so that way we can let you play your sport, but to do it in the safest way monitor possible by knowing what you have, why you have it, and if there's ways of treating your problem to minimize or mitigate any risk around activity or sporting.

Annie Zaleski: Well, is there anything else that you know about kids playing sports who are living with certain heart conditions? Is there anything else that parents need to know or any sort of angles that we haven't covered that you feel is important to mention?

Dr. Akash Patel: Yeah, I think it's really important that athletes, those kids who are playing recreational sports, but more concerning are competitive sports, get their screen done yearly, and that's again having a conversation with your child. You don't have to wait till the year visit to do that. So, anytime during the year where a child has a sign or symptom, so even though they passed a screen and something develops, then that should prompt appropriate follow-up with their primary care provider or their cardiologist, if they have one.

I think second is a lot of what we talked about was things to identify patients who might be at risk for a sudden cardiac arrest or death event, which is exceeding exceedingly common, but very impactful. But there are situations where, unfortunately, despite the best screening, these events can still happen. And I think one of the important things that families should always be mindful of is, how do we create the safest environment for some kid to have. If they were to have an event, how could they be the safest?

And I think one of the things that we have, we advocate for in many schools across the country and in the region do this already, is really to make sure that the athletic coaches and trainers that care for the kids that they're trained in CPR. So, if an event happened, that they can provide CPR to keep a child safe until emergency services arrive and hopefully to be able to resuscitate that child. I tell families who have children who have cardiac conditions that all care providers, parents, nannies, stuff like that who care for the kid or going to be around them, should learn CPR. I think it's a good life skill that any person should have.

And then sometimes, there are situations where when they have an event that their heart rhythm is abnormal and dangerous. And in that setting, they need to have someone shock them in back into a normal rhythm. Clearly, when you call 911, the police or fire department or EMS will bring a defibrillator or AED to the patient and put the stickers on the child. And if the device detect that is abnormal, it can shock them out of that and get them back into a normal rhythm. And that is critically important. The sooner you can do that and the faster you can get them back, the most important. You still should always do CPR. That takes precedent over anything. But if you want get them out of the danger situation, that may be important.

So one avenue is clearly 911, and the emergency services provide that. But now, more and more schools have AEDs available. So, if you have kids who play sports, inquiring whether your school has an AED available. And if so, where is that relative to the sporting fields? And if they have any policies or protocols in terms of who uses it. And again, because if you are at a sporting event and a child has an event and the school can provide that support even well before the ambulance arrives, that can drastically improve their ability to potentially survive one of these life threatening events.

So, I think though we like to avoid these events, when they do happen, it's always important to be prepared. So, making sure that CPR is known and that, if possible, AEDs are available. And then for those specific cardiac conditions, that we talked about a little bit earlier, that we worry about or maybe are at more risk. So for instance, patients who have an inherited arrhythmia condition long QT syndrome, we know if they're on appropriate medication and their ECG suggests that they have low risk features, that we may allow them to play sports, but then, they need to have the additional, having an AED available at sporting events and people that know how to do CPR.

And so when schools can't provide the AED, there are situations where families purchase that on their own. So, it's not needed for again, healthy kids, but it is something that is shown to provide benefit for those patients who are risk. And oftentimes, many of these things are used because of the parents or the grandparents who are in the stands and get excited. And they may have heart conditions that may present itself similar with excitement or activity. And so there may be secondary benefit from having that equipment around. So, that's I would say the only thing to think about when we think about sports and CPR.

The only other thing that we didn't talk about, but I think is timely is the pandemic and how COVID has impacted our thoughts about sports because clearly which symptoms, chest discomfort, shortness of breath, feeling fatigued. Well, when your kid has the flu or cold, they may have some of those symptoms. And you're saying, well, those are not cardiac symptoms. Those are just flu symptoms. And so how do we think about COVID. It's new and we're learning about it. But I would say most kids who've had COVID can play sports and we sort of bend them into three categories.

So one is kids who've had mild symptoms. So, the typical upper respiratory infection that lasts just less than four days, no really high grade fevers. Then, they should sort of avoid sports until they finish their quarantining or isolation, which is usually five to 10 days and their symptoms have all resolved and then they can get back. They should follow up with their primary care provider, make sure they are healthy, recovered, and then they should get back to playing sports relatively soon.

The second is then the group of patients that have sort of more significant, we call moderate COVID. So, those are kids who had symptoms for more than four days, high grade fever, kids who've had to be hospitalized because they've developed pneumonia, take a long while to recover. And those kids, same thing is really, you want to wait for all the symptoms to resolve before reengaging in sports. And that may be a week to two weeks. And once that's done again, following up with your primary care provider, making sure things look good and getting back to sports. In some subset of patients, if they've had chest pain, discomfort or there's some concerns about cardiac symptoms, they may get an EKG as part of that evaluation to clear them. And if that EKG looks normal, then clearly, they can go back to sport. If it doesn't, then they'll get referred to a cardiologist.

And the third is sort of a condition that you can see with other viral infections, like the flu, where you can have severe COVID and that can affect multiple organ systems, kids that needed to be in the intensive care unit, which are uncommon, or COVID that affects the heart called myocarditis or inflammation of heart. And those kids, even if those symptoms resolve pretty quickly, we generally recommend that they don't play sports for three to six months because even though their symptoms resolve, there can be small changes to the heart that we don't see on exam or EKG or even ultrasound of the heart that may still pose risk for them having life-threatening arrhythmia. So, we want to really allow for the heart to completely recover from that sort of viral cardiac infection before getting back to full sports. And so for the vast majority of kids, you're back after your symptoms resolve like any other cold or things. But if your symptoms are more significant, then definitely it's worth getting looked at by your primary care provider before engaging in sporting activities or exercise.

Annie Zaleski: Tell me a little bit about them. What are kind of the signs and symptoms of myocarditis? What should parents and kids be looking out for?

Dr. Akash Patel: So, it can be as subtle as chest pain, right? So, consistent chest pain. It may worsen with positional change. They can have elevated heart rate. So, if they're just sitting around and a typical 15-, 16-year-old sitting around and you notice now their heart's beating 140 times a minute, that would raise concerns. If they have fast heartbeat, again, not in the setting of the field, if they pass out, that can be a sign of myocarditis. If they're having regular rapid heartbeats or some of the same symptoms that we talked about.

The other thing is really when you have viral infection of the heart, things that can happen is the heart doesn't squeeze as well. And so it's hard for the heart to pump blood and thus, you can have signs of heart failure. And so those would include difficulty breathing because you're developing fluid on the lungs, chronic fatigue, lack of energy. If the heart is not pumping blood well enough, they may have changes to their mental status where they're clearly they're confused. And then if the blood's not getting to the body, they can have symptoms, vomiting, nauseous.

But generally, when you think about myocarditis, it's usually in the context of having some sort of viral symptomatology, so fevers running off, something that would suggest a virus affecting them. And you're overlaying the cardiac symptoms that I've described because clearly there are many kids that can just get the stomach bug and have vomiting and diarrhea or constipation that would not be myocarditis, but really be having a viral infection. And now having cardiac specific symptoms that tell us of a heart failure.

And then some kids can present really extreme pretty quickly from the time they get infected to having that. So, that can be within 12 to 24 hours really becoming quite ill. So ,it is mindful any kid who has — whether that's COVID or any viral infection — is make sure that are they following the course of a cough for cold and are they starting to get better or are they not following the typical course and things are progressing and they're getting worse and that should always some evaluation. And usually, when you get evaluated, there are tests that can be done to help determine whether there is myocarditis or not or whether it's just a viral infection you feel.

Annie Zaleski: So it's more important than ever it seems because I think in years past, it might be, “Oh, I feel a little off. I'm just going to play through it.” And it seems like now, especially that if you're feeling a little bit like, “Oh, I'm not really feeling right,” you should not go to practice. You should stay at home. You should rest. You should hydrate and just really take it very seriously.

Dr. Akash Patel: Yeah. I think with anything, right, you have to use your best judgment, but at the end of the day, right, you want to play sports safely. And the best way to play sports best is if you're a hundred percent healthy, right. And if you're not a hundred percent healthy, right, then your ability to perform at your peak ability is not going to be there. So, yeah. Take any symptoms seriously. Make sure that if you have questions, reach out to your primary care providers and make sure that you're getting better before you reengage, right? So, those are really important things as kids get, as fall season starts soon and kids are starting to practice for fall sports is really to enjoy the summer. Make sure they're healthy. Make sure they get screened before fall starts and have a successful school athletic year.

Annie Zaleski: I think that's a good question that how long in advance because you're right, there's summer conditioning starts very soon. How long in advance are people getting a cardiac screening? Would it be the end of the previous school year? Would it be a month before? What is sort of the recommended length of time?

Dr. Akash Patel: Yeah, usually it falls into two bins. One is most kids will have a yearly primary care provider visit. So, whenever that falls, right, you should have this, especially if you're known athletes, right, have that as part of your screen done then. And then if nothing is changed before that and when you play sports, you're good for the year. The other is, right, you've already seen your doctor. They've been screened. But then you decided now you want to play sports. Right? And so at that point, right then to sort of reach out to the primary care provider's office to decide whether you need to come back in for a reevaluation or whether your visit was close enough to when you decided to play sports to be able to fill out the form and answer the questions to make sure that things are up to date.

And clearly, you know throughout the year, as you're playing sports, to be mindful of the symptoms, like the red flag symptoms that we've talked about is if those come up, then don't wait till the next year to raise that to attention. You should raise that to attention at that moment. So, it's a good question. I think usually easiest to just do it at your yearly visit. And then if you've done your yearly visit and then you're going to start sports, then usually, they'll want you to reach out to your primary care provider to get the forms filled out and to make sure that nothing has changed in terms of your health status, your family's health status before starting.

Annie Zaleski: We mentioned summer training and I think one of the things that's always a factor, especially in Ohio, is heat. What are some tips that you usually give for athletes to stay safe in summer heat? And are there specific athletes that are at a risk for a cardiac event due to basically the heat and exercising in the summer weather?

Dr. Akash Patel: Yeah, that is a fantastic question. I think one of the things that we gloss over and don't appreciate as much or we sort of used to tough it out or is heat stroke, right, or heat exhaustion. Right? And we know that in severe cases, heat stroke can be life threatening or even result in death. And so it's really important to take that seriously. So, generally, things to consider are one, is most coaches, if not all coaches, are really good about figuring out is this a good day to practice and if we're going to practice, is it going to be inside or outside relative to what the temperature and humidity level and key index is? So I think that's always an important thing.

I think two is to stay very well hydrated throughout that because in addition to just the normal hydration you need throughout the day is in the setting of heat you sweat a lot. And so you're getting, losing a lot of fluid just through sweating and you're not allowed to oftentimes, can't get off the heat fast enough. So, it is important to stay well hydrated if you're in between activities, right, to find shade while you're resting or cooling down to give your body the ability to let the heat dissipate.

And then, with anything, I tell all my patients and anybody, you're your strongest advocate as a child who plays sports. And so it's really important to say, if you don't feel well, if you feel like you're winded, tired, right, your vision's changing because you feel like you've run for two miles and you're exhausted, then it is really important and it's OK to say, "I need to take a break," right? So, listen to your body. And I think that's the most important thing when it is hot outside is to really listen to your body because if you're having any symptoms of dizziness, lightheadedness clearly passing out, cramping and feeling like you're dehydrated or really fatigued, you should stop, take a break, rest hydrate, and then you can get back out there.

So, I think those are the things I would think about as good hydration, staying in shade and then being mindful of the temperature and activities you're doing to avoid heat stroke or heat exhaustion because one of the conditions that we worry about the most is that if you get overheated, then your muscle can break down. And with that cramping, when the muscle breaks down, then that can affect your kidney, your electrolytes. And those can be things that can cause your heart to beat abnormally or have an abnormal heart rhythm that can be dangerous. So, clearly it is keeping your body hydrated, cool as best you can and taking breaks in the shade if possible.

Annie Zaleski: Yeah. Don't push through it. I think sometimes, people have the tendency, “Oh, I'll be fine. I'll be fine.” And that is definitely a case you don't want to mess around. You want to make sure that you're taking care and erring on the side of caution.

Dr. Akash Patel: Yeah. And coaches are great about that. With any sport, it's often competitive. So, you want to be the best at what you do. Your team needs to be the best. So, you're always going to push yourself a little bit harder to be a little bit better. But you can always push yourself, but you shouldn't have bad symptoms when you're pushing yourself. And so, that mean, maybe you're not going to be able to push yourself all today, but maybe it's going to take three or four days to gradually get up to where you need to do that. And so, I think, when you feel like you are beyond your limits, then you should speak up and take a break and take a pause and then, you're not going to lose ground. You're just going to get back out there and do that. But it's always an important thing to have a dialogue with your trainers and your coaches when you're doing sports or even practicing to make sure that you are practicing within your body's limits.

Annie Zaleski: So, we've covered a lot of ground and this has been a lot of really excellent information. And I think one of my last questions here is then, are there any common questions or concerns you hear from parents about their kids playing sports as it relates to heart safety that we haven't covered?

Dr. Akash Patel: I don't think so. I think a lot of it is around I think the biggest thing that parents have, and rightfully so, when you see a 16-year-old kid and every year, we see this in every community in Northeast Ohio a couple times a year, we have a student athlete who passes away on a football field or basketball court or track meet and it's on the news. And all of a sudden, parents are worried and they look at their child and they're like ... so and so kid was completely healthy. No one ever knew. But when you look back at things, sometimes, some of those kids and a lot of them may have had symptoms and they just didn't vocalize it or they didn't speak up. Or there are certain situations where they can be healthy and even under the best circumstances, we can't find everything.

But that's where I think when a parent is worried or anxious or recognizes there's concern is really to talk to their child and say, "Are you sure there's nothing going wrong? If is everything OK?" And if there is concern, then to then to seek out care. And I would say that's usually the times when families are the most worried is when something happens, either a college athlete or a professional athlete or a high school athlete, an event happens in their community. And it sort of makes them more aware of not everything is always benign or safe.

But again, the take home points are many kids play sports. Most kids, if not all, the vast majority are healthy. Even those who have cardiac conditions, many can play sports to alleviate family's concerns. It is really our good job as parents and providers is to let kids play sports, but to do it safely. And so, that's I think the goal is with any parent, you want to make sure is your child safe and if any of these things that we discussed today prompt concern or questions, then always reach out to your primary care provider or us at Cleveland Clinic here to help alleviate your questions and concerns.

Annie Zaleski: It's wonderful advice. Thank you so much for being here, Dr. Patel. Like I said, this has been really interesting and I think this is going to help a lot of people.

Dr. Akash Patel: Thank you for having me. And it was a pleasure talking about this. And I'm a big sports fan and like to play sports. And it is a great pastime of many kids and families. And so looking forward to having a bunch of healthy kids this fall and throughout the year play sports and do it safely.

Annie Zaleski: Thank you so much for being here, Dr. Patel. What a wonderful conversation. To learn more about Cleveland Clinic Children's pediatric and congenital cardiology and heart surgery treatment options, visit

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