Sports Cardiology and Heart Safety for Young Athletes

Dr. Richard So, MD:

Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Peter Aziz, MD:

Every parent wants their young athlete to play hard, have fun and stay safe, but heart health can bring up a lot of questions. I'm Dr. Peter Aziz, a pediatric cardiologist at Cleveland Clinic Children's. And today, we're talking about sports cardiology. We'll discuss everyday athletic fatigue, how screenings offer peace of mind, and ways to support your child on and off the field. Joining me is Dr. Nicholas Szugye. He's a pediatric cardiologist and director of the Pediatric Cardiopulmonary Exercise Lab at Cleveland Clinic Children's. Welcome to Little Health, Dr. Szugye. Please tell us a little bit about yourself.

Dr. Nicholas Szugye, MD:

Thank you very much. I'm very excited to be here. So I'm a pediatric cardiologist. I run our cardiopulmonary exercise lab and co-director of the Sports Cardiology Clinic. I've had a passion for exercise and physical activity my whole life. And in taking over this program, it's been really uniting some of my passions for caring for children with, you know, physical activity and physical wellbeing.

Dr. Peter Aziz, MD:

Great, Nick. You know, one thing, Dr. Szugye, that I'm often asked as a pediatric cardiologist is why do kids have heart problems and why does our discipline even exist? Kids should be healthy.

Dr. Nicholas Szugye, MD:

And I think most kids are healthy, and even healthy kids can have complaints that can make them a little bit worried about their heart. And then also some kids are born with some congenital heart differences. And my goal in my profession is to help all of those kids to be able to gain the benefits of physical activity. Now, things like chest pain, shortness of breath, early fatigue with exercise can be very distressing. And one of the things that I am passionate about is helping people to understand their bodies better when they come to me with those complaints. And that's one of the ideas behind having a subspecialty clinic for sports cardiology.

Dr. Peter Aziz, MD:

Do you think that that approach for a child is different than it would be, let's say, for a professional athlete or just somebody that's older in general?

Dr. Nicholas Szugye, MD:

So I think with children, we're looking at different, you know, likelihood of conditions that could be going on. In older adults, a lot of times we're more worried about acquired heart disease and coronary disease, and children we're less so worried about that. But there are things, some things that we're on the lookout for.

Dr. Peter Aziz, MD:

So Dr. Szugye, in evaluating a pediatric patient, I know in my own practice that kids have lots of different complaints. Some are specific and some are non-specific. What is the challenge in trying to figure out whether a child's complaints are really a red flag as it pertains to their heart? And how do you know when to dig a little bit deeper?

Dr. Nicholas Szugye, MD:

I do think being a pediatrician first, that's how I see myself, is being able to understand how kids are describing their complaints is really important and understanding what the parents are bringing up as well. So there can be lots of different kinds of chest pain. Most of them are not cardiac. And from having the experience of asking these questions, I can usually sort through, you know, what might be a little more of a red flag for chest pain that versus what might be something that can be kind of musculoskeletal or, you know, reflux related. So for example, and then with talking with kids and s - helping them sort through their complaints, I think it's really important to understand how worried they are about it as well, because everybody comes to a clinic appointment with kind of different, different understanding of what's going on and different concerns and worries.

Dr. Peter Aziz, MD:

Yeah, you mentioned chest pain. I'm sure that's a common one. Are there other symptoms that, that kids present with or concerns that families have where you say, "Hey, that's, that's something we really gotta stop in our tracks and pay attention to?"

Dr. Nicholas Szugye, MD:

Yeah. Another one we see sometimes, especially in athletes over the summertime, is passing out where they'll faint, you know, either before, during, or after exercise. And, you know, it is common for people to pass out, you know, after exercise or after they've exerted themselves. But certainly a red flag for me is when somebody's passing out in the middle of exercise. That's something that we take very seriously and we'd want to see them and look into that a little bit deeper.

Dr. Peter Aziz, MD:

Okay. So patients with chest pain when they exercise sounds like a worrisome sign, patients that pass out while they exercise also sounds like a worrisome sign. Anything else?

Dr. Nicholas Szugye, MD:

Yeah, those are two of the big ones. And then sometimes unusual palpitations where you feel your heart beating. Now, a lot of us can feel our heart beating at various times and it can be a normal finding, but I think sometimes if you feel your heart beating very unusually in the time surrounding exercise, that can also be something we're worried about.

Dr. Peter Aziz, MD:

Okay, great. So I, I think we've outlined pretty clearly what signs and symptoms you would be concerned about. Paint the picture for us. Somebody comes in for evaluation. Generally speaking, what is your task? What do you use to help you try to figure out whether they're safe or not safe to play?

Dr. Nicholas Szugye, MD:

A lot of it is just asking lots of questions to get down in the nitty-gritty of what the patient is experiencing. That's honestly about 90% of where I get my information from. The physical exam helps a little bit as well. And then we sort out what kind of tests we need. So most people will get an EKG if they don't already have one. And then there's other things that we potentially might need to do, like an echocardiogram, exercise tests, or sometimes even sending somebody home with a heart rhythm monitor.

Dr. Peter Aziz, MD:

Great. And you mentioned an EKG. What does an EKG do? What does it look for?

Dr. Nicholas Szugye, MD:

So an EKG is an electrocardiogram and it's looking at the electrical activity of the heart. And from that, we can get some other information about heart chamber size and how the heart is beating and then resetting itself. So there's some good information we can get from that, and it's a pretty straightforward screening test for us. And it can identify some of the things that people are worried about with their kids being out on the field.

Dr. Peter Aziz, MD:

Sounds good. And to my knowledge, non-invasive bunch of stickers on the chest, right?

Dr. Nicholas Szugye, MD:

That's right. Yeah. So yeah, so it's, it's about, you know, 12 stickers that go on the chest and that's what helps us to look at the heart.

Dr. Peter Aziz, MD:

Great. And the echocardiogram is an ultrasound?

Dr. Nicholas Szugye, MD:

And so that's an ultrasound of the heart and it takes about 30 minutes or so, also non-invasive. We're just doing an ultrasound from the outside of the chest, taking a look inside at the heart.

Dr. Peter Aziz, MD:

Okay. And let's say, Dr. Szugye, that you come across something, stops in your tracks to say, "Hey, we got a problem here and there is concern." What are the next steps and how do you decide whether somebody's okay enough to play or not?

Dr. Nicholas Szugye, MD:

So a lot of times what we're doing is if we have those red flags, we'll do the extra tests and we're trying to identify whether there's anything suspicious going on from an anatomy standpoint or a function standpoint. And from there we can kind of figure out whether there is some kind of risk or not. Now, if we identify that there's nothing unusual and all of our tests come back normal, then we help them sort through the symptoms because there might be something that's non-cardiac going on. And then we'll refer to some of our other colleagues that, you know, we've identified that are familiar with caring for athletes.

Dr. Peter Aziz, MD:

Okay. I feel that back in the day, perhaps, if a cardiologist stumbles a c - uh, you know, upon a diagnosis that carries with it pretty significant risk, the easy decision is to say, "Hey, you're out. You're getting sidelined. Let's talk about chess club things that are perhaps non-cardiovascularly intense as a safer route." Debate that with me. Is that the right way to go? What have we learned since then?

Dr. Nicholas Szugye, MD:

Yeah. I think we've figured out that we can help kids to exercise in a safe way while looking at those uncommon situations that can pose some risk. So a lot of what we do is shared decision making with our patients to say, "Hey, there is this thing that's going on, but I think that you should still be okay to do these sorts of exercises," because the risk of being sedentary is actually higher. And sometimes, you know, exercise is a good chance for a community. If you're doing sports, it's good for psychosocial wellbeing. So there's so many benefits, especially in kids in, in school that we don't wanna just restrict them, you know. So that's a really important part of what we do.

Dr. Peter Aziz, MD:

And for the most part, do you feel like with the shared decision-making model employed, you can get most kids back out there on the field?

Dr. Nicholas Szugye, MD:

Yeah. I think by and large, we're able to get most kids back out and we're not really talking about restricting them. We're talking about enabling them and giving them confidence in what they can do.

Dr. Peter Aziz, MD:

I like that, enabling them. Very nice. Sounds like in this day and age, our major objective is to make sure that kids that can play are, are out there playing and engaging in sports. You mentioned the positive benefits, social engagement, the, obviously the cardiovascular health benefits that kids get. For those kids that still have some risk, and for those kids, let's say, that aren't even diagnosed yet, what do we know about what's going on in the community? What do we know about how our local environment is really set up now, perhaps differently than what it was before to help keep kids safe?

Dr. Nicholas Szugye, MD:

So in the past several decades, there's been a lot of work to create more of a safety net surrounding sports and athletics in, in middle school and high school especially. So at sporting events, we'll have automated external defibrillators or AEDs, and those are capable of when a patient becomes unconscious of actually resetting their heart and keeping them safe. And there's also been a lot of education for coaches and all those athletic trainers and those that are involved. So Lindsay's law has been really important, raising the level of knowledge base of our athletic directors and, and coaches, so.

Dr. Peter Aziz, MD:

Yeah, I'm proud to be an Ohio citizen. I think Ohio has taken the lead on many of those initiatives. It's been really great to see that. We've talked about mostly non-controversial topics, I think, just in terms of how to evaluate a patient, what signs or symptoms are concerning, when to get a kid back into playing sports safely and how to do that. Let's talk for a moment about what I've certainly come across as a more controversial topic of ECG sports screening. So by the way, ECG and EKG are interchangeable. They both refer to the same thing. If an EKG or an ECG can identify a cardiac condition in a patient, why aren't we doing them in everybody?

Dr. Nicholas Szugye, MD:

So this is kind of a hot button issue right now. Some places are starting to screen with ECGs for all athletes. We haven't done this widespread in the United States to date, and a big reason is that EKGs are a good test, but they're not a perfect test. So they can identify sub-abnormalities. They can also have lots of false positives that could point towards disease when there isn't, and that can lead to extra testing or even restricting somebody from sports unnecessarily. And not all of the things that we're concerned about can be captured on EKG either. So it's, you know, with it not being a perfect test, there are some issues with trying to, to deploy this for every single child.

Dr. Peter Aziz, MD:

Yeah, for sure. I, I've experienced the same type of dilemmas, and I'll admit to you that when many of our patients come to see us, their questions are, "You identified a problem with my child through an ECG. Why aren't we doing this in everybody? I just don't understand." I think it's a big barrier that we have with the community. Let's say you could wave a magic wand and AI, for example, could read ECGs. And AI, it's not perfect, but it's getting pretty close. I think the more and more we have experience with it, the more and more we can teach an algorithm model. Do you think there's gonna be a time where we can feed, let's say, thousands of ECGs into an AI model and get closer to the truth and have it be more helpful than harmful?

Dr. Nicholas Szugye, MD:

You know, that's a really interesting question. I feel like in the future, it might be something we could move towards, because I think with AI, we can teach it to be an expert level reader. Now, having said that, you could probably only approach, you know, m- maybe an expert like yourself or, and maybe even pick up a few things that we're not able to see with our human eyes. I think there's probably still a limitation with the ECG as it is as a test, that it wouldn't be 100% specific and sensitive to throw some medical terms out. So, you know, it wouldn't get rid of all the false positives and false negatives, but, you know, it might move the needle enough that, that we could in the future deploy it. And that, that should be an area of, of research, I think.

Dr. Peter Aziz, MD:

Yeah, I wonder the same. I wonder if we're so close that just a bit of a push to get this a bit more perfect might, might get us over the edge. I think there's gonna be lots more to come on that specific topic too, so I can't wait to see how that emerges.

This is a personal question from personal experience for my own children. I've caught them on a handful of occasions using energy drinks before they work out. I found them in a, in a refrigerator and I was like, "Who bought these?" And I've tried to explain to them the harms of those types of practices. Tell me, Dr. Szugye, what in your experience is the harm really in energy drinks and workout powders and things of that nature?

Dr. Nicholas Szugye, MD:

I, I have lots of patients that come to me and they don't always say it, but their parents usually bring it up. <laugh> And the question is, you know, is this safe? What should, what should I be telling my child? And in general, especially with growing children, I stay, I say to stay away from those energy drinks because they have a lot of caffeine in them and some other things that, you know, to be f- frank, we don't know exactly what it does to your heart, but we do know that it, it can't be good. So in general, my recommendations are to stay away from it. And if you are going to be having it, to not have a full drink, and definitely don't do it more than one or two times per week. But, you know, in general, I say to stay away from it.

Dr. Peter Aziz, MD:

Sounds like pretty good advice. I think one thing that we've learned, Dr. Szugye, is if we can't identify everybody with a cardiovascular condition, if we're not screening everybody and we can't screen everybody, exposing people to things like this that can provide risk is definitely not the right thing to do. So I, I totally hear you there. We are now inundated with the world of, I'm wearing one right now with smartwatch. There is data constantly informing us, I think, in ways that are helpful and, and also ways that can be kind of confusing. How in your practice do you use those data to help inform you and guide sports participation and guide, you know, really being a clinician?

Dr. Nicholas Szugye, MD:

The big thing that we see is for those wearing some kind of smartwatch or a wearable is that it's recording your heart rate all the time, right? And this is the reason that we do get some patients to come into clinic, because they'll be wearing their watch and something will alarm off or they'll notice that their heart rate is unusually high, things like that. And, you know, I think it can be, you know, a clue for us, but it's probably not gonna make the diagnosis. We do know that in kids, the algorithms that are built into the smartwatches are not perfect. They're designed for, you know, older adults to be able to pick up kind of arrhythmias that can happen with older adults. And in kids, usually, it's, it's not atrial fibrillation or something like that.

Dr. Peter Aziz, MD:

Have you ever found the use of smartwatches or wearable devices that are available commercially to be helpful in your practice?

Dr. Nicholas Szugye, MD:

So, so sometimes it will be a reason that somebody comes into clinic. What we do sometimes now is we'll actually send patients with exercise prescriptions, in which case they'll be targeting a certain heart rate. And actually it can be helpful then because it's, it's something that's readily available for most people and they already have it. So, you know, it can be helpful for us for treatment as well as diagnosis. I do try to caution people because I want them to get more in tune with their body to not necessarily use the heart rate f- for minute by minute, but just to get used to their own level of exertion. But sometimes it can be helpful because, you know, they're already looking at their, their heart rates very frequently, so to be able to give patients kind of the tools to empower themselves can be helpful.

Dr. Peter Aziz, MD:

That's great advice. I, I find that for the most part, if somebody doesn't feel symptoms, it becomes a little less relevant what their heart rate is. Though I found it to be pretty useful in some of our patients where they have arrhythmia events pretty sporadically and they're hard to predict, where we can prescribe monitors, let's say, that are uncomfortable and cumbersome and, you know, sort of shine perhaps a bad light on them in terms of socially and their friends and such. These monitors can be a little bit more subtle and sometimes we can capture events that we may not have been able to capture with the traditional monitoring equipment that we've used in the past. But there's a balance, it sounds like. Is that right Dr. Szugye?

Dr. Nicholas Szugye, MD:

I, I think so, yeah. Yeah.

Dr. Peter Aziz, MD:

Okay. So Dr. Szugye, we've talked a lot about what the sports cardiology program does, what we're looking for, how participation in sports is important, and how ultimately we wanna get kids back on the playing field, and we think that's an important part of their health.

We talked about using ECGs and other tests, and we talked about AEDs. Dr. Szugye, we also have employed emergency action plans for some of our cardiac patients that are heading back to sports, really as a guide for schools so that schools can understand what is a big red flag versus maybe what perhaps isn't as, as important to, to be concerned about. Tell me, do you use emergency action plans in your practice and what does that look like?

Dr. Nicholas Szugye, MD:

I do. I love emergency action plans because it helps give clarity and helps people know what to do, you know, in an emergency and in a everyday situation. So, you know, typically we'll have a green light, yellow light, red light type of situation. So starting from the bottom, red light is something that's a true emergency that needs to be acted on immediately. Normally, that's some kind of symptoms such as passing out or, you know, it can be anything like chest pain pertaining to the individual where we'd wanna have help immediately. It might include calling 911, calling the squad.

Working our way backwards, sometimes we'll have a yellow light, which is something that, you know, should be approached with caution, maybe go to the school nurse, call parent, um, something like that. And then green light is kind of every day how things are going and what's okay for a patient to do.

Dr. Peter Aziz, MD:

What would a green light curious?

Dr. Nicholas Szugye, MD:

So the reason I like the green light is because we focus so much on restrictions all the time and I want people to be aware of what they're able to do.

Dr. Peter Aziz, MD:

Oh, I like that.

Dr. Nicholas Szugye, MD:

And sometimes there, yeah, there can be a tendency or a bias to take breaks or stop, but, you know, we want our kids to feel as normal as possible. So I really like having a, a well-defined green light so that, you know, kids feel normal and accepted and, and like they can live their lives.

Dr. Peter Aziz, MD:

This is what I love, Dr. Szugye, about these conversations is I hadn't employed that strategy before, but I think that green light's a really nice one because we're always telling children, and parents are too, what not to do. I think it's very helpful to say, "This is what you can do, and, and this is what we know is safe." I love that.

Okay. Now that we've been informed, Dr. Szugye, you've taught us a lot about what we're looking for, how we evaluate for those things that you're looking for and concerned about, how the family can play a role into it, what questions we ask the family about their health. Try to sort of paint this picture for me. What does a day in a clinic visit look like for you in your sports cardiology clinic?

Dr. Nicholas Szugye, MD:

So I'll try to walk you through what it might look like from the patient perspective. So o- once they come in, our nurse will get vital signs, heart rate, blood pressure, pulse oximetry, all those things, and ask a few kind of screening questions of the patient family. And then usually at that point, we'll do a EKG, which we've talked about already. And then after that, I'll be looking up their medical history that, as that's happening, and then I'll come and talk with a family. We'll spend a long time talking. I will ask about what brought them there, what their past medical history is. I ask a lot about family history, so other family members that have had heart issues, because sometimes that'll be a clue towards whether a patient has inherited something.

Dr. Peter Aziz, MD:

Can I ask you, what do you specifically ask the family?

Dr. Nicholas Szugye, MD:

So I, I ask about anybody that's had heart issues as a young person. I'll ask if anybody's had events where somebody passed away suddenly without a cause identified. That's very important for us. And then I'll ask if there's any, you know, inherited abnormal heart rhythms, thing- things like that.

Dr. Peter Aziz, MD:

Yeah, one thing. I appreciate that, Dr. Szugye. One thing that we ask about in our clinic, and I'm sure you do as well, but just to point this out because it causes some confusion is, has anybody in the family drowned in a lake or a pool that was a good swimmer, anybody in the family born deaf? These sound like very bizarre que - I get very funny looks when I ask these questions. Can you please teach us why would we ask those questions?

Dr. Nicholas Szugye, MD:

So sometimes a drowning might actually not be a drowning. It could be due to some kind of abnormal heart rhythm where somebody had an arrhythmia while they're swimming. And sometimes I'll, you know, I'll ask also about if somebody died of a car accident where, you know, they were a good driver and they had passed away in a single car car accident. So these can be clues that something might have been due to a heart arrhythmia rather than an accident. And the same thing with the congenital deafness or born not being able to hear, that can be a clue towards some kind of inherited rhythm abnormality.

Dr. Peter Aziz, MD:

Yeah. Very, again, seemingly bizarre questions, but very focused and intentional, I think, right?

Dr. Nicholas Szugye, MD:

Yeah.

Dr. Peter Aziz, MD:

Okay.

Dr. Nicholas Szugye, MD:

Mm-hmm.

Dr. Peter Aziz, MD:

Anything else to add about the clinic visit?

Dr. Nicholas Szugye, MD:

So, you know, once we do the, the full history, then I'll do a physical exam, so looking for any, uh, unusual heart sounds or cardiovascular pulse differences, things like that. And then, you know, depending on the situation, sometimes we'll do some further testing. Sometimes it'll include an echocardiogram, whether if we suspect some kind of anatomic heart issue. Going from there, then I'll have a nice talk with the family about what I think is going on. And from there, they can expect to know, you know, whether I think something is serious going on, whether they can just go right back to playing sports, because I feel like it's low risk. If there's a lingering symptom that we can't really explain from the heart, then I'll say, "Okay, let's talk to these other folks to see if we can get you in with the right doctor that can help you with what you're dealing with." If we identify something unusual, then we'll usually perform some other testing at that point as well, but we'll talk through what it all means.

And, you know, my goal is that everybody leaves with clarity, and if we need to deal with some kind of cardiovascular issue, then I'm their partner the whole time as we're dealing with it. So I want them to know that we'll be able to continue to help them, and then it's not the end of the road for them.

Dr. Peter Aziz, MD:

I like that. This is a relationship you're establishing, right? It's not a one and done kind of situation, like much of what we do.

Dr. Nicholas Szugye, MD:

Mm-hmm.

Dr. Peter Aziz, MD:

All right. Anything else to add, Dr. Szugye?

Dr. Nicholas Szugye, MD:

You know, I think the only other thing that I'll say is that, you know, with, with children, we, we do have to meet them at their level. So I, I make it a important part of my job to talk to a 10-year-old the way a 10-year-old needs to be talked to, talk to a 16-year-old the way they need to, or sometimes I'll see collegiate athletes, and, you know, that all involves different levels of communication. And I think that's a very important thing because, you know, sometimes we can talk with the parents rather than the kid, but I think it's really important that they know what's going on with them.

Dr. Peter Aziz, MD:

Yeah, it's interesting that you mentioned that, because this isn't something that we're specifically instructed on how to do, I think, when we're going through our training.

Dr. Nicholas Szugye, MD:

That's right, yeah.

Dr. Peter Aziz, MD:

But I think as you go through the process, you learn that i- in order to be effective, you really have to talk directly to the patients.

Dr. Nicholas Szugye, MD:

Mm-hmm.

Dr. Peter Aziz, MD:

And involve the family in that conversation -

Dr. Nicholas Szugye, MD:

That's right.

Dr. Peter Aziz, MD:

Which can be a real big challenge sometimes.

Dr. Nicholas Szugye, MD:

That's right. Mm-hmm.

Dr. Peter Aziz, MD:

But it's also a lot of fun, I think, and I'm sure you agree.

Dr. Nicholas Szugye, MD:

Absolutely.

Dr. Peter Aziz, MD:

All right. That was excellent.

Dr. Nicholas Szugye, MD:

Thank you very much.

Dr. Peter Aziz, MD:

Taking care of a young athlete's heart isn't about keeping them on the sidelines. It's about giving them the confidence to play safely. If you have questions or concerns, discuss with your pediatrician or reach out to a pediatric sports specialist. To schedule an appointment with Dr. Szugye or our team at Cleveland Clinic Children's, please call 216.445.5000. That's 216.445.5000. Thanks, everybody.

Dr. Richard So, MD:

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the Little Health tips coming, subscribe wherever you get your podcasts or visit clevelandclinicchildrens.org/littlehealth.