Exertional chest pain?

Physical examination (seeks to rule out hypertension, Marfan habitus, aortic stenosis or coarctation, and hypertrophic obstructive cardiomyopathy)

Brief musculoskeletal survey Bilateral brachial blood pressures Cardiac auscultation in seated or standing position Reduces or eliminates innocent flow murmurs.

Enhances the murmur of hypertrophic obstructive cardiomyopathy

Increases physiologic splitting of S2 (possible atrial septal defect if fixed splitting)

Include Valsalva maneuver Based on abnormal screening findings, it is possible that as many as 10-20% of athletes could be referred for more costly evaluations, including ECG, echocardiogram, or evaluation by a cardiologist. An alternative approach would be to perform a limited echocardiogram at the time of mass screening of a group of athletes. Data on this approach are incomplete.

When should an athlete’s participation in competitive-level or high-intensity sports be restricted?

The American College of Cardiology recommendations are:

Restricted activity

Uncontrolled hypertension Hypertrophic cardiomyopathy Marfan’s syndrome Aortic stenosis (more than mild)

If question of congenital or acquired coronary artery disease, restrict participation, until athlete is further evaluated.

Partially restricted activity

Moderate aortic insufficiency (discourage isometric/power training)

Other congenital heart lesions (appropriate medical follow-up necessary)

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