Sudden death screening.

SCD is a tragic-event that rarely affects exercising individuals. It is important for the practitioner to recognize the normal physiologic changes that occur in the exercising athlete that correspond to AHS so as to differentiate them from conditions placing an athlete at risk for SCD. Different clinical entities account for SCD in athletes under age 30 as opposed to over age 30, although there is some overlap. Comprehensive and expensive screening tests have not proved to be cost-effective, nor are they able consistently to identify athletes at risk. A quality history and thorough cardiac screening examination are the best means to identify athletes at risk for SCD and lead to a cost-effective means to pursue further workup. Table 7 lists a screening battery of tests and what the tests detect and miss. In general, a history and physical examination detect aortic stenosis and a portion of HCM and Marfan's syndrome. If the physical examination is suggestive of Marfan's syndrome and a chest roentgenogram is done, a larger portion of cystic medial necrosis will be found. When an ECG is added to the series, most of the HCM patients at risk for SCD can be diagnosed. In addition, if echocardiography is added, most patients with HCM and cystic medial necrosis can be identified. If an exercise stress test is then performed, 20% of coronary artery disease and congenital artery anomalies are identified. Additional studies, including Holter monitoring, electrophysiologic studies, and thallium scintigraphy, can be added to identify further at-risk patients. Because some asymptomatic patients present with SCD, it is virtually impossible to identify comprehensively all patients at risk. By knowing what questions to ask, performing a thorough cardiac screening examination, and being more aware of potential diagnostic clues, the practitioner can feel comfortable in identifying most patients at risk for SCD. Specific history and physical examination guidelines regarding screening for competition are included. Supplemental information is found in the 16th Bethesda Conference. In addition, a well-outlined emergency plan needs to be established when physicians, athletic trainers, or coaches are working with athletes. Proper recognition of cardiac symptoms is a key point. Appropriate education including basic first aid and cardiopulmonary resuscitation training should be encouraged for anyone working extensively with athletes. The emergency plan should include on-site treatment, mechanism to contact emergency personnel, and proper transport to a qualified facility.