Pre-participation sports evaluation — formative SAQs

SAQ 1 (10 marks) — The fifteen-year-old basketball player who blacked out on the court

Stem: A fifteen-year-old boy presents for a pre-participation sports evaluation before the basketball season. He mentions that he blacked out briefly during a sprint at training last month, recovering fully within a minute. He has no chest pain. His father's brother died suddenly at forty-one. On examination his heart sounds are normal and his blood pressure is 118 over 72. Outline your cardiovascular screen, your interpretation of the red flags, and your immediate management and clearance decision. ^{[1] [5]}

Model answer

The cardiovascular screen and the 14 elements (3 marks). I take the AHA 14-element cardiovascular history and perform the four physical examination elements. The history divides into seven personal items, three family items, and the examination. The seven personal items cover exertional chest pain, unexplained syncope or near-syncope, excessive dyspnea or fatigue with exercise, a prior heart murmur, an elevated blood pressure, a prior restriction from sport, and prior cardiac testing. The three family items cover a sudden death before fifty in a relative, disability from heart disease in a close relative under fifty, and a known familial cardiomyopathy or channelopathy. The examination listens to the heart supine and standing, palpates the femoral pulses, seeks the stigmata of Marfan syndrome, and measures the brachial blood pressure in both arms. ^[1]

The red flags in this athlete (3 marks). This athlete has two red flags. The first is the exertional syncope — a blackout during a sprint is syncope on exertion, and exertional syncope is sudden cardiac death until proven otherwise, because it is the presenting symptom of hypertrophic cardiomyopathy, a coronary artery anomaly, or an ion channelopathy. The second is the paternal uncle's sudden death at forty-one, which is a positive family history of premature sudden death before fifty. Either flag alone would demand a work-up; the two together make a dangerous cardiac condition the leading diagnosis until excluded. ^{[5] [1]}

Immediate management and the clearance decision (4 marks). I do not clear this athlete. I restrict him from sport pending an urgent cardiology referral, a twelve-lead electrocardiogram, and an echocardiogram, and I arrange a Holter monitor or an exercise test as the cardiologist directs. He is placed in the restricted-pending-evaluation clearance category, and the return-to-sport decision waits for the work-up. I would not clear him and review later, because the next exertional event may be the fatal one. I also confirm that the school and the club hold a written emergency action plan with access to an automated external defibrillator, because the defibrillator protects every athlete when the screen misses. ^{[3] [1]}