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It was like rowing through mud.

2000 Olympic gold medalist Rob Waddell describes the consequences of developing atrial fibrillation partway through a 2000 m trial race for the New Zealand men’s single sculls berth at the Beijing 2008 Olympics. Waddell suffered a relapse of atrial fibrillation, having previously been free for some seven years. He fell rapidly behind and lost the race.

As discussed in Chapter 48, sudden cardiac death is the leading cause of death in young athletes during sport, and is typically the result of undiagnosed structural or electrical cardiovascular disease.13 Some sportspeople present with symptoms that can alert the clinician to underlying cardiac pathologies. This chapter focuses on the clinical approach to those symptoms.

In this chapter we:

  • highlight that certain symptoms can point to significant cardiovascular problems

  • discuss the management of five symptoms

    • syncope

    • seizures

    • exertional chest pain

    • palpitations

    • fatigue/excessive dyspnea

  • discuss physical examination findings that may be relevant to cardiovascular health

  • provide an overview of contemporary investigations for cardiovascular disease which now include genetic testing, as well as the traditional investigations such as electrocardiogram (ECG/EKG) and echocardiography

  • discuss the approach to temporary and permanent disqualification from sport because of cardiac diagnoses.


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ARVC Arrhythmogenic right ventricular cardiomyopathy
CCAA Congenital coronary artery anomalies
CPVT Catecholaminergic polymorphic ventricular tachycardia
LQTS Long QT syndrome
HCM Hypertrophic cardiomyopathy

Cardiovascular symptoms: potentially life or death decisions

Some athletes who later suffer sudden cardiac arrest have warning symptoms or signs but others do not.4 For example, in studies, only 21% of athletes who died from HCM5 and 44% of athletes who died of an CCAA6 had any signs or symptoms of cardiovascular disease prior to death. Similarly only 10–20% of autopsy-negative sudden unexplained death had previous symptoms.7, 8

Symptoms are present in some other cardiovascular disorders. In a review of sudden cardiac death from ARVC, 68% of athletes had prodromal symptoms which included syncope, chest pain, or palpitations.9 Ion channel disorders, such as LQTS and CPVT, also commonly present with recurrent syncope or unexplained seizure activity triggered by vigorous physical exertion or acute emotion (Table 49.1).10, 11

Table 49.1

Symptoms associated with certain cardiac ion channel disorders


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