Cardiovascular Screening of Volleyball Players
Nov. 2, 2004
John D. Cantwell, M.D.
My involvement as the cardiovascular consultant to Georgia Tech Athletics began shortly after the sudden death of the famed Olympic volleyball player, Flo Hyman. She died of a ruptured thoracic aortic aneurysm, secondary to Marfan's syndrome.
Our pre-season cardiovascular screening of volleyball players at Georgia Tech begins with a standard questionnaire (Table 1 -- see bottom of page).
On the physical examination we listen carefully for a heart murmur. Athletes can sometimes have mild systolic heart murmurs of a physiologic (innocent, functional) nature due perhaps to the rushing or turbulence of blood flow passing across the valves. If present, we have the athlete do a Valsalva maneuver (breath holding while straining to tighten the abdominal muscles) to be sure the murmur does not increase in intensity. The latter could indicate either hypertrophic cardiomyopathy (the heart muscle abnormality that is the leading cardiovascular cause of death in athletes) or possibly mitral valve prolapse.
Signs on the physical examination of possible Marfan's syndrome include an arm span exceeding the height (it should be shorter, but this is not that specific). The normal upper-to-lower body ratio in Caucasians is 0.92 ± .04, while in African Americans it is 0.85 ± .03. In the Marfan's syndrome, the ratio is often lower because of the elongated lower extremities.
Preseason laboratory studies include blood lipids. We counsel athletes with elevated readings, and sometimes need to use drug therapy if extremely high, especially if there is a family history of early coronary disease.
Each freshman athlete gets a limited echocardiogram, which costs $50 to $60 to us, looking for hypertrophic cardiomyopathy and dilation of the ascending aorta (seen in the Marfan's syndrome) in particular. (Editor's note: The cost of this test may be much higher in other locations and has not been recommended for mass screenings for athletes by the American Heart Association primarily due to the cost.)
The diagnosis of Marfan's syndrome is considered when an athlete has at least two of the four major features:
1. Positive family history.
After the initial evaluation, athletes with certain problems such as hypertension (high blood pressure) are closely followed, treated initially with non-drug measures such as diet, and with a medication (preferably an ACE-inhibitor or an angiotensin receptor blocker rather than a beta blocker) if the pressure remains above 140/90 mmHg.
Athletes who develop any problems with effort-related chest discomfort get treadmill exercise testing, looking especially for ischemia that could arise from an anomalous coronary artery. The latter, if suspected, can also be assessed with the electron beam CT scan of the heart, a non-invasive test that takes 10 minutes to do.
Athletes will soon become coronary-prone adults, and need to be educated about primary preventive measures and coronary risk factor modification.
A recent addition to our preventive medicine measures is the availability of the automatic external defibrillator, at courtside during practices and games, in the rare event of a blow to the chest that triggers a potentially fatal cardiac dysrhythmia (commotio cordis) or the sudden collapse of an athlete, coach or spectator from other cardiovascular problems.