Introduction

Pediatric sports cardiology is an emerging subspecialty garnering much attention due to devastating reports of exercise-related sudden cardiac arrest and collapse in young athletes. As opposed to adult sports cardiology, nearly 70% of children and adolescents engage in sports, making questions regarding participation and safety a frequent consideration. In addition, improved outcomes for those living with congenital heart disease (CHD) and an increasing recognition of genetic heart conditions have brought unique challenges to the field.

As the medical community shifts from a framework of restriction to one of exercise promotion, it is important to continue to ensure athlete safety during sports participation. Unique to pediatric cardiology is the heterogeneity of physiology within age groups, across specific disease processes, and even within the same patient as they grow and develop. Recent guidelines regarding adult sports participation for diseases such as hypertrophic cardiomyopathy (HCM) pose specific concerns when extending the recommendations to pediatrics.

Is it safe for a child with HCM, Wolff-Parkinson-White syndrome, or repaired CHD to play? Should every child get a screening electrocardiogram (ECG)? How do parental stakeholders and mature adolescents affect shared decision-making (SDM)? Dr. Jonathan Kim and his guests Drs. Peter Dean, Keri Shafer, and Jonathan Edelson recently discussed these questions on their podcast ACC CardiaCast: Courtside With the Chair: The Emergence of Pediatric Sports Cardiology.

Conversation Highlights

Risk Stratification Across a Spectrum of Ages

Kim: How do you approach age guidelines for sports participation?

Edelson: It is hard to prescribe age-based guidelines for sports participation because development differs so much at different ages, in terms of anatomy and physical growth, but also in terms of what level of sports with which they're engaging. We've all seen children and young adults who are participating in highly competitive sports even at a young age, and we know that puberty is taking place at younger ages. Those things coalesce to have one 9-year-old who is very different from another. Furthermore, many diseases that we take care of in pediatric cardiology such as HCM are phenotypically silent for a period of childhood, then blossom in adolescence.

Kim: How do you think about HCM across age groups?

Dean: We don't know as much for the younger age groups, but we do know that the same phenotype at a younger age may represent a different risk. HCM is an evolving disease and gets worse through adolescence. When applying the adult risk criteria to pediatrics, I worry that the 12-year-old who is manifesting a 25 mm septum is different than the adult with a 25 mm septum, not only on proportion to body surface area and z scores, but more so because this is a more malignant phenotype by showing up early.

Kim: What tools are most appropriate to risk stratify in pediatric HCM?

Edelson: I take myocardial scar very seriously, and it worries me a great deal when I see that. Another tool for risk stratification in pediatric HCM is exercise testing. Dr. [Jennifer] Conway published literature linking exercise-related ST- or T-wave changes to negative outcomes among individuals with HCM. So, I pay close attention to those pieces of information when we're stressing our teenage athletes.¹

ECG Screening in Pediatric Athletes

Kim: How do you think about ECG screening in the pediatric population?

Edelson: ECG screening is always a lively discussion with some notable limitations unique to the pediatric athlete.² First, screening every pediatric athlete involves a lot of resources. Second, there are several false-positives that require follow-up. Third, an ECG is not going to capture every pediatric patient at risk for sudden death.³ For example, coronary abnormalities are responsible for a significant portion of pediatric athlete deaths and we're unlikely to catch them on screening ECGs. Finally, pediatric cardiac disease changes over time. If you screen the 9-year-old and their ECG is totally normal, they may still develop HCM later in life.

Kim: How do you ensure equity in ECG screening for pediatrics?

Dean: First, if we're going to start screening pediatrics, then we need to do this on every student and not just athletes. The difference between a student and an athlete is very little during early adolescence. Yes, college athletes are very different from nonathletes, but when we see a 10-year-old athlete versus a 10-year-old student, they are doing very similar things on the playground as the sports field. For universal screenings, you're going to need a lot more ECG readers and pediatric cardiologists to follow-up on abnormal ECGs, and our workforce isn't staffed to handle that kind of volume. For many athletes who don't have expedited access to a pediatric cardiologist, they can be restricted for weeks to months while waiting for follow-up. They could miss a whole season—that's a big deal.

Counseling and Shared Decision-Making

Kim: What strategies do you use when counseling the pediatric athlete?

Shafer: The number one thing is education. We should dispel the perception that exercise to the point of physical exhaustion is more beneficial than we physiologically know it to be. I also use exercise stress testing with an education component. We can augment our exercise testing protocols to mimic practice and counsel athletes to understand what is safe and what exercise intensities should be avoided.

Kim: What does SDM look like in pediatric sports cardiology?

Edelson: First, there are additional stakeholders—the parents—who may have separate thoughts and ideas from one another. One thing I think is important to do is keep the athlete in the room. My sense is that if a person is not of the maturity to be in the room to hear the information, then SDM isn't appropriate. Second, it's important to be honest about what we know versus things we are less certain about. Third, SDM does not abdicate us from responsibility. If there is a child who I think is unsafe to participate, then I'm honest with them about that. It's only the cases where it's borderline where we entertain the concept of SDM.⁴

References

1. Conway J, Min S, Villa C, et al. The prevalence and association of exercise test abnormalities with sudden cardiac death and transplant-free survival in childhood hypertrophic cardiomyopathy. Circulation 2023;147(9):718-727.
2. Sharma S, Drezner JA, Baggish A, et al. International recommendations for electrocardiographic interpretation in athletes. J Am Coll Cardiol 2017;69(8):1057-1075.
3. Oh Y, Flynn P, Skaria A, Oshiro K, Abramson E, Dayton J. ECG screening for sudden cardiac death in an asymptomatic pediatric cohort. Pediatrics 2020;146(1_MeetingAbstract):646-648.
4. Baggish AL, Ackerman MJ, Putukian M, Lampert R. Shared decision making for athletes with cardiovascular disease: practical considerations. Curr Sports Med Rep 2019;18(3):76-81.