Sports Cardiology & Syncope Questions¶
Question 1¶
Which finding during pre-participation screening MOST warrants immediate disqualification pending further evaluation?
A) Systolic murmur at LLSB that decreases with Valsalva B) Systolic murmur that increases with Valsalva C) Split S2 at LUSB D) Sinus arrhythmia on auscultation E) Blood pressure 118/75
Answer
**Correct Answer: B** Murmur that **increases with Valsalva** = HCM: - Decreased preload worsens obstruction - Immediate evaluation needed - No sports until cleared Most innocent murmurs decrease with Valsalva/standing. **Board Pearl:** Murmur increases with Valsalva = HCM; decreases = likely innocentQuestion 2¶
An athlete with Wolff-Parkinson-White has shortest pre-excited RR interval of 220 ms during induced atrial fibrillation at EP study. What is the recommendation?
A) Sports participation without restriction B) Ablation recommended before sports C) Beta-blocker and sports participation D) Digoxin for rate control E) Observation with annual follow-up
Answer
**Correct Answer: B** Shortest pre-excited RR ≤250 ms = **high-risk pathway**: - Can conduct rapidly during AF → VF risk - Ablation recommended before competitive sports - >250 ms = lower risk, more individualized **Board Pearl:** WPW SPERRI ≤250 ms = high risk, ablation before sportsQuestion 3¶
Which feature MOST suggests vasovagal syncope in an adolescent?
A) Syncope during exercise B) Syncope associated with chest pain C) Prodrome of warmth, nausea, diaphoresis with triggers D) Family history of sudden death E) Palpitations before event
Answer
**Correct Answer: C** Vasovagal syncope features: - **Prodrome** (warmth, nausea, lightheadedness, tunnel vision) - Identifiable triggers (standing, heat, blood draw) - Rapid recovery - Occurs when upright - Relieved by recumbency **Board Pearl:** Vasovagal = prodrome + trigger + recovery; cardiac = during exertion, no prodromeQuestion 4¶
A 16-year-old has syncope while standing in line. ECG shows QTc of 485 ms. Family history is negative. What is the next step?
A) Reassurance - normal ECG B) Sports restriction and repeat ECG in 1 week C) Genetic testing for LQTS D) Start beta-blocker immediately E) Exercise stress testing first
Answer
**Correct Answer: C** QTc 485 ms with syncope: - QTc >460 = prolonged; >480 more concerning - With syncope → strongly suspect LQTS - Genetic testing to confirm and guide management - Also family screening - Activity restriction until evaluated **Board Pearl:** Syncope + prolonged QTc = evaluate for LQTS; genetic testing indicatedQuestion 5¶
Which condition allows sports participation using shared decision-making per 2020 guidelines?
A) CPVT on medications B) LQTS on beta-blocker, asymptomatic C) Unrepaired AAOLCA D) Active myocarditis E) Severe aortic stenosis
Answer
**Correct Answer: B** **LQTS** allows shared decision-making (SDM): - On appropriate therapy - AED available - No competitive swimming for LQT1 - Athlete/family understand risks CPVT and unrepaired AAOLCA = restricted. **Board Pearl:** LQTS = SDM allows sports; CPVT and AAOLCA = restrictedQuestion 6¶
How long should an athlete wait after myocarditis before returning to competitive sports?
A) 2 weeks B) 4 weeks C) 3-6 months D) 12 months E) Return when symptoms resolve
Answer
**Correct Answer: C** Myocarditis return to play: - **3-6 months** minimum - Normal echo, Holter, exercise test - CMR without active inflammation - No symptoms during activity - Some recommend 6 months for all **Board Pearl:** Myocarditis = 3-6 month restriction; normal testing before returnQuestion 7¶
A 14-year-old has recurrent syncope. Tilt table test shows heart rate increase from 70 to 140 bpm with standing but BP remains stable. What is the diagnosis?
A) Vasovagal syncope B) Orthostatic hypotension C) Postural orthostatic tachycardia syndrome (POTS) D) Long QT syndrome E) Situational syncope
Answer
**Correct Answer: C** **POTS** criteria: - Heart rate increase ≥30 bpm (or >120) within 10 min of standing - Without significant BP drop - Chronic symptoms (>6 months) - More common in females, post-viral **Board Pearl:** POTS = HR increase ≥30 bpm standing without hypotensionQuestion 8¶
What is the minimum rest period after uncomplicated pericarditis before returning to sports?
A) 1 week B) 2-4 weeks C) 3 months D) 6 months E) When pain resolves
Answer
**Correct Answer: B** Pericarditis return to sports: - **2-4 weeks** if uncomplicated - Asymptomatic + normal CRP + normal echo - If troponin elevated (myopericarditis) = 3-6 months **Board Pearl:** Pericarditis = 2-4 weeks; myopericarditis = 3-6 monthsQuestion 9¶
An athlete is found down on the field without pulse. AED shows VF. What is the most likely cause in a young athlete?
A) Commotio cordis B) Coronary artery disease C) HCM, ARVC, or coronary anomaly D) Drug use E) Pulmonary embolism
Answer
**Correct Answer: C** Causes of SCD in young athletes: - **HCM** (most common in older studies) - **AAOCA** (increasingly recognized) - **ARVC** - Commotio cordis (if blunt chest trauma) - Channelopathies (LQTS, CPVT) **Board Pearl:** SCD in athletes: HCM, AAOCA, ARVC most common structural causesQuestion 10¶
A swimmer with LQT1 wants to continue competitive swimming. What is the appropriate recommendation?
A) Competitive swimming is acceptable with AED present B) Competitive swimming is contraindicated C) Swimming only in supervised pools is acceptable D) No water activities of any kind E) Swimming with a buddy system is acceptable