What is the evaluation and management approach for exertional chest pain in a young athlete?

Evaluation and Management of Exertional Chest Pain in Young Athletes

Young athletes with exertional chest pain require a comprehensive cardiovascular evaluation to rule out potentially life-threatening conditions, as these symptoms may be the first manifestation of underlying cardiovascular disease that could lead to sudden cardiac death.

Initial Assessment

History - Key Elements

• Timing of pain in relation to exercise (during, immediately after, delayed)
• Character of pain (sharp, dull, pressure, radiating)
• Associated symptoms (syncope, near-syncope, dizziness, palpitations, dyspnea)
• Family history of premature cardiac disease or sudden death
• Prior episodes of similar symptoms

Physical Examination - Critical Findings

• Cardiac murmurs (especially systolic murmurs suggesting aortic stenosis)
• Abnormal carotid pulse (delayed upstroke suggesting aortic stenosis)
• Blood pressure differences between arms (suggesting aortic pathology)
• Marfanoid features (suggesting connective tissue disorders)

Diagnostic Evaluation Algorithm

1. 12-lead ECG - First-line screening test

   • Look for: T-wave inversions, ST-segment abnormalities, conduction delays, chamber enlargement 1
   • ECG abnormalities are present in >50% of athletes with arrhythmogenic right ventricular cardiomyopathy (ARVC) 1

2. Echocardiography

   • Essential for evaluating:
     • Structural heart disease (hypertrophic cardiomyopathy, ARVC)
     • Valvular abnormalities (aortic stenosis, mitral valve prolapse)
     • Wall motion abnormalities
     • Left ventricular function 1
   • Assess aortic valve morphology and function using Doppler 1

3. Exercise Stress Testing

   • Critical for reproducing symptoms
   • Evaluate for:
     • Exercise-induced ischemia
     • Arrhythmias
     • Blood pressure response
     • Exercise tolerance 1
   • Should include ECG and blood pressure monitoring 1

4. Advanced Imaging (based on initial findings)

   • Cardiac MRI: Gold standard for myocarditis, ARVC, and myocardial fibrosis 1
   • Coronary CT angiography: For suspected coronary anomalies 1
   • Nuclear imaging: Consider if other tests are inconclusive 1

Common Cardiovascular Causes in Young Athletes

1. Congenital Coronary Anomalies

• Second most common cause of sudden cardiac death in young athletes 1
• Most common: anomalous origin of left main coronary artery from right sinus of Valsalva 1
• Often asymptomatic until exertional chest pain or sudden death 1
• Definitive diagnosis: CT coronary angiography or cardiac catheterization 1

2. Hypertrophic Cardiomyopathy (HCM)

• Most common cause of sudden cardiac death in young athletes (up to one-third of fatal events) 1
• Echocardiography is essential for diagnosis 1
• Look for asymmetric septal hypertrophy and dynamic left ventricular outflow obstruction

3. Myocarditis/Pericarditis

• Presents with chest pain, often following recent viral illness
• ECG may show ST-segment alterations and arrhythmias 1
• Echocardiography may show wall motion abnormalities or pericardial effusion 1

4. Aortic Stenosis

• Well-known cause of exertional sudden cardiac death (<4% of cases) 1
• Severity assessment requires Doppler echocardiography 1
• Exercise testing can reveal unexpectedly low exercise tolerance or exercise hypotension 1

5. Coronary Artery Spasm

• Uncommon but important cause of exercise-related chest pain
• May cause life-threatening arrhythmias 1
• Treatment includes calcium channel blockers and nitrates 1

Management Recommendations

Immediate Management

• Any young athlete with concerning symptoms (syncope, severe chest pain) requires immediate evaluation
• Temporary restriction from competition until evaluation is complete 1

Return to Play Decisions

1. Low-risk findings:

   • Non-cardiac chest pain
   • Normal cardiac evaluation
   • May return to full participation

2. Moderate-risk findings:

   • Mild valvular disease (e.g., mild aortic stenosis)
   • Annual re-evaluation recommended 1
   • May participate with appropriate monitoring

3. High-risk findings (require restriction):

   • Hypertrophic cardiomyopathy
   • Significant coronary anomalies
   • Severe aortic stenosis
   • Active myocarditis/pericarditis
   • Documented coronary artery disease with ischemia 1

Special Considerations

Post-COVID-19 Evaluation

• Additional screening recommended for athletes recovering from COVID-19
• Focus on myocarditis and other cardiac sequelae
• Exercise testing should be avoided during acute infection 1

Psychological Factors

• Consider anxiety/panic disorder if organic causes are ruled out
• Psychogenic chest pain is uncommon but possible 2

Pitfalls to Avoid

1. Dismissing chest pain as "just musculoskeletal" without proper cardiac evaluation

   • While most chest pain in young athletes is benign, potentially lethal causes must be excluded 3, 4

2. Inadequate follow-up of abnormal ECG findings

   • T-wave inversions and other subtle ECG changes may indicate underlying pathology 5

3. Missing coronary anomalies

   • Standard exercise testing may be normal; advanced imaging is often required 6

4. Allowing return to play too soon

   • Athletes with active myocarditis should be restricted from competition for 3-6 months 1

5. Failing to recognize warning signs

   • Exertional syncope, chest pain, or dyspnea should never be dismissed without thorough evaluation 1

By following this structured approach to evaluation and management, clinicians can effectively identify potentially life-threatening cardiovascular conditions in young athletes presenting with exertional chest pain.