Warning Symptoms in Athletes

Warning or "red flag" symptoms that may indicate the presence of an underlying cardiovascular disorder should be recognized and further assessed before medical clearance. Syncope that occurs during but not after exercise is of great concern and warrants a comprehensive cardiology evaluation to rule out the presence of an occult cardiac disorder that may lead to sudden death. Other worrying symptoms include palpitations, chest pain, lightheaded-ness, and fatigue or dyspnea greater than expected for the level of activity. Athletes with warning symptoms should be evaluated by an electrocardiogram (ECG), echocardio-gram, and exercise stress test and referred to a cardiologist. In addition, systolic murmurs of grade 3/6 in severity, all diastolic murmurs, any murmur that becomes louder with a Valsalva maneuver or on standing (suspicious for hypertrophic cardiomyopathy), and a concerning family history of premature sudden cardiac death or hereditary cardiac disorder should be further evaluated by a cardiovascular specialist.

If a cardiac abnormality is identified, the decision to withhold medical clearance for participation in competitive sports is difficult and should be carefully considered on an individual basis. The American College of Cardiology 36 th

Bethesda Conference defined eligibility recommendations for athletes with cardiovascular abnormalities (Maron and Zipes, 2005).

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