Thomas K. Chin, MD, Division Head of Pediatric Cardiology in the University of Maryland School of Medicine's Department of Pediatrics and Co-Director of the Children's Heart Program at the University of Maryland Children's Hospital, gave a Grand Rounds presentation on the prevention of sudden cardiac death in children who play sports.

To help catch children who may need further evaluation by a pediatric cardiologist, the Preparticipation Physical Evaluation (PPE 4) is a 14-question screening tool for competitive athletes. The PPE 4 is a good predictor of school-age children who need additional cardiac evaluation. It can lead to evaluation of structural heart abnormalities and functional heart abnormalities that could increase a student athlete's chance of suffering sudden cardiac death.

About Sports Restriction

In some cases, a child's cardiac health may necessitate restriction from certain kinds of sports. There are two components of exercise that are considered when developing restrictions:

  • Static component of exercise – associated with an increase in blood pressure – includes anaerobic activities (like weightlifting)
  • Dynamic component of exercise – associated with an increase in cardiac output required to participate in these activities – includes aerobic exercises

Classifying various sports in terms of their relative static and dynamic components is visualized as a nine-part grid, on an x/y axis:

  • In the lower left box (1A) are the sports that are lowest in both static and dynamic demand. They are generally considered safe from a cardiovascular perspective – examples include bowling and golf.
  • In the upper right box (3C) are activities that are high in both static and dynamic requirements. For that reason, they are the most highly restricted – examples include cycling and rowing.

For many of these children, being completely sedentary is worse for them than doing sports, according to Dr. Chin. "It's more important to allow patients to perform to the maximum of their capabilities, as long as it's safe," he noted, with the caveat that no activity is 100-percent safe.

Conditions That Can Cause Sudden Cardiac Death in Young Athletes


Hypertrophic cardiomyopathy – is the top cause of sudden cardiac death in young athletes.

Dilated and restrictive cardiomyopathy are not as common, but still important to mention.
Left ventricular noncompaction should be considered the fourth form of cardiomyopathy, Dr. Chin said. It's much more common than previously thought. A portion of these patients develop heart failure and an enlarged heart. The condition can result in ventricular arrhythmias or strokes, both of which can be fatal.

Restriction recommendations for patients with cardiomyopathies:

  • Participation is allowed for genotype (+), phenotype (-)
  • Low intensity (1A) only, if phenotype (+)
    • Unchanged after medications – still restricted
    • Unchanged after defibrillators – still restricted


  • Children can return to training if there is a normal left ventricle (LV) on echo, normal markers for inflammation, normal Holter, and normal stress test.
  • They can return to competitive sports after 3 to 6 months if normal LV on echo, normal markers for inflammation, normal Holter, and normal stress test.

Coronary anomolies

  • Anomalous LCA or RCA from pulmonary artery: preoperative 1A, postoperative restrictions based on sequalae
  • Anomalous LCA from right sinus – preoperative 1A
  • Anomalous RCA from left sinus – preoperative 1A

Congenital heart defects – acyanotic

  • Atrial septal defect: no restrictions – 1A if pulmonary hypertension (PH) is present
  • Ventricular septal defect: small, after 6 months no restrictions, unless PH is present
  • Patent ductus arteriosus: small, after repair, no restrictions unless PH is present
  • Aortic stenosis: moderate 1A, 1B, 2A; severe 1A
  • Pulmonary stenosis: moderate to severe, 1A, 1B, 2B
  • Aortic coarctation – gradient > 20 mm Hg, exercise-induced hypertension, ascending aorta dilation, 1A – 3 months post-op, 1A, 1B, 2A, 2B
  • Pulmonary hypertension – mean PA > 25 mm Hg: 1A

Congenital heart defects – cyanotic

  • Tetralogy of Fallot (TOF) – unrepaired, 1A
  • TOF post-op: evaluation required with an exam, EKG echo, stress test
  • Transposition of the great arteries post-op: evaluation required with an exam, EKG echo, stress test
  • Single ventricle – evaluation required: generally 1A, but participation in other sports can be determined on an individual basis


  • Evaluation is required for all: exam, EKG echo, stress test
  • No restrictions for many
  • For sustained ventricular tachycardia –no restrictions after it's well controlled with medications or ablation
  • If the heart is structurally abnormal, then 1A restrictions

Pacemakers and ICDs

  • Recommendations to wear protective equipment or avoid collisions
  • After an ICD placement, 1A; if the VF or VT has been controlled for three months, then no restrictions

Exercise and Hypertension

Understanding blood pressure often goes beyond a single reading. Dr. Chin often recommends parents get a blood pressure cuff to get baselines at home.


  • For stage 1 prehypertension – no exercise restrictions, but regular follow-ups to check blood pressure
  • For stage 2 prehypertension – restriction from high static sports (weightlifting, boxing, wrestling)

The Children's Heart Program at the University of Maryland Children's Hospital is committed to providing comprehensive cardiac care for children, from fetal life into adulthood, with congenital heart disease, and for children with acquired heart disease.

View Dr. Chin's complete presentation.