In a recent publication, Maron et al. reported the causes of sudden death in athletes from data collected in the US National Registry of Sudden Death in Athletes at the Minneapolis Heart Institute Registry. It is not surprising that in this study, cardiovascular disease is reported as the most common cause of sudden death in athletes (56%). The most frequently encountered cardiac pathology was hypertrophic cardiomyopathy (36% of the population who died of cardiac disease). Coronary artery anomalies of wrong sinus origin were next in frequency (17%). Less common causes attributed to coronary pathology were Kawasaki disease, origin of the left coronary artery from the pulmonary artery, atherosclerotic coronary artery disease, and myocardial bridging of the left anterior descending artery. Echocardiographic imaging along with color and pulsed-wave Doppler has been widely employed to visualize the anatomy and function of the heart and proves to be a valuable instrument in the identification of coronary artery abnormalities. Moreover, coronary CT angiography provides additional confirmatory information. This article will discuss the scope, importance, and implications of echocardiographic and coronary CT angiography imaging of the major coronary anomalies and abnormalities in young athletes who are at risk of sudden death and who otherwise have a structurally normal heart.

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PurposeAlthough numerous studies have documented the declining ability of medical students to identify heart murmurs, no studies have examined why students make errors. We designed a study to compare medical students' documented cardiac exam findings with the diagnoses they assigned.MethodsAt the end of the third year of medical school, all medical students at our institution take a multistation clinical performance exam (CPX). Each station consists of a 15-minute standardized patient interaction followed by a 5-minute written exercise. During the 2005 CPX, one station consisted of taking a history from a patient with chest pain and performing a focused cardiac exam on a Harvey cardiac simulator. On the written exercise, students were asked to document their cardiac exam findings and provide a diagnosis. All students were randomized to one of two settings on the Harvey simulator: hypertension (HTN), which consisted of an S4 at the apex, and aortic stenosis (AS), which consisted of a crescendo-decrescendo murmur at the aortic area and an S4 at the apex.ResultsA total of 92 students completed the 2005 CPX-47 examined the Harvey on the HTN setting and 45 on the AS setting. Of those students listening to the HTN setting, only two students (4%) correctly identified the S4 gallop. Eleven students (23%) misidentified the S4 gallop as an S3 and four (9%) as a split S2. Of those listening to the aortic stenosis setting, 17 (38%) correctly identified the murmur. For both settings, 78 students (35 for AS and 43 for HTN) provided a complete description (location and character) of their cardiac findings and a diagnosis. Of those with complete descriptions, only 45% of students provided a diagnosis, which was consistent with their documented exam findings (both location and character of the heart sounds). For example, several students made a correct diagnosis of aortic stenosis yet described a holosystolic murmur at the apex, whereas other students correctly described a crescendo-decrescendo murmur at the aortic area but made a diagnosis of mitral regurgitation.ConclusionsSimilar to prior studies, overall cardiac diagnostic accuracy of third-year medical students is low. Although auscultation skills can explain some of the errors, many students assign diagnoses that are inconsistent with their reported physical exam findings. Further education appears necessary to improve the clinical decision-making when interpreting a cardiac examination and arriving at a diagnosis.