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Sudden Cardiac Death in Athletes

By Robert S. McKelvie, MD, PhD, Professor of Medicine; Secondary Prevention and Heart Failure Programs, Western University; St. Joseph's Health Care

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An estimated 1 to 3/100,000 apparently healthy young athletes develop abrupt-onset ventricular tachycardia or ventricular fibrillation and die suddenly during exercise. Males are affected 10 times more often than females. Basketball and football players in the US and soccer players in Europe may be at highest risk (1).

In young athletes, sudden cardiac death has many causes (see Table: Causes of Sudden Cardiovascular Death in Young Athletes), but the most common is

Commotio cordis (sudden ventricular tachycardia or fibrillation after a blow to the precordium) is a risk in athletes with thin, compliant chest walls even when no cardiovascular disorder is present. The blow may involve a moderate-force projectile (eg, baseball, hockey puck, lacrosse ball) or impact with another player during a vulnerable phase of myocardial repolarization.

Other causes include inherited arrhythmia syndromes (eg, long QT syndrome, Brugada syndrome). Some young athletes die of aortic aneurysm rupture (in Marfan syndrome).

In older athletes, sudden cardiac death is typically caused by

Occasionally, hypertrophic cardiomyopathy, mitral valve prolapse, or acquired valvular disease is involved.

In other conditions underlying sudden death in athletes (eg, asthma, heatstroke, illicit or performance-enhancing drug-related complications), ventricular tachycardia or fibrillation is a terminal, not a primary event.

Symptoms and signs are those of cardiovascular collapse; diagnosis is obvious.

Immediate treatment with advanced cardiac life support is successful in < 20%; the percentage may increase as distribution of community-based, automated external defibrillators expands. For survivors, treatment is management of the underlying condition. In some cases, an implanted cardioverter-defibrillator may ultimately be required.

Causes of Sudden Cardiovascular Death in Young Athletes

Commotio cordis

Coronary artery anomalies (eg, anomalous left main coronary artery origin, anomalous right coronary artery origin, coronary arterial hypoplasia)


Ruptured aortic aneurysm

Arrhythmogenic right ventricular dysplasia

Tunneled left anterior descending coronary artery

Premature atherosclerotic coronary artery disease

Myxomatous degeneration of mitral valve

Wolff-Parkinson-White syndrome (anterograde conduction only)

Catecholaminergic polymorphic tachycardia

Right ventricular outflow tract tachycardia

Coronary vasospasm

Cardiac sarcoidosis

Cardiac trauma

Ruptured cerebral artery aneurysm

General reference

Cardiovascular Screening for Sports Participation

Athletes are commonly screened to identify risk before participation in sports, and they are reevaluated every 2 yr (if high school age) or every 4 yr (if college age or older).

Screening recommendations in the US for college-age young adults—as well as for children and adolescents—include the following:

  • Medical, family, and drug history (including use of performance-enhancing drugs and drugs that predispose to long QT syndrome)

  • Physical examination (including BP and supine and standing cardiac auscultation)

  • Selected testing based on findings on history and physical examination

European guidelines differ from American guidelines in that a screening electrocardiogram (ECG) is recommended for all children, adolescents, and college-age athletes.

Screening for older adults (35 yr or older) may include incremental symptom-limited exercise testing.

History and examination are neither sensitive nor specific; false-negative and false-positive findings are common because prevalence of cardiac disorders in an apparently healthy population is very low. Use of screening ECG or echocardiography would improve disease detection but would produce even more false-positive diagnoses and is impractical at a population level.

Genetic testing for hypertrophic cardiomyopathy or long QT syndrome is not recommended or even feasible for the screening of athletes.

Selected testing

Athletes with a family history or symptoms or signs of hypertrophic cardiomyopathy, long QT syndrome, or Marfan syndrome require further evaluation, typically with ECG, echocardiography, or both. Confirmation of any of these disorders may preclude sports participation.

Athletes with presyncope or syncope can also be evaluated for anomalous coronary arteries (eg, by cardiac catheterization).

If ECG reveals Mobitz type II heart block, complete heart block, true right bundle branch block, or left bundle branch block, or there is clinical or electrocardiographic evidence of supraventricular or ventricular rhythm disorders, a search for cardiac disease is required (see Atrioventricular Block).

If an enlarged aorta is detected on echocardiography (or incidentally), further assessment is needed.


Athletes should be counseled against use of illicit and performance-enhancing drugs. Patients with mild or moderate valvular heart disease may participate in vigorous activity; however, patients with severe valvular heart disease, particularly of the stenotic variety, should not participate in competitive sports or high-intensity recreational sports. Patients with most structural or arrhythmogenic heart disorders (eg, hypertrophic cardiomyopathy, coronary artery anomalies, arrhythmogenic right ventricular dysplasia) should not participate in competitive sports or high-intensity recreational sports.

Key Points

  • Sudden cardiac death during exercise is rare and is most commonly due to hypertrophic cardiomyopathy (younger athletes) and coronary artery disease (older athletes).

  • Screen younger participants (children through young adults) with history and physical examination; those with abnormal findings or positive family history typically have ECG and/or echocardiography.

  • Screen older participants with history, physical examination, and usually an exercise stress test.

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