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Sudden Cardiac Death in Athletes

By

Robert S. McKelvie

, MD, PhD, Western University

Last full review/revision Oct 2020| Content last modified Oct 2020
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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.

In older athletes, sudden cardiac death is typically caused by

Occasionally, hypertrophic cardiomyopathy or valvular disease is involved.

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 (AEDs) expands. In fact, studies have demonstrated that the presence of AEDs can increase the neurologically intact survival rates to over 80% (3 General references 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 up... read more ). For survivors, treatment is management of the underlying condition. In some cases, an implanted cardioverter-defibrillator may ultimately be required.

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General references

  • 1. Maron BJ, Shirani J, Poliac LC, et al: Sudden death in young competitive athletes: Clinical, demographic, and pathological profiles. JAMA 276(3):199–204, 1996.

  • 2. Maron BJ, Haas TJ, Ahluwalia A, et al: Demographics and epidemiology of sudden deaths in young competitive athletes: From the United States National Registry. Am J Med 129:1170–1177, 2016. doi: 10.1016/j.amjmed.2016.02.031

  • 3. Johri AM, Poirier P, Dorian P, et al: Canadian Cardiovascular Society/Canadian Heart Rhythm Society joint position statement on the cardiovascular screening of competitive athletes. Can J Cardiol 35:1-11, 2019. doi: 10.1016/j.cjca.2018.10.016

Cardiovascular Screening for Sports Participation

Athletes are commonly screened to identify risk before participation in sports. In the United States, they are reevaluated every 2 years (if high school age) or every 4 years (if college age or older). In Europe, screening is repeated every 2 years regardless of age.

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

Screening for older adults (35 years or older) with risk factors may include incremental symptom-limited exercise testing Stress Testing In stress testing, the heart is monitored by electrocardiography (ECG) and often imaging studies during an induced episode of increased cardiac demand so that ischemic areas potentially at risk... read more Stress Testing , especially if they have been sedentary for a number of years.

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.

Selected testing

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

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

Recommendations

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 Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy is a congenital or acquired disorder characterized by marked ventricular hypertrophy with diastolic dysfunction but without increased afterload (eg, due to valvular... read more 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 risk factors (particularly if they have been sedentary for a number of years) with history, physical examination, and usually an exercise stress test.

More Information

  • Johri AM, Poirier P, Dorian P, et al: Canadian Cardiovascular Society/Canadian Heart Rhythm Society joint position statement on the cardiovascular screening of competitive athletes. Can J Cardiol 35:1-11, 2019. doi: 10.1016/j.cjca.2018.10.016

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