Merck Manual

Please confirm that you are a health care professional

honeypot link

Sudden Cardiac Death in Athletes

By

Robert S. McKelvie

, MD, PhD, Western University

Last full review/revision Sep 2022| Content last modified Sep 2022
Click here for Patient Education
Topic Resources

An estimated 1 to 3/100,000 apparently healthy young athletes die suddenly during exercise. Males are affected up to 10 times more often than females. Basketball and football players in the US and soccer players in Europe may be at highest risk (1 General references An estimated 1 to 3/100,000 apparently healthy young athletes die suddenly during exercise. Males are affected up to 10 times more often than females. Basketball and football players in the... read more ).

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% (4 General references An estimated 1 to 3/100,000 apparently healthy young athletes die suddenly during exercise. Males are affected up to 10 times more often than females. Basketball and football players in the... read more ). For survivors, treatment is management of the underlying condition. In some cases, an implanted cardioverter-defibrillator may ultimately be required.

Table

General references

  • 1. 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

  • 2. Finocchiaro G, Papadakis M, Robertus JL, et al: Etiology of sudden death in sports: insights from a United Kingdom regional registry. J Am Coll Cardiol 67:2108–2115, 2016. doi: 10.1016/j.jacc.2016.02.062

  • 3. Harmon KG, Asif IM, Klossner D, Drezner JA: Incidence of sudden cardiac death in National Collegiate Athletic Association athletes. Circulation 123:1594–1600, 2011. doi: 10.1161/CIRCULATIONAHA.110.004622

  • 4. 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:

The Canadian Guidelines recommend screening in three tiers:

  • History/questionnaire

  • Physical examination

  • ECG only when indicated according to clinical findings

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

  • ECG

  • Echocardiography

Confirmation of any of these disorders may preclude sports participation.

Athletes with presyncope or syncope can also be evaluated for anomalous coronary arteries if the above noninvasive tests are not helpful, using

  • Cardiac catheterization

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

Recommendations for sports participation

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.

Cardiovascular screening reference

  • 1. 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

Key Points

  • Sudden cardiac death during exercise is rare and may be due to hypertrophic cardiomyopathy, but many patients have a structurally normal heart at autopsy (younger athletes) or 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 should 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.

  • Recommend against participation in athletes with severe valvular disease and most structural or arrhythmogenic heart disorders (eg, hypertrophic cardiomyopathy).

More Information

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

  • Baggish AL, Battle RW, Beaver TA, et al: Recommendations on the use of multimodality cardiovascular imaging in young adult competitive athletes: A report from the American Society of Echocardiography in collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 33 (5): 523–549, 2020. doi: 10.1016/j.echo.2020.02.009

  • 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

  • Martinez MW, Kim JH, Shah, AB, et al: Exercise-induced cardiovascular adaptations and approach to exercise and cardiovascular disease. JACC State-Of-The-Art Review, J Am Col Cardiol 78 (14):1454-1470, 2021.

Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
quiz link

Test your knowledge

Take a Quiz! 
iOS ANDROID
iOS ANDROID
iOS ANDROID
TOP