Sudden Death in Athletes
Sudden Death in Athletes
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Original abstract
Sudden death in athletes is a tragic occurrence in sports medicine, cardiology, primary care, and pediatrics. By far, the most common cause of unexpected death in younger athletes during competition is cardiac disease, usually of congenital origin. However, the use of anabolic steroids, peptide hormones, and stimulants has led to the emergence of acquired heart disease in younger and middle-aged athletes. In contrast, sudden death in an older athlete is typically due to atherosclerotic coronary artery disease. Various congenital cardiac disorders occur in the general population. Most can be categorized as structural or nonstructural. Congenital structural heart disease generally affects intracardiac blood flow and blood flow from the heart. Examples include hypertrophic obstructive cardiomyopathy (HOCM), arrhythmogenic right ventricular dysplasia (ARVD), and coronary artery anomalies. Conversely, nonstructural heart disease involves defects in the electrical system of the heart, which may induce unstable and dangerous arrhythmias. Examples include long QT syndrome, Brugada syndrome, Wolff-Parkinson-White syndrome, and catecholaminergic polymorphic ventricular tachycardia. Other congenital structural and nonstructural cardiac disorders have also been described in association with physical activity and athletics. Drug-induced cardiac effects are also important considerations. Anabolic steroids and peptide hormones can induce structural changes in the heart, whereas stimulants can cause dangerous arrhythmias. Affected athletes may present with syncope or presyncope and, in some instances, sudden unexpected death. The associated mortality underscores the importance of early screening and identification of underlying heart disease in athletes. Many athletes with preexisting heart disease are asymptomatic, and cardiac arrest may be the initial manifestation of underlying pathology. Identifying affected athletes remains challenging because screening must balance the detection of disease against the risk of excessive or unnecessary invasive testing. A thorough sports physical examination, including a review of personal and family history, a physical examination, and an electrocardiogram, can be a useful screening tool for asymptomatic athletes at low risk. Athletes at higher risk, including those with symptoms or abnormal findings, may require more extensive testing. After diagnosis, athletes undergo risk stratification, followed by initiation of a long-term treatment regimen to minimize the risk of sudden cardiac death. Medical treatment is a common option, while surgical procedures are reserved for specific cases. Implantation of an implantable cardioverter-defibrillator (ICD) is appropriate for individuals considered at risk of cardiac arrest secondary to a fatal arrhythmia. The decision to continue or discontinue participation in a chosen sport should be made through shared decision-making between clinicians and athletes. The purpose of this article is to review the causes of sudden death in athletes, with a particular focus on the most common etiologies in younger athletes, their presentation, and evaluation.