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Sudden Cardiac Death in Athletes
2016 Apr-Jun Methodist DeBakey Cardiovascular Journal

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4969030/

“Sudden cardiac death (SCD) is the most frequent medical cause of sudden death in athletes, and estimates vary widely based on the population.”

“Though SCD is rare, its occurrence in athletes who are often young and presumably healthy has a large emotional and social impact on the surrounding community.”

“The definition of an athlete varies. A competitive athlete has been proposed to be “one who participates in an organized team or individual sport that requires competition against others as a central component, places a high premium on excellence and achievement, and requires some form of systematic (and usually intense) training.” This definition is considerably easier to apply to high school, collegiate, and professional organized sport participants but more difficult to apply to younger and older populations who participate in recreational activities (i.e., a heterogeneous group of adults participating in a running race). Therefore, when estimating SCD incidence, the population of athletes “at risk” may be difficult to quantify.”

“The most common causes of SCD in athletes are shown in Table 2. In athletes under 35 years of age, inherited cardiac conditions predominate, with hypertrophic cardiomyopathy (HCM) and anomalous origin of a coronary artery being the two most common causes in the United States. In athletes older than 35, most SCD events are due to acquired atherosclerotic coronary artery disease. Many of these diagnoses may not be clinically apparent and may first present with sudden death.”

“Although rare, SCD in the athlete is a traumatic event that has a large impact on society. The incidence of SCD varies widely depending on the athlete population. In older athletes, SCD is primarily due to CAD and associated complications. In younger athletes, it is due to congenital or genetically mediated cardiovascular disease, such as HCM, coronary artery anomalies, other cardiomyopathies, or primary arrhythmogenic disorders. All preparticipation screening programs aimed at identifying athletes at high risk of SCD begin with a focused history and physical. The addition of the 12-lead ECG and/or additional cardiac testing is a source of considerable ongoing debate. The optimal preparticipation evaluation for a given group depends on the athlete population and the available screening resources, including clinicians with expertise in the cardiovascular care of athletes. It is highly unlikely that any screening program will be effective at appropriately identifying all athletes at risk of SCD; therefore, increased access to automated external defibrillators as well as training in cardiopulmonary resuscitation at a community level are important means of reducing SCD in athletes.”

Sudden Cardiac Death in the Athlete
22 May 2012 Circulation

https://www.ahajournals.org/doi/10.1161/circulationaha.111.023861

“Sudden cardiac death (SCD) in a young athlete commonly brings to the forefront the many gaps in knowledge regarding how to predict and prevent these rare tragic events. Although the number of athletic sudden deaths is relatively small, with ≈100 to 150 competitive deaths during sports in the United States annually, they represent an important and emotionally charged public health issue, perhaps out of proportion to the relative risks of other pediatric deaths. Despite identification of the cardiovascular conditions that predispose to these events, much remains unknown regarding many fundamental issues related to athletic sudden death. The precise frequency with which these events occur in the United States remains unclear because of the absence of athletic death registries (and indeed any SCD registry) with mandatory reporting requirements. In fact, whether these events are more common in athletes is not at all certain. Additionally, significant gaps in evidence exist related to effectiveness of preventing sudden death in the athlete with preparticipation screening strategies.”

Is the Risk of SCD Higher in the Athlete?

“On average, every 3 days in the United States a competitive athlete experiences a SCD, and many of these deaths are nationally noted. However, this same intense media speculation is not given to a nonathlete who experiences SCD or indeed to a competitive athlete who has SCD off the athletic field. On the basis of media reports it would appear that SCD deaths in athletes are much more common than in nonathletes. However, the data supporting such a claim have many limitations.”

“The lack of mandatory reporting requirements for SCD also hinders accurate assessment of the incidence of athletic SCD. Accurate incidence and prevalence data are essential for assessing strategies for primary prevention thorough preparticipation screening and secondary prevention with emergency response systems. It is evident that precise data are essential to assess the efficacy of both primary and secondary prevention. Although the underlying causes of sudden death in the athlete are known, the frequency with which sudden death occur remains to be precisely defined by sex, age, race, nationality, and sport. Currently in the United States, the incidence is derived from identification of cases from media reports and estimated participation rates. Accordingly, the precise number of deaths (numerator) is unknown as is the exact number of athletic participants (denominator).”

“SCD is a very real public health issue and personal issue for not only the athlete, but also for the nonathlete. SCD in a young individual is devastating. Appropriate measures of prevention and treatment are critical. However, based on the best available evidence, it is evident that measures conclusively effective in reducing athletic SCD remain unknown. Nearly all available data are limited by their observational nature. Standard definitions of competitive athletes and athletic sudden death are needed. Robust national registries of athletic sudden death are also essential. Randomized trials of screening and restriction prospectively collecting cost and outcomes data are needed. The ethics of selectively screening athletes for cardiovascular conditions that predispose to SCD without broader screening of the nonathletic population merit careful consideration. Additional studies are needed to evaluate the long-term consequences of athletic restriction. The considerable controversy related to many of the issues regarding athletic sudden death stems from the lack of evidence to resolve them. Experience indicates that when there is disagreement among experts, there is a dearth of reliable data. The best available data indicate that the total number of athletic deaths is relatively small. Furthermore, proven strategies to prevent athletic sudden death are not currently available. Based on these considerations, the most reasoned approach currently is advancing the available evidence by obtaining data from appropriately designed studies rather than prematurely advancing well-intended yet unproven strategies.”

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