Sports and sudden death

Abstract

The sudden and unexpected death in young athletes is always a tragic event with tremendous impact on the family and the community. Sudden cardiac death is one of the most significant and challenging problems facing modern medicine today. In the past years, an enormous amount of information has become available leading to our current understanding of mechanisms, etiology, epidemiology, risk stratification, and management of these, unfortunately too often occurring, life-threatening situations. Distinct structural cardiac disorders such as hypertrophic cardiomyopathy (approximately 36%), coronary artery anomalies (17%), inflammatory disorders (6%), as well as conditions without structural cardiac abnormalities such as primary electrical diseases (Brugada’s syndrome, long QT syndrome, short QT syndrome, and catecholaminergic polymorphic ventricular tachyarrhythmias; approximately 10–20%) are important causes of all incidences of sudden death. There are interesting geographic differences in the epidemiology of sudden death in athletes: for instance, in northern Italy the most frequent cause of sudden death in athletes is arrhythmogenic right ventricular cardiomyopathy (ARVC), in the USA it is hypertropic cardiomyopathy. The most important challenge remains the identification of high-risk candidates for this event. Other efforts include public education, and screening programs to identify patients at risk. In this issue, we tried to invite experts in the field of sudden death to provide us with a complete overview of what the cardiologist should know for optimal management of individuals with this risk. Corrado et al. [1] present one of the long-running Italian program of preparticipation cardiovascular evaluation of competitive athletes and appropriate strategies for prevention of sudden cardiac death during sports activity. Their tremendous experience has influenced the implementation of present guidelines for screening on this side of the Atlantic. The Italian protocol for preparticipation screening has not aimed to exclude individuals from sports activity but rather to assist athletes in safe participation. Cheitlin & MacGregor [2] have a vast experience in athletes regarding the role of the pathogenesis of sudden cardiac death. They evaluated the most frequent causes of sudden death in nearly 1,500 young competitive athletes from 1980 to 2005, where hypertrophic cardiomyopathy was the cause in 36% and coronary anomalies in 17%. Schimpf et al. [3] and Boldt & Haverkamp [4] address the significant advances in our understanding of the genetic basis for various forms of inherited cardiac diseases predisposing to ventricular arrhythmias and sudden cardiac death. It has been estimated, that ARVC accounts for up to 10% of sudden cardiac death cases in individuals < 35 years of age, especially in competitive athletes. Physical exercise or sports might accelerate and modify the disease progression. Therefore, patients with ARVC should avoid competitive sports, and in selected patients programmed ventricular stimulation can help in the decision-making process when to implant a cardioverter defibrillator (ICD). The focus of Frick et al. [5] is on the diagnosis, treatment, and prevention of disorders such as inflammatory, infiltrative, neoplastic cardiomyopathy including viral myocarditis, amyloidosis, and hemochromatosis. Diagnostic tools including myocardial biopsy and the therapeutic options are clearly outlined. Seggewiss et al. [6] address different profiles in the diagnosis of hypertrophic cardiomyopathy, e.g., the risk of sudden death, symptom progression, and appropriate management. Finally, Stuhlinger et al. [7] discuss the role and risk of arrhythmias such as nonsustained tachycardia and the role of palpitations in athletes and their risk during sports activity. At this point, I would like to promote my firm belief that we have made extreme advances in our understanding regarding the management of the problem of sudden cardiac death in athletes and we are able to select the candidates for electrophysiological ablation, as well as to decide when to implant an ICD, and what measures to take in order to reduce sudden cardiac death in athletes. The editors of Herz/Cardiovascular Diseases are indebted to the contributing authors. They are all leading authorities in the field of sudden cardiac death and have done an extraordinary job in synthesizing basic science and clinical information to provide balanced reviews on each topic. I hope that this format will provide the reader with essential background information and valuable practical tips on all facets of sudden cardiac death in sports medicine. 1 Department of Internal Medicine III – Cardiology, Medical University of Innsbruck, Austria.