Sports-related Sudden Cardiac Death Research Articles

The forensic pathological analysis of sport-related sudden cardiac death in Southern China

Studies regarding sport-related sudden cardiac death (SCD) mainly focus on competitive athletes; similar data are rare in the general population, especially in China. We conducted a retrospective study (from September 1998 to August 2013) to investigate the aetiological distribution and epidemiological features of sport-related SCD in Southern China. Selections of cases are based on details, and two subgroups were established: one was the sport-related SCD group, and the other was the disease-free accident victims group which was matched with the sport-related SCD group in gender, age and year of death. Among the 3770 sudden-death cases, 1656 cases were SCD cases. A total of 65 cases (57 males) out of 1 656 SCD cases were sport-related. The age range of the 65 sport-related SCD cases was from 12 to 68 years old with a mean (35.92 ± 14.23) years old. Only two of these cases were competitive athletes. The most common circumstances of the 65 sport-related SCD cases were heavy physical labour (46.15%) and running (30.77%). The three leading forensic diagnoses were the coronary atherosclerotic disease (CAD, 28 cases), cardiomyopathy (CM, 14 cases) and sudden unexplained death (7 cases). CM was the most common forensic diagnosis in those ≤35 years old, while CAD was the most common one in those >35 years old. Left anterior descending in which atherosclerotic plaques was most commonly found was the principal artery branch associated with sport-related SCD. There was a statistically significant difference in the weight of hearts between the 65 sport-related SCD cases and 65 diseases-free accidental cases. This study highlights the need to attract public attention to sport-related SCD and to issue a prevention strategy to the public, and to make the SCD-related genetic sequencing a routine tool in both forensic pathological examination and clinic screening.

Sports-related sudden cardiac deaths in the young population of Switzerland.

BackgroundIn Switzerland, ECG screening was first recommended for national squad athletes in 1998. Since 2001 it has become mandatory in selected high-risk professional sports. Its impact on the rates of sports-related sudden cardiac death (SCD) is unknown.ObjectiveWe aimed to study the incidence, causes and time trends of sports-related SCD in comparison to SCD unrelated to exercise in Switzerland.MethodsWe reviewed all forensic reports of SCDs of the German-speaking region of Switzerland in the age group of 10 to 39 years, occurring between 1999 and 2010. Cases were classified into three categories based on whether or not deaths were associated with sports: no sports (NONE), recreational sports (REC), and competitive sports (COMP).ResultsOver the 12-year study period, 349 SCD cases were recorded (mean age 30±7 years, 76.5% male); 297 cases were categorized as NONE, 31 as REC, and 21 as COMP. Incidences of SCD per 100,000 person-years [mean (95% CI)] were the lowest in REC [0.43 (0.35–0.56)], followed by COMP [1.19 (0.89–1.60)] and NONE [2.46 (2.27–2.66)]. In all three categories, coronary artery disease (CAD) with or without acute myocardial infarction (MI) was the most common cause of SCD. Three professional athletes were identified in COMP category which all had SCD due to acute MI. There were no time trends, neither in overall, nor in cause-specific incidences of SCD.ConclusionsThe incidence of SCD in young individuals in Switzerland is low, both related and unrelated to sports. In regions, like Switzerland, where CAD is the leading cause of SCD associated with competitions, screening for cardiovascular risk factors in addition to the current PPS recommendations might be indicated to improve detection of silent CAD and further decrease the incidence of SCD.

Avoiding sports-related sudden cardiac death in children with congenital channelopathy : Recommendations for sports activities.

For the past few years, children affected by an inherited channelopathy have been counseled to avoid (recreational) sports activities and all competitive sports so as to prevent exercise-induced arrhythmia and sudden cardiac death. An increased understanding of the pathophysiological mechanisms, better anti-arrhythmic strategies, and, in particular, more epidemiological data on exercise-induced arrhythmia in active athletes with channelopathies have changed the universal recommendation of "no sports," leading to revised, less strict, and more differentiated guidelines (published by the American Heart Association/American College of Cardiology in 2015). In this review, we outline the disease- and genotype-specific mechanisms of exercise-induced arrhythmia; give an overview of trigger-, symptom-, and genotype-dependent guidance in sports activities for children with long QT syndrome (LQTS), Brugada syndrome (BrS), catecholaminergic polymorphic ventricular tachycardia (CPVT), or short QT syndrome (SQTS); and highlight the novelties in the current guidelines compared with previous versions. While it is still recommended for patients with LQT1 and CPVT (even when asymptomatic) and all symptomatic LQTS patients (independent of genotype) to avoid any competitive and high-intensity sports, other LQTS patients successfully treated with anti-arrhythmic therapies and phenotype-negative genotype-positive patients may be allowed to perform sports at different activity levels - provided they undergo regular, sophisticated evaluations to detect any changes in arrhythmogenic risk.

Sports-related sudden cardiac death: How to prove an effect of preparticipation screening?

Sports-related sudden cardiac death: How to prove an effect of preparticipation screening?

Sports-related sudden cardiac death in Switzerland classified by static and dynamic components of exercise.

Sports-related sudden cardiac deaths (SrSCDs) occur most frequently in highly dynamic and/or static sports. We aimed to assess the incidence and characteristics of SrSCDs in Switzerland and to compare SrSCD occurrence according to sports categories with the sports participation behaviour in the general population. Between 1999 and 2010, forensic reports of SrSCDs in young individuals (10-39 years of age) were retrospectively reviewed and categorised based on peak static (increasing from I to III) and dynamic sports components (increasing from A to C). Data were compared to the sports participation behaviour of the Swiss population. Sixty-nine SrSCDs were identified. Forty-eight (69.6%) occurred during recreational sports (REC) and 21 (30.4%) during competitive sports (COMP). Incidences (per 100,000 athlete person-years) for COMP and REC were 0.90 and 0.52, respectively (p = 0.001). Most SrSCDs occurred in IC (23 cases, 33.3%), followed by IIC (13, 18.9%), IIIA and IIIC (11 each, 15.9%), IIIB (6, 8.7%), IIA (4, 5.8%) and IB sports categories (1, 1.5%). No SrSCDs were found in IA and IIB sports categories. Incidences between sports categories (IIIA 0.25, IB 0.25, IC 0.18, IIC 0.33 and IIIC 0.25) were not significantly different except to IIA (0.94, p < 0.001), due to the fact that few people were involved in this sports category. Coronary artery disease (CAD) was the most common underlying pathology of SrSCD. In this Swiss cohort, incidence of SrSCD was very low and similar in all sports categories classified by their static and dynamic components. However, the incidence was higher in COMP compared to REC, and CAD proved to be the most common underlying cause of SrSCD.

Sudden cardiac death among general population and sport related population in forensic experience

PurposeThe goal of the study was to assess the causes and analyze the cases of sudden cardiac death (SCD) victims referred to the department of forensic medicine in Lausanne, with a particular focus on sports-related fatalities including also leisure sporting activities. To date, no such published assessment has been done nor for Switzerland nor for the central Europe. MethodsThis is a retrospective study based on autopsy records of SCD victims, from 10 to 50 years of age, performed at the University Centre of Legal Medicine in Lausanne from 1995 to 2010. The study population was divided into two groups: sport-related (SR) and not sport-related (NSR) SCDs. ResultsDuring the study period, 188 cases of SCD were recorded: 166 (88%) were NSR and 22 (12%) SR. The mean age of the 188 victims was 37.3 ± 10.1 years, with the majority of the cases being male (79%). A cause of death was established in 84%, and the pathology responsible for death varied according to the age of the victims.In the NSR group, the mean age was 38.2 ± 9.2 years and there was 82% of male. Coronary artery disease (CAD) was the main diagnosis in the victims aged 30–50 years. The majority of morphologically normal hearts were observed in the 15–29 year age range. There was no case in the 10–14 year age range.In the SR group, 91% of victims died during leisure sporting activities. In this group the mean age was 30.5 ± 13.5 years, with the majority being male (82%). The main cause of death was CAD, with 6 cases (27%) and a mean age of 40.8 ± 5.5 years. The youngest victim with CAD was 33 years old. A morphologically normal heart was observed in 5 cases (23%), with a mean age of 24.4 ± 14.9 years. The most frequently implicated sporting activities were hiking (26%) and swimming (17%). ConclusionIn this study, CAD was the most common cause of death in both groups. Although this pathology most often affects adults over 35 years of age, there were also some victims under 35 years of age in both groups. SCDs during sport are mostly related to leisure sporting activities, for which preventive measures are not yet usually established. This study highlights also the need to inform both athletes and non athletes of the cardiovascular risks during sport activities and the role of a forensic autopsy and registries involving forensic pathologists for SR SCD.

Data from a nationwide registry on sports-related sudden cardiac deaths in Germany.

BackgroundProspective national registries examining the incidence and aetiology of sports-related sudden cardiac death (SrSCD) not only in competitive athletes but also in recreational sports participants are uncommon. In May 2012, a prospective registry on SrSCD was installed to examine the incidence and particularly the aetiology of such events in the general population in Germany.MethodsThe registry consists of a web-based platform to record SrSCD cases. Media-monitoring and cooperation with 15 institutes of forensic medicine complemented the search. SrSCD was defined as death occurring during sports activity or up to 1 hour after its cessation, regardless of successful resuscitation. We included subjects at all levels of competition as well as recreational athletes.ResultsAfter 30 months of observation, 144 SrSCDs were recorded (mean age 46.8 ± 16.2 years). The overall incidence was 1.2–1.5/million/year, with 97% being male. Most of the cases occurred in the context of non-elite competitive or recreational sports. Football and running were the most common disciplines. In subjects ≤35 years, myocarditis prevailed, whereas in athletes ≥35 years, CAD predominated by far. Few cardiomyopathies were observed.ConclusionsIn Germany, the largest proportion of SrSCDs occurs in middle-aged men during recreational sports or non-elite competitive sports. The distribution of cardiac diseases responsible for SrSCD seems to vary among European countries. Our findings may indicate the need for a larger focus on myocarditis prevention in the young as well as widening the screening scope to younger athletes below the ‘elite’ level and to senior athletes.

Sudden death in athletes: Preventable or inevitable?

Sudden cardiac death (SCD) is a tragic and devastating complication of a number of underlying cardiovascular diseases. In people younger than 35 years, genetic heart diseases such as inherited cardiomyopathies, namely, hypertrophic cardiomyopathy (HCM), and primary arrhythmogenic disorders, including familial long QT syndrome, represent an important cause of SCD. In those younger than 35 years, coronary artery disease and myocardial infarction together comprise over 90% of SCD cases. Understanding the causes and arrhythmogenic substrates underpinning SCD and elucidating what specific factors may trigger malignant arrhythmias represent key foundations for the development of treatment and prevention strategies to reduce SCD in our communities. In this issue of HeartRhythm, Risgaard et al present findings from a retrospective nationwide study of SCD in Denmark, with data from SCD cases collected over a 3-year period from 2007 to 2009. The main focus was on SCD cases aged 12–49 years and specifically to compare SCD incidence rates between competitive and noncompetitive athletes, so-called sports-related SCD cases. Of 881 SCD cases aged 12–49 years over the study period, 44 sports-related SCD cases were identified (0.54 per 100,000 person-years). Significantly, in the age group of 12–35 years, there was no difference in the incidence of SCD between competitive (0.47 per 100,000 athlete person-years) and noncompetitive (0.43 per 100,000 athlete person-years) athletes. The incidence of sports-related SCD in those aged 36–49 years was significantly increased in both competitive and noncompetitive athletes. Importantly, the overall incidence of SCD in the general population was found to be much more prevalent than that of sports-related SCD in all age groups. The authors are to be congratulated for the rigorous and dedicated efforts to collect this important data set. These

Sports-related sudden cardiac death in a competitive and a noncompetitive athlete population aged 12 to 49 years: data from an unselected nationwide study in Denmark.

Preparticipation screening programs have been suggested to reduce the numbers of sports-related sudden cardiac deaths (SrSCD). The purpose of this study was to identify and characterize all SrSCD aged 12-49 years and to address the difference in incidence rates between competitive and noncompetitive athletes. All deaths among persons aged 12-49 years from 2007-2009 were included. Death certificates were reviewed. History of previous admissions to hospital was assessed, and discharge summaries and autopsy reports were read. Sudden cardiac deaths (SCDs) and SrSCD cases were identified. In the 3-year period, there were 881 SCDs, of which we identified 44 SrSCD. In noncompetitive athletes aged 12-35 years, the incidence rate of SrSCD was 0.43 (95% confidence interval [CI] 0.16-0.94) per 100,000 athlete person-years vs 2.95 (95% CI 1.95-4.30) in noncompetitive athletes aged 36-49 years. In competitive athletes, the incidence rate of SrSCD was 0.47 (95% CI 0.10-1.14) and 6.64 (95% CI 2.86-13.1) per 100,000 athlete person-years in those aged 12-35 years and 36-49 years, respectively. The incidence rate of SCD in the general population was 10.7 (95% CI 10.0-11.5) per 100.000 person-years. The incidence rates of SrSCD in noncompetitive and competitive athletes are not different. The study showed an increase in the incidence rate of SrSCD in persons aged 36-49 years in both noncompetitive and competitive athletes compared to those aged 12-35 years. Importantly, SCD in the general population is much more prevalent than is SrSCD in all age groups.

Nationwide (Denmark) Study of Symptoms Preceding Sudden Death due to Arrhythmogenic Right Ventricular Cardiomyopathy

In this study, we investigated medical history and symptoms before death in all subjects aged 1 to 35 years who died a sudden cardiac death (SCD) from arrhythmogenic right ventricular cardiomyopathy (ARVC) in Denmark in the years 2000 to 2006. All deaths (n=6,629) in subjects aged 1 to 35 years in Denmark in the period 2000 to 2006 were included. A total of 16 cases of SCD due to ARVC were identified based on histopathologic examination. Information on medical history was retrieved from The National Patient Registry, general practitioners, and hospitals. Symptoms before death were compared with 2 control groups in the same age group and time interval: one consisting of subjects who died in traffic accidents (n=74) and the other consisting of patients who died a SCD due to coronary artery disease (CAD; n=34). In the case group, 8 of the 16 patients with ARVC experienced antecedent cardiac symptoms and 7 of them sought medical attention. None were diagnosed with ARVC before death. Only 1 patient in the healthy control group and 31 of the 39 patients with CAD experienced cardiac symptoms before death. A total of 6 patients of the 16 with ARVC died during strenuous physical activity and 4 of the deaths were sports-related SCDs. In conclusion, antecedent cardiac symptoms before SCD in the young were seen in 1/2 of the patients who died because of ARVC, and this is significantly higher than in the healthy control group. When considering the ARVC and CAD groups collectively, antecedent cardiac symptoms are seen in the majority.

Characteristics and Outcomes of Sudden Cardiac Arrest During Sports in Women

No specific data are available on characteristics and outcome of sudden cardiac death (SCD) during sport activities among women in the general population. From a prospective 5-year national survey, involving 820 subjects 10 to 75 years old who presented with SCD (resuscitated or not) during competitive or recreational sport activities, 43 (5.2%) such events occurred in women, principally during jogging, cycling, and swimming. The level of activity at the time of SCD was moderate to vigorous in 35 cases (81.4%). The overall incidence of sport-related SCD, among 15- to 75-year-old women, was estimated as 0.59 (95% confidence interval [CI], 0.39-0.79) to 2.17 (95% CI, 1.38-2.96) per year per million female sports participants for the 80th and 20th percentiles of reporting districts, respectively. Compared with men, the incidence of SCDs in women was dramatically lower, particularly in the 45- to 54-year range (relative risk, 0.033; 95% CI, 0.015-0.075). Despite similar circumstances of occurrence, survival at hospital admission (46.5%; 95% CI, 31.0-60.0) was significantly higher than that for men (30.0%; 95% CI, 26.8-33.2; P=0.02), although this did not reach statistical significance for hospital discharge. Favorable neurological outcomes were similar (80%). Cause of death seemed less likely to be associated with structural heart disease in women compared with men (58.3% versus 95.8%; P=0.003). Sports-related SCDs in women participants seems dramatically less common (up to 30-fold less frequent) compared with men. Our results also suggest a higher likelihood of successful resuscitation as well as less frequency of structural heart disease in women compared with men.

Reply to the Editor—Incidence of Sports-Related Sudden Cardiac Death: The Danish Paradox

Reply to the Editor—Incidence of Sports-Related Sudden Cardiac Death: The Danish Paradox

Incidence and etiology of sports-related sudden cardiac death in Denmark—Implications for preparticipation screening

Studies on incidences of sports-related sudden cardiac death (SrSCD) are few and data are needed for the discussion of preparticipation screening for cardiac disease. We sought to chart the incidence and etiology of SrSCD in the young in Denmark (population 5.4 million) and to compare this to the incidence of sudden cardiac death (SCD) in the background population. All 5,662 death certificates for decedents in the period 2000 to 2006 in the age group 12 to 35 years in Denmark were read independently by 2 physicians to identify cases of SCD. Information from autopsy reports, selected hospital records, and multiple registries was used to identify cases of SCD and SrSCD. SrSCD was defined as SCD occurring during or within 1 hour after exercise in a competitive athlete. The size of the athlete population was estimated from national survey data. Fifteen (range 0 to 5 per year) cases of SrSCD were found, 8 of which had antecedent symptoms. The incidence rate was 1.21 (95% confidence interval [CI]: 0.68 to 2.00) per 100,000 athlete person-years. The most common autopsy findings were arrhythmogenic right ventricular cardiomyopathy (n = 4), sudden unexplained death (n = 4), and coronary artery disease (n = 2). The incidence of SCD in the general population age 12 to 35 was 3.76 (95% CI: 3.42 to 4.14) per 100,000 person-years. In Denmark, SrSCD is a rare occurrence and the incidence rate is lower than that of SCD in the general population. This may imply a low value of preparticipation screening of athletes in Denmark.

Sudden death due to ischaemic heart disease in young aboriginal sportsmen in the Northern Territory, 1982-1996.

To estimate the incidence of sport-related sudden cardiac death due to ischaemic heart disease (IHD) in competitive young Aboriginal sportsmen. Northern Territory (NT), 1982-1996. Retrospective case series with cases identified from Australian Bureau of Statistics cause-of-death listings and NT coronial autopsy records. Circumstances and incidence of sport-related sudden cardiac deaths due to IHD; autopsy findings. Between 1982 and 1996, there were eight sudden cardiac deaths due to IHD and related to sporting activity among Aboriginal sportsmen aged 15-37 years in the NT. Six were associated with games of Australian (rules) football. All occurred in the Top End of the NT in the wet season, and all occurred after the first half, or within an hour of, a game. Four of the players had macrosopic myocardial abnormalities (hypertrophy or previous infarcts) on autopsy. The estimated incidence of IHD-related sudden cardiac death among Aboriginal Australian football players in the NT was 19-24 per 100,000 player-years, compared with 0.54 per 100,000 player-years among Australian rules footballers of similar ages in Victoria. Incidence of sudden cardiac death attributable to underlying IHD was extremely high among young NT Aboriginal Australian footballers. Prevention will best be achieved by funding culturally appropriate long-term strategies to reduce the incidence of IHD. However, in the short-term, community-controlled programs with education of athletes, heat-stress reduction strategies, and cardiovascular screening should reduce the incidence of sudden cardiac death in sport.