Sudden Cardiac Death In Athletes Research Articles

Coronary atherosclerosis in athletes: emerging concepts and preventive strategies.

There should be no assumption that an athlete is immune to coronary artery disease (CAD), even when traditional cardiovascular (CV) risk factors appear well-managed. Excelling in certain aspects of health does not equate to total CV protection. Recent data from cardiac imaging studies have raised the possibility that long-term, high-volume, high-intensity endurance exercise is associated with coronary atherosclerosis. Whilst the risk of CV events has not been shown to rise with athletic activity, the potential for CAD should not be overlooked as it is the leading cause of sudden cardiac death in athletes >35 years of age (i.e. 'Masters athletes'). Evaluating both traditional and non-traditional risk factors for CAD is the most important part of pre-participation evaluation in Masters athletes. When managing athletes at risk of CAD it is important to adopt a shared decision-making approach regarding lifestyle adaptation and lipid-lowering treatments. In the great majority of athletes, after excluding the presence of symptoms and inducible ischaemia, this advice should include encouragement to continue exercising as available data indicate that higher levels of fitness are associated with a markedly attenuated incidence of coronary events regardless of the severity of coronary disease. Future research is needed to establish the relationship between clinically relevant CAD outcomes and coronary artery calcification in Masters Athletes, the role of sex, as well as exploration of the mechanisms underpinning these unexpected CV adaptations.

Sudden cardiac death in athletes – Addressing the silent threat

Sudden cardiac death in athletes – Addressing the silent threat

Sudden cardiac death in athletes: A 20-year analysis in Portugal

Introduction and objectivesSudden cardiac death (SCD) in athletes is a tragic event, with some evidence remaining controversial. The aim of this study was to evaluate cases of SCD in athletes in Portugal within the last 20 years. MethodsAn advanced Google search using a combination of several keywords and systematic searches on websites of national newspapers/television stations was conducted. Additionally, 54 Portuguese sports federations and the Portuguese Institute of Sports and Youth were contacted by email and/or phone. All sports-related SCD cases in competitive athletes, occurring between 2003 and 2023 in Portugal, were included. The total number of athletes at risk used for the calculation of SCD incidence, was collected from official national records. ResultsA total of 42 SCD cases in athletes were identified, with a median age of 27 [18;42] years, and the great majority were male (n=39; 93%). Most events occurred in outdoor sports (n=28; 67%), especially in football (n=13; 31%), athletics (n=4; 10%) and trail running (n=4; 10%), and during competition or training sessions (n=27; 64%). The higher number of cases were reported in 2021 and 2022, while in several years no occurrences were found. The yearly average SCD incidence was 0.39 cases per 100000 athletes/year. ConclusionsThe incidence of SCD in athletes in Portugal is very low, mainly occurring in male, outdoor sports and during competitions or training sessions. Due to the limitations of passive data collection, prospective registries are needed, with standardization of the most relevant data, especially regarding their etiology and circumstances.

Sudden Cardiac Death in Athletes: Magnitude, Causes, and Prevention Strategies - A Literature Review

Sudden cardiac death (SCD) in athletes, though rare, is the leading cause of exercise-related mortality and poses significant concern due to the symbolic health and vitality of athletes. This review examines the epidemiology, causes, and prevention strategies of SCD in athletes. SCD, defined as sudden death presumed to be of cardiac origin within one hour of symptom onset, affects athletes variably depending on age, race, and type of sports. Key causes include hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC) in younger athletes, and coronary artery disease (CAD) in older athletes. Ion channelopathies and structural heart diseases also contribute significantly. Preparticipation screening (PPE) involving ECGs, lifestyle adjustments, and medical interventions are critical in prevention. Continuous research and adaptive guidelines are essential for safeguarding athletes against these fatal events. Keywords: sudden cardiac death, athletes, sports, exercise, cardiovascular diseases, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, coronary artery disease, ion channelopathies, long QT syndrome, Brugada syndrome, preparticipation screening, electrocardiogram (ECG), risk factors, prevention strategies.

The Spectrum of Coronary Artery Disease in Elite Endurance Athletes-A Long-Standing Debate: State-of-the-Art Review.

Physical activity is recommended for the prevention of primary and secondary cardiovascular (CV) disease as it is linked to a number of health benefits, especially CV. However, recent research suggests that high-volume, long-term endurance exercise may hasten rather than slow the coronary atherosclerosis progression. This contentious theory has generated a great discussion and is still a major source of doubt when it comes to the clinical treatment of coronary artery disease (CAD) in athletes. CAD is the primary cause of sudden cardiac death in athletes over 35 years. Thus, recent studies evaluated the prevalence of CAD in athletes and its clinical and prognostic implications. Indeed, many studies have shown a relationship between endurance sports and higher volumes of coronary calcified plaque as determined by computed tomography. However, the precise pathogenetic substrate for the existence of an increased coronary calcification burden among endurance athletes remains unclear. Moreover, the idea that coronary plaques in elite athletes present a benign morphology has been cast into doubt by some recent studies showing potential association with adverse cardiovascular events. This review aims to analyze the association between physical activity and CAD, explaining possible underlying mechanisms of atherosclerotic progression and non-ischemic coronary lesions, focusing primarily on clinical and prognostic implications, multimodal evaluation, and management of CAD in endurance athletes.

Ethnicity and sudden cardiac death in athletes: insights from a large United Kingdom registry.

The relationship between ethnicity and causes of sudden cardiac death (SCD) in athletes is poorly understood. To investigate aetiology of SCD among different ethnicities in a large cohort of athletes. Between 1994 and November 2022, 7880 cases of SCD were consecutively referred from all over the United Kingdom to our national cardiac pathology centre; 848 (11%) were athletes. All cases underwent detailed autopsy evaluation by expert cardiac pathologists. Clinical information was obtained from referring coroners. Most of athletes were white (n = 758; 89%). Black and Asian athletes were in number of 51 (6%) and 39 (5%), respectively. A structurally normal heart, indicative of sudden arrhythmic death syndrome (SADS) was the most common autopsy finding (n = 385; 45%), followed by myocardial diseases (n = 275; 32%), atherosclerotic coronary artery disease (CAD) (n = 58; 7%), and coronary artery anomalies (n = 29; 3%). In most of cases, death occurred during exercise (n = 737; 87%). Arrhythmogenic cardiomyopathy (ACM) was more common in black (n = 13; 25%) than in white (n = 109; 14%) and Asian (n = 3; 8%) athletes (P = 0.03 between black and white athletes; P = 0.04 between black and Asian athletes); in contrast, CAD was more common in Asians (n = 6; 15% vs. n = 51; 7% in whites vs. n = 1; 2%; in blacks, P = 0.02 between Asian and black athletes). Among white athletes, ACM was more common in individuals who died during exercise than in the ones who died at rest (P = 0.005). Such a difference was not observed in Asian and black athletes. In Asian athletes, CAD was the diagnosis at autopsy in 18% of individuals who died during exercise and in none of individuals who died at rest. A structurally normal heart at autopsy and myocardial diseases are the most common findings in athletes who died suddenly. While ACM is more common in black athletes, atherosclerotic CAD is more common in Asian athletes, with a strong association with exercise-induced SCD. ACM appears to be a driver of exercise-induced SCD in white athletes, however this is not the case in black and Asian athletes.

Sudden death of athletes: is it so unpredictable?

Sudden death of athletes: is it so unpredictable?

Sudden Death In Sports: Modern Concepts.

Regular physical activity provides significant health benefits and reduces the risk of premature death from any cause, including cardiovascular diseases (CVD). However, physical activity may provoke sudden cardiac death (SCD), especially in presence of unrecognized diseases. It is essential to identify risk factors that contribute to SCD in athletes and to implement effective prevention of such episodes. For this purpose, SCD registries are being created, medical terminology is being unified, and schedules of medical examination are being developed. The best strategy to combat SCD during sport activities is a combination of primary prevention by screening examination to identify athletes with CVD at risk and a proper planning of first aid measures during sports events, including the availability of an automatic external defibrillator on site.

Advanced cardiac imaging in preventing sudden cardiac death in athletes

Advanced cardiac imaging in preventing sudden cardiac death in athletes

Arrhythmias and sudden cardiac death in athletes

This case-based review provides an overview of the most relevant supraventricular and ventricular arrhythmias in athletes, elucidating their connections with intensive exercise and sports and the risk of sudden cardiac arrest. It highlights typical symptoms and key diagnostic characteristics of these arrhythmias. Additionally, it discusses potential treatment strategies, aligning them with the latest guidelines and recommendations. It aims to enhance sports physicians’ understanding of arrhythmias in athletes and to provide practical guidance on their management.

Cardiac magnetic resonance imaging in athletes with suspected structural myocardial disease: results of a high volume single-center study

Abstract Introduction Structural heart disease is one of the leading causes of sudden cardiac death in athletes. Cardiac magnetic resonance imaging (CMR) has a key role in the diagnosis, providing accurate functional and morphological information. Aim To investigate the prevalence of structural heart disease and the etiology of sudden cardiac death (SCD) in athletes. Methods We enrolled athletes (training ≥6 hours/week) who underwent CMR due to suspected structural myocardial disease at our Heart and Vascular Center between 2009 and 2022. We also performed cardiogenetic testing with new-generation sequencing (174 genes) in athletes with confirmed structural heart disease and/or malignant arrhythmia who gave consent. Results CMR was performed on a total of 556 athletes (445 male, 24±10 age). The indications for CMR were as follows: aborted sudden cardiac death/sustained ventricular tachycardia (3%), ECG (46%) or echocardiographic abnormality (36%), positive family history of SCD or cardiomyopathy (CMP) (3%), or athletes' complaints (31%). Structural myocardial abnormalities were confirmed in 99 athletes: hypertrophic (HCM) in 27, arrhythmogenic (AC) in 11, dilated (DCM) CMP in 7, and left ventricular non-compaction (LVNC) in 9 cases. MR images consistent with Fabry disease were found in 5 patients. We have discovered post-myocardial infarction scars in 10 cases, and atypical non-ischemic scarring (excluding hinge point fibrosis) was observed in 32 athletes. Besides pathological abnormalities, minor alterations were identified in 76 patients. Among the athletes examined after aborted sudden cardiac death/sustained ventricular tachycardia (n=18), we found structural heart disease in 14 patients, AC was confirmed in 7, HCM in two, non-ischemic fibrosis in three cases and LVNC in one athlete. Cardiogenetic test was performed in 26 athletes, we found pathogenic or likely pathogenic mutations in 5 cases, typical of HCM, AC, DCM (MYBPC3, PKP2, LMNA, TTN). The genetic test showed VUS (variant of unknown significance) in 15 additional athletes. Conclusions HCM was identified as the most frequent CMP, whereas AC and nonischaemic scar was the leading cause of SCD or SVT in our athletes.Figure A)Short axis late gadolinium ehancement CMR image of a 26-year-old female tennis player with hypertrophic cardiomyopathy and nonischemic fibrosis (arrow) and MYBPC3 pathogenic variant.Figure B)Short axis late gadolinium enhancement CMR image of a 40-year-old male elite discus thrower with sustained ventricular tacchycardia and nonischaemic scar formation (arrows). LMNA and titin pathogenic variants could be detected.

Cardiopulmonary Resuscitation Management for Sudden Cardiac Arrest on Field Sport Activity

Background: Sudden cardiac arrest (SCA) is the most common cause of sudden death in athletes, accounting for 75% of all deaths during activity and sports. In order to preserve athletes' lives, cardiopulmonary resuscitation (CPR) and on-site defibrillation with an Automated external defibrillator (AED) should be undertaken immediately. Thus, observers ought not to hesitate in performing cardiac compression to restore circulation. Aim: to increase the number of coaches or teams commencing CPR and so improve the opportunities of survival after sudden cardiac arrest. Material and Methods: By collecting a total of ten studies, this article implements a literature review methodology to evaluate CPR administration in occurrences of SCA among field athletes. CPR administration, on-field sports, SCA, and athletes as subjects are the study's main objectives. Results: In accordance with the study's results, administering AEDs earlier is more effective. The majority of cardiac arrests in the field aren't treated immediately and accurately, which leads to fatalities. Because a cardiac arrest occurring during the first 10 minutes is critical for the athlete's survival, each minute lowers the athlete's chances of surviving by 7-10%. Conclusion: SCA in athletes is a serious medical condition that frequently results in death. To save athletes' lives, CPR and on-site defibrillation using an AED must be performed immediately.

Analysis of sudden cardiac death in competitive athletes, possibilities for reducing cases

Sudden cardiac death in athletes is rare (0.5 to 1 per 100000 athlete years), but sudden cardiac death in known athletes causes general shock. Our research aim was to collect and study as many sudden cardiac death cases as possible, judge the role of stress and look for ways to reduce fatal tragedies. From registers and newspaper articles found on the Internet, we collected 360 (including 14 women) athletes' sudden cardiac death cases where the sport, age and place of death (during training/competition/after) could be determined. From these, a single database has been prepared in order of the year of death. The cases were grouped and analyzed by sports. Based on our results and literature data, we made recommendations to reduce fatalities. There were more sudden cardiac deaths in competitions than in trainings (239 vs. 99), but tragedies also happened during warm-ups and chess without physical exertion, furthermore, there was no sudden cardiac death in the stakeless training of marathon/half marathon/triathlon athletes; all these prove the role of stress, so we recommend a psychological conversation before a high-stakes race. There were also a lot of sudden cardiac deaths (79/360) during team sports trainings, so we recommend reanimation readiness there as well. After training/competition, sudden cardiac death happened mainly in sports requiring high static effort, where post-competition monitoring is also recommended. Those who died in training were younger than those who died during the race (p<0.01), so young people should be monitored more closely for medical and (under)fitness. Marathon runners and triathletes were older than team athletes (p<0.005) and only died in competition, so for them a basic examination and an ECG within 1 month before competition are recommended. Conclusions drawn from literature data: sports medicine examination should be standardized and documented in an accessible way; since resuscitation started earlier and professionally is more effective, all competitors should receive reanimation training. Orv Hetil. 2023; 164(29): 1155-1163.

Is Brugada Syndrome a Risk for Sudden Cardiac Death in Athletes? A Review of the Current Literature

Is Brugada Syndrome a Risk for Sudden Cardiac Death in Athletes? A Review of the Current Literature

Focused echocardiographic screening of the aortic valve and aorta in elite rugby players

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Grant from the charitable organisation Cardiac Risk in the Young. Background Pre-participation cardiac screening (PPS) of professional rugby players in the United Kingdom consists of an ECG-based evaluation. However, structural abnormalities that would not manifest on an ECG, such as aortic dilatation might be underdiagnosed and aortic dissection has previously been identified as a cause of sudden cardiac death in athletes (1). Purpose To trial focused transthoracic echocardiography (FTTE) screening for aortopathy as part of PPS and to determine normative aortic root measurements in rugby players, comparing dimensions with sedentary controls. Methods Professional male rugby players undergoing PPS were consented to have an FTTE performed as part of their cardiac evaluation. The aortic valve was visualised in the parasternal long and short axis views to delineate valve morphology. Aortic root measurements were taken at the sinus of Valsalva (SOV), sinotubular junction (STJ) and ascending aorta (AA) at end-diastole, from inner edge to inner edge. All measurements were indexed to the individuals height (in metres). Dilatation was defined as a dimension of &amp;gt;40mm at any aortic level. The findings were compared with a control population of sedentary age, and height-matched volunteers (defined as &amp;lt;2 hours physical activity per week) recruited from a national screening programme offered by the charitable organisation Cardiac Risk in the Young (CRY). Results 131 rugby players were screened, mean age 20.5years and on average engaged in 16 hours of mixed aerobic and strength-based training per week. 187 age-and-height-matched sedentary controls were included. Overall, rugby players had a significantly larger aortic root at all levels measured, compared with controls (Table 1). The only exception was the indexed ascending aorta dimensions. 2 rugby players had aortic dimensions &amp;gt;40mm at the SOV compared with no controls. A bicuspid aortic valve (BAV) was identified in 1 in one rugby player and 2 controls. These were excluded from the comparison of aortic dimensions due to the likelihood of them having an associated aortopathy. Conclusion Incorporating FTTE as part of existing PPS algorithms is an inexpensive way of screening for aortopathy and BAV. Identifying abnormalities may enable individuals to be suitably followed-up. Elite rugby players have a larger aortic root than sedentary controls. The significance of this requires corroboration in larger-scale, longitudinal studies.

Sudden Cardiac Death in Athletes: Consensuses and Controversies.

Exercise is widely considered beneficial for cardiovascular health. However, on rare occasions, athletes experience sudden cardiac death without any preceding symptoms. The devastating nature of these events necessitates us to understand the underlying causes. In younger athletes (age <35), the underlying causes are usually hereditary/genetic, whereasin older athletes (age >35), coronary artery disease is prevalent. Sudden cardiac death in athletes can occur regardless of the presence of any structural abnormality in the heart. Despite divergence between guidelines, the majority of cardiology societies recommend at least taking a comprehensive history and performing physical examinations for initial screening for all athletes.This article reviews the consensuses and controversies regarding the incidence, causes, and prevention of sudden cardiac death in athletes.

Comparison of four electrocardiographic criteria for the detection of cardiac abnormalities in Singapore athletes.

Sudden cardiac death in athletes is a rare occurrence, the most common cause being hypertrophic cardiomyopathy, which increases the risk of sustained ventricular tachycardia or ventricular fibrillation. Most of these young athletes are asymptomatic prior to the cardiac arrest. Several electrocardiogram criteria such as the European Society of Cardiology group 2 Criteria changes, Seattle Criteria, Refined Criteria, and most recently the 2017 International Criteria, have sought to improve the accuracy of identifying these at-risk athletes during pre-participation screening while minimising unnecessary investigations for the majority of athletes at low risk.We aimed to compare the above four criteria in our Singapore athlete population to identify which criterion performed the best in detecting cardiac abnormalities on echocardiography. Out of 1,515 athletes included in Changi General Hospital, Singapore registry between June 2007 and June 2014, the electrocardiograms of 270 athletes with further cardiac investigations were analysed. We compared the above four electrocardiographic criteria to evaluate which performed best for detecting cardiac abnormalities on echocardiography in our Southeast Asian athlete population. The European Society of Cardiology, Seattle, Refined and 2017 International Criteria had a sensitivity of 20%, 0%, 20% and 5%, respectively; a specificity of 64%, 93%, 84% and 97%, respectively; a positive predictive value of 4%, 0%, 9% and 11%, respectively; and a negative predictive value of 91%, 92%, 93% and 93%, respectively for detecting abnormalities on echocardiography. The latest 2017 International Criteria performed the best as it had the highest specificity and positive predictive value, joint highest negative predictive value, and lowest false positive rate.

Prevalence and diagnostic significance of de-novo 12-lead electrocardiogram patterns following covid-19 infection in elite soccer players

Abstract Funding Acknowledgements Type of funding sources: None. Background Considering that myocarditis is implicated in 5-15% of all exercise related sudden cardiac deaths in athletes, following a novel viral pandemic, the identification and risk-stratification of affected athletes remains an important priority. Given its widespread availability, the inclusion of a 12-lead electrocardiogram (ECG) is common to all consensus-based protocols from North America and Europe. However, a single cross-sectional ECG is problematic because several physiological repolarisation changes are also common manifestations in individuals with myopericarditis. Purpose The aim of our study was to report on the prevalence and diagnostic significance of de-novo ECG patterns following COVID-19 infection in a well-defined cohort of elite soccer players in the English, Dutch and Brazilian leagues. Methods In this multicentre observational study, between March 2020–May 2022, we evaluated consecutive athletes with COVID-19 infection. ECGs were reported in accordance with the International recommendations for ECG interpretation in athletes. The following patterns were also considered abnormal if they were not detected on the pre-COVID-19 infection ECG: PR-segment depression, new J-point and ST segment elevation, low QRS voltages, QRS fragmentation, new ST-segment depression, new T-wave inversion, biphasic T-waves and a reduction in the T-wave amplitude by 50% or T-wave flattening. Athletes exhibiting de-novo ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all players (n=30) following COVID-19 infection, despite the absence of cardiac symptoms or de-novo ECG changes. Results 511 soccer players (median age 21-years, IQR:18-26-years) were included, of which 88% were male and 58% white. 17 (3%) athletes demonstrated de-novo ECG changes, which included, a reduction in T-wave amplitude in the inferior and lateral leads (n=5), inferior leads (n=4) and lateral leads (n=4); inferior T-wave inversion (n=7), and ST-segment depression (n=2). 15 (88%) athletes with de-novo ECG changes revealed CMR evidence of inflammatory cardiac sequalae. All athletes who underwent a mandatory CMR irrespective of illness severity or ECG findings, had normal findings. Athletes revealing de-novo ECG changes, had a higher prevalence of cardiac symptoms (71% v 12%; p&amp;lt;0.0001) and longer median symptom duration (5-days, IQR:3-10) compared with athletes without de-novo ECG changes (2-days, IQR:1-3; p&amp;lt;0.001). Among athletes without cardiac symptoms, the additional yield of de-novo ECG changes to detect cardiac inflammation was 17%. Conclusions 3% of athletes demonstrated de-novo ECG changes post COVID-19 infection, of which 88% were diagnosed with inflammatory cardiac sequalae. Most affected athletes exhibited cardiac symptoms; however de-novo ECG changes contributed to a diagnosis of cardiac inflammation in 17% of athletes without cardiac symptoms.

Mitral Valve Prolapse and Sudden Cardiac Death in Athletes at High Risk.

Mitral valve prolapse (MVP) is the most frequent valvulopathy in the general population, with usually a favourable prognosis. Although it can be associated with some complications, ventricular arrhythmias (VA) and sudden cardiac death (SCD) are the most worrying. The estimated risk of SCD in MVP is between 0.2% to 1.9% per year, including MVP patients with and without severe mitral regurgitation (MR). The association between SCD and MVP is expressed by a phenotype called "malignant MVP" characterized by transthoracic echocardiography (TTE) findings such as bileaflet myxomatous prolapse and mitral annulus disjunction (MAD), ECG findings such as repolarization abnormalities, complex ventricular arrhythmias (c-VAs) and LV fibrosis of papillary muscles (PMs) and inferobasal wall visualized by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Therefore, attention is raised for patients with "arrhythmic MVP" characterized from an ECG point of view by frequent premature ventricular contractions (PVCs) arising from one or both PMs as well as by T-wave inversion in the inferolateral leads. In athletes, SCD is the most frequent medical cause of death and in young subjects (< 35 years) usually is due to electrical mechanism affecting who has a silent cardiovascular disease and are not considered per se a cause of increased mortality. In MVP, SCD was reported to happen during sports activity or immediately after and valve prolapse was the only pathological aspect detected. The aim of the present paper is to explore the association between SCD and MVP in athletes, focusing attention on ECG, TTE in particular, and CMR findings that could help to identify subjects at high risk for complex arrhythmias and eventually SCD. In addition, it is also examined if sports activity might predispose patients with MVP to develop major arrhythmias.

Sudden cardiac death in athletes – can we prevent it?

Introduction and purpose: Sudden cardiac death (SCD) is a rare condition, however it is the leading medical cause of death in population of athletes. This study reviews the epidemiology and common causes of SCD in this group. The literature on the role of pre-participation screening and of the other preventive measures was also reviewed. Review methods: A review of the available literature on sudden cardiac death in athletes was conducted using PubMed and Google Scholar databases. Description of the state of knowledge: SCD is the leading cause of death in athletes. However, the incidence is difficult to estimate and varies in different populations. The etiology is age-dependent, in young individuals the most common cause of sudden cardiac death are hypertrophic cardiomyopathy and congenital coronary artery anomalies. In the older athlete population (over 35 years old) atherosclerotic coronary artery disease is the main cause. Screening process varies between countries and besides taking the medical history and physical examination can involve electrocardiogram, echocardiography and other examinations. Conclusions: A review of the following studies has shown, that pre-participation screening of athletes may help to reduce the incidence of sudden death. Equal focus should be put on the availability of medical facilities during sports events, including experienced medical team and access to automated external defibrillation.