An estimated 1 to 3/100,000 apparently healthy young athletes die suddenly during exercise. Males are affected up to 10 times more often than females. Basketball and football players in the United States and soccer players in Europe may be at highest risk (1).
In young athletes, sudden cardiac death has many causes (see table Some Causes of Sudden Cardiovascular Death in Young Athletes). The most common cause of sudden cardiac death was thought to be hypertrophic cardiomyopathy. More recent studies suggest that hypertrophic cardiomyopathy accounts for a lower proportion of sudden cardiac deaths and that the majority of sudden cardiac deaths occur in patients whose hearts are found to be structurally normal during autopsy (2, 3).
Commotio cordis (sudden ventricular tachycardia or fibrillation after a blow to the precordium) is a risk in athletes with thin, compliant chest walls even when no cardiovascular disorder is present. The blow may involve a moderate-force projectile (eg, baseball, hockey puck, lacrosse ball) or impact with another player during a vulnerable phase of myocardial repolarization.
Other causes include inherited arrhythmia syndromes (eg, long QT syndrome, Brugada syndrome). Some young athletes die of aortic aneurysm rupture (in Marfan syndrome).
In older athletes, sudden cardiac death is typically caused by
Occasionally, hypertrophic cardiomyopathy or valvular disease is involved.
In other conditions underlying sudden death in athletes (eg, asthma, heatstroke, complications related to use of illicit or performance-enhancing drugs), ventricular tachycardia or ventricular fibrillation is a terminal, not a primary, event.
Symptoms and signs are those of cardiovascular collapse; diagnosis is obvious.
Immediate treatment with advanced cardiac life support is successful in < 20%; the percentage may increase as distribution of community-based, automated external defibrillators (AEDs) expands. Studies have demonstrated that the presence of AEDs can increase the neurologically intact survival rates to over 80% (4). For survivors, treatment is management of the underlying condition. In some cases, an implanted cardioverter-defibrillator may ultimately be required.
Some Causes of Sudden Cardiovascular Death in Young Athletes
Commotio cordis |
Coronary artery anomalies (eg, anomalous left main coronary artery origin, anomalous right coronary artery origin, coronary arterial hypoplasia) |
Ruptured aortic aneurysm |
Tunneled left anterior descending coronary artery |
Premature atherosclerotic coronary artery disease |
Myxomatous degeneration of mitral valve |
Wolff-Parkinson-White syndrome (anterograde conduction only) |
Right ventricular outflow tract tachycardia |
Cardiac trauma |
Ruptured cerebral artery aneurysm |
General references
1. Maron BJ, Haas TJ, Ahluwalia A, et al: Demographics and epidemiology of sudden deaths in young competitive athletes: From the United States National Registry. Am J Med 129:1170–1177, 2016. doi: 10.1016/j.amjmed.2016.02.031
2. Finocchiaro G, Papadakis M, Robertus JL, et al: Etiology of sudden death in sports: insights from a United Kingdom regional registry. J Am Coll Cardiol 67:2108–2115, 2016. doi: 10.1016/j.jacc.2016.02.062
3. Harmon KG, Asif IM, Klossner D, Drezner JA: Incidence of sudden cardiac death in National Collegiate Athletic Association athletes. Circulation 123:1594–1600, 2011. doi: 10.1161/CIRCULATIONAHA.110.004622
4. Johri AM, Poirier P, Dorian P, et al: Canadian Cardiovascular Society/Canadian Heart Rhythm Society joint position statement on the cardiovascular screening of competitive athletes. Can J Cardiol 35:1-11, 2019. doi: 10.1016/j.cjca.2018.10.016
Key Points
Sudden cardiac death during exercise is rare and may be due to hypertrophic cardiomyopathy, but many patients have a structurally normal heart at autopsy (typically younger athletes) or coronary artery disease (older athletes).
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Baggish AL, Battle RW, Beaver TA, et al: Recommendations on the use of multimodality cardiovascular imaging in young adult competitive athletes: A report from the American Society of Echocardiography in collaboration with the Society of Cardiovascular Computed Tomography and the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 33 (5): 523–549, 2020. doi: 10.1016/j.echo.2020.02.009
Johri AM, Poirier P, Dorian P, et al: Canadian Cardiovascular Society/Canadian Heart Rhythm Society joint position statement on the cardiovascular screening of competitive athletes. Can J Cardiol 35:1–11, 2019. doi: 10.1016/j.cjca.2018.10.016
Martinez MW, Kim JH, Shah, AB, et al: Exercise-induced cardiovascular adaptations and approach to exercise and cardiovascular disease. JACC State-Of-The-Art Review, J Am Col Cardiol 78 (14):1454-1470, 2021.
