Sudden Death in Young Athletes
Special Report
Sudden Death in Young Athletes
By Alan H. Friedman, MD, FAAP
Whenever a young, fit, previously healthy athlete dies during or after a sporting event, it is difficult for family, teammates, friends, coaches, and the general public to comprehend. Of course, recent media attention on the deaths of such popular athletes as Hank Gathers and Reggie Lewis from basketball and Sergei Grinkov from Olympic ice-skating has focused even more attention on this catastrophic problem. Many questions are raised after such an event, and in the following discussion, an attempt will be made to answer some of them from the physician’s point of view.
What is the Risk, Who Succumbs, Why, and From What?
The answers to these questions are sometimes clear but can be complex. First, the estimated risk of sudden death in young athletes (high school and college aged) is between one in 100,000-300,000,1 and it is more common in the male athlete. Second, the intensity of the exercise is related to the incidence of sudden death. For example, Maron and colleagues1 showed that sports such as basketball, football, track, and soccer have the highest incidence of sudden death in young athletes. Third, the common denominator in the majority of athletes who have died suddenly is development of a fatal arrhythmia in a heart that was vulnerable to such events. In other words, the substrate exists in these "at-risk" athletes. Fourth, the most common causes of sudden death in young athletes are hypertrophic cardiomyopathy, anomalous coronary arteries, coronary artery disease, myocarditis, and arrhythmogenic right ventricular dysplasia. (The latter is a rare cause of sudden death in North America, but it is the most common cause in northern Italy.)
What Can be Done to Identify the Athlete at Risk?
Several studies have attempted to answer this question. Certainly, a detailed medical history including family history of sudden death, arrhythmia, and cardiomyopathy coupled with a thorough cardiovascular examination is essential. What is the role for screening tests such as electrocardiography, exercise electrocardiography, and even echocardiography? Certainly, the latter two are expensive in both time and medical resources, and there continues to be debate as to the routine use of screening electrocardiography. Recently, Corrado and associates2 reported the results of a 17-year study undertaken in Italy, in which all competitive athletes were required to undergo a preparticipation evaluation that included a medical history and physical examination with blood pressure, resting 12-lead electrocardiogram, and a limited exercise (step) test. A total of 33,735 athletes underwent the screening, and, of these, 3016 (8.9%) were referred for echocardiography. This system disqualified 621 individuals for cardiovascular conditions and identified 22 athletes who previously had unrecognized hypertrophic cardiomyopathy (0.07% of the athletes). None of these 22 people died during the follow-up period and, not surprisingly, the number of sudden deaths due to hypertrophic cardiomyopathy was low, at 2% (presumably a case that was not recognized). Corrado et al concluded that this type of screening evaluation selectively reduced the incidence of sudden death resulting from hypertrophic cardiomyopathy. Fuller and colleagues3 performed electrocardiogram screening of 5615 high school athletes and found it to be a specific tool for identifying athletes with cardiovascular abnormalities. Others have found it to be less useful. LaCorte et al4 performed electrocardiograms on 1424 high school students as a preparticipation screen. A total of 5.1% of the students had an abnormal electrocardiogram, but no student was found to have hypertrophic cardiomyopathy and no student was restricted from sports participation. Cost-effectiveness of routine electrocardiography for all young athletes remains a significant issue.
What Should we Do?
The extent of the preparticipation cardiovascular screening examination continues to be debated; however, guidelines for accepted criteria have been established for the team physician.5,6 Several guidelines have been put forward by the American Heart Association, the American Academy of Pediatrics, and the American College of Cardiology and they include5:
• All high school and college athletes should undergo a routine, preparticipation examination. The examination is considered mandatory and should be performed before participation in high school and collegiate sports.
• The examination is to be performed by a health care worker (preferably a licensed physician) who has the medical skills, background, and training to perform a reliable history examination and physical examination and to recognize heart disease.
• The evaluation should include a complete medical history and physical examination, including brachial artery blood pressure measurement.
• In the high school athlete, screening must occur every two years, with an interim history in intervening years.
• For the collegiate athlete, a comprehensive history and physical examination must be performed in the first year on entering the institution and before training and competition. In each of the subsequent years, an interim history and blood pressure measurement should be obtained. Any significant change indicates that another examination and possible further testing should be performed.
A thorough cardiac history should include a history of chest pain or tightness, especially with exertion, dyspnea at rest or mild exertion, palpitations or irregular heartbeat, and lightheadedness or syncope. Previous history should include prior heart murmur, rheumatic fever, or cardiac surgery. The family history is essential since diseases such as hypertrophic cardiomyopathy, the long QT syndrome, and Marfan’s syndrome have familial transmission. A particularly important question is the family history of any sudden death before the age of 40 years, as this may be the only clue to one of the above-mentioned familial diseases. Finally, an athlete’s use of anabolic steroids, cocaine, or other illicit drugs should be reviewed. A thorough review of cardiovascular disease in athletes is listed in the references.7
The Athlete with Symptoms
Any young athlete who experiences unexplained chest pain, chest tightness, lightheadedness, syncope, or palpitations requires immediate cardiovascular evaluation by a professional who is specifically trained to evaluate patients for cardiovascular abnormalities. It should be remembered that syncope with exercise is never normal and may be an ominous sign. At a minimum, the evaluation should include a complete history, physical examination, and an electrocardiogram. Additional testing based on symptoms and examination findings may be necessary.
Conclusion
The incidence of sudden death in young athletes is low, but its occurrence is devastating. When it does occur, it is most commonly related to congenital anomalies of the cardiovascular system. All young athletes should undergo a preparticipation sports screening evaluation that attempts to identify athletes at risk, but one must recognize the limitations of such examinations. There continues to be debate as to the cost-effectiveness of routine electrocardiogram screening of young athletes, but at least one recent large study suggests that this can significantly identify those athletes with hypertrophic cardiomyopathy, a leading disease causing sudden death in young athletes. Any athlete who develops unexplained lightheadedness, syncope, palpitations, or chest pain requires immediate medical evaluation.
References
1. Maron BJ, et al. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA 1996;276:199-204.
2. Corrado D, et al. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339: 364-369.
3. Fuller CM, et al. Prospective screening of 5,615 high school athletes for risk of sudden cardiac death. Med Sci Sports Exerc 1997;29(9):1131-1138.
4. LaCorte MA, et al. EKG screening program for school athletes. Clin Cardiol 1989;12(1):42-44.
5. Maron BJ, et al. Cardiovascular preparticipation screening examination of competitive athletes. Circulation 1996;94:850-856.
6. Maron BJ, et al. Cardiovascular preparticipation screening examination of competitive athletes: Addendum. Circulation 1998;97:2294.
7. Basilico FC. Cardiovascular disease in athletes. Am J Sports Med 1999;27(1):108-121.
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