Athlete Screening for Causes of Sudden Cardiac Death

Medical evaluation before competition offers the potential to detect still-asymptomatic athletes with life-threatening heart diseases and to protect them from sudden cardiac death (SCD). Physicians and athletic trainers should ensure that athletes are systematically screened to identify those with potentially lethal heart diseases and to protect them against the increased risk of SCD.

SCD during sports is often the first and definitive manifestation of an underlying cardiovascular disease which usually has a silent clinical course. The causes of SCD include anatomic and structural abnormalities of the heart, primary electrical cardiac disorders, stimulant use (eg, cocaine, ephedra), and trauma (commotiocordis). Importantly, be-cause many of these disorders are genetic, the identification of a first affected family member may unravel extensive family involvement.

Cardiovascular fatalities during sports are rare; however, the public health relevance of such an event is enormous. The sudden and unexpected death of a young athlete is always a powerful and tragic event that devastates families, other competitors, schools, and the community. The sudden demise of a young athlete has a tremendous impact because it affects young and apparently healthy individuals who are regarded as the healthiest group in society and often as heroes. Instinctively, everyone wonders what intervention might have prevented the death.

The incidence of SCD among U.S. middle-school to college athletes (age range 12 to 24 years) has been estimated to be 1 to 3 in 100,000 participants/year. The risk of SCD in athletes increases with age and is greater in male subjects. Athletic participation carries an inherent risk of SCD. Young athletes involved in a sports activity have an estimated risk of SCD 3 times greater than that of their nonathletic counterparts. Highly competitive aerobic and impact sports such as football, basketball, soccer, swimming, track and cross country are of most concern. It is the combination of physical exercise and underlying cardiovascular disorders rather than exercise alone that triggers athletic-fi eld arrhythmic cardiac arrest.

Annual Incidence Rates of Sudden Cardiac Death Among Screened Com-
petitive Athletes and Unscreened Nonathletes in the Veneto Region of Italy
From 1979 to 2004, Modified from Corrado et al.

A nationwide program of pre-participation screening of young competitive athletes, mainly based on 12-lead electrocardiography (ECG), was launched in Italy in 1982. Screening resulted in a reduction in the rate of SCD in athletes three-fold, even below that of non-athletes. Currently, mass screening is in debate.

Screening consists of a careful review of the athlete’s medical and family history (answers to the questions on the following panel) and an ECG reviewed by an expert. Abnormalities found by this screen may be followed by additional studies such as an ultrasound or a stress test if necessary.

All participants in competitive sports should be screened preseason annually beginning in middle school through college.

All screening by definition is limited in detecting all cases and causes of SCD. Screening detects many cases and in a population significantly reduces events as the Italian study shows but it does not guarantee that it will detect all cases.

Currently, insurance companies do not cover the cost of screening. The expense is usually paid out-of-pocket. If an abnormality is detected, insurance usually covers the evaluation.

Screening consists of a careful review of the athlete’s medical and family history (answers to the questions on the following panel) and an ECG reviewed by an expert. Abnormalities found by this screen may be followed by additional studies such as an ultrasound or a stress test if necessary.