Sudden Death in Athletes

Sudden death in athletes has been a tragic occurrence in the fields of sports medicine, cardiology, primary care, and pediatrics. By far the most common cause of unexpected death for a younger athlete on the competitive field is cardiac illness; usually that of congenital etiology. However, the use of anabolic steroids, peptide hormones, and stimulants have led to the emergence of acquired heart disease in younger and middle-aged athletes. In contrast, sudden death in an older athlete is typically due to atherosclerotic coronary artery disease. There are a variety of congenital heart illnesses that occur in the general population. Most of them categorize into structural and non-structural varieties. Congenital structural heart disease will generally affect blood flow within the heart and flow from the heart. Examples include hypertrophic obstructive cardiomyopathy (HOCM), arrhythmogenic right ventricular dysplasia (ARVD), and coronary artery anomalies. Non-structural heart disease involves defects in the electrical system of the heart which may induce unstable and dangerous arrhythmias. Examples include long QT syndrome, Brugada syndrome, Wolff-Parkinson-White (WPW) syndrome and catecholaminergic polymorphic ventricular tachycardia (CPVD). Other congenital structural and non-structural heart diseases exist and have been described previously in the setting of physical activity and athletics. Also, drug-induced cardiac effects are of important notice. Anabolic steroids and peptide hormones induce structural changes in the heart. Stimulants can cause dangerous arrhythmias. These conditions can clinically manifest as syncope/pre-syncope, and in some instances can present as a sudden, unexpected death. The associated mortality underscores the importance of early screening and identification of existing heart disease in athletes. Many athletes with pre-existing heart disease are often asymptomatic with a cardiac arrest being the initial manifestation of underlying pathology. The challenging aspect of identifying affected athletes is adequately screening the general population without excessive and unnecessary invasive testing. A thorough sports physical examination including an assessment of personal history, family history, physical exam, and an electrocardiogram can be a useful screening tool in asymptomatic and low-risk athletes. Higher risk athletes, such as those who have abnormal findings or have symptoms, may require more extensive testing. Upon arriving at a diagnosis, an athlete will undergo risk stratification. Then, a long-term treatment regime is initiated to minimize the risk of sudden cardiac death. Medical management is a common option, while surgical intervention is reserved for specific cases. Inserting an implantable cardioverter-defibrillator (ICD) is appropriate for anyone considered to be at risk for cardiac arrest secondary to a fatal arrhythmia. The decision to continue or abandon the sport of choice results from shared decision making between the physician and patient. The purpose of this article is to review the causes of sudden death in athletes with a significant focus on the most common etiologies in younger athletes and their presentation and evaluation