Sudden Death in Athletes

News media occasionally present us with tragic cases of famous young athletes dying suddenly during sports activity. Theses cases commonly provoke discussions on how to prevent such dreadful incidents. Then, in a few days, everybody seems to have forgotten about it, until next time?

Sudden death in young athletes, associated with athletic activity, is a rare but well-known disorder. Most of these cases do not receive any media coverage. However, family and friends are left in deep shock. Many questions are left unanswered. How could this happen? Did we miss any warning signs? Could we have done something to prevent this from happening?

The majority of sudden cardiac death incidents in athletes are caused by disturbances in heart rhythm (ventricular tachycardia or ventricular fibrillation), leading to loss of blood circulation. Immediate treatment is aimed at restoring normal heart rhythm, usually by electric shocks given by so-called defibrillators.

The most common cause of disturbances in heart rhythm leading to sudden death in young athletes is underlying heart disease. Often, the disease is not diagnosed until after the event. As a result, there is great interest in detecting such disorders early, in order to be able to define appropriate treatment and activity restrictions for the individual.

The most common underlying cause of sudden death in young athletes is so-called hypertrophic cardiomyopathy. This is a disorder which sometimes runs in families. However, in many cases there is no family history at all. In this disease, the muscle of the left ventricle of the heart becomes abnormally thick. Young people with this disorder commonly have no symptoms at all. There are a number of other underlying heart diseases that may lead to sudden death. Most of them are rare. Some may be temporary, such as viral infections of the heart muscle. Some may be congenital.

The only way to prevent sudden cardiac death in young athletes is to find the underlying heart disease before it leads to collapse and sudden death. This is a huge challenge, because some of these diseases are difficult to detect. The responsibility is within the medical community and among sports regulatory authorities. An important questions is whether regular screening of young athletes, by health professionals, can reduce the risk of sudden death.

There are two important questions we have to ask about screening for heart disease in young athletes. The first one involves how screening should be performed and what methods should be used. The second addresses what restrictions should be placed on athletes who turn out to have heart disease.

There are some data available on the impact of screening programs on the incidence of sudden deaths among athletes. A mandatory screening program for competitive athletes was launched in Italy in 1982. The annual incidence of sudden cardiac death in athletes decreased from 3.6/100.000 person ? years in 1979 ? 1980 to 0.4/100.000 person ? years in 2003 ? 2004. This implies an 89 percent reduction in 25 years. During the same period there was no change in the incidence of sudden cardiac death among non-athletes in the same age group.

Both the American Heart Association (AHA) and the European Society of Cardiology (ESC) have proposed guidelines for the screening of young athletes participating in competitive sports. The main difference between these guidelines is that the AHA relies on history and physical examination without further routine testing, while the ESC includes an ECG (electrocardiogram). Inclusion of an ECG is in accordance with the Italian experience. Individuals with abnormal findings in screening are referred for further testing. Such testing may involve echocardiography (ultrasound of the heart), ambulatory heart rhythm monitoring, exercise ? ECG or cardiac magnetic resonance imaging (MRI).

Although an ECG can sometimes be helpful in detecting heart disease it is commonly abnormal among healthy young athletes. This is one of the reasons why the AHA does not include an ECG in their guidelines. Furthermore, some heart diseases me not be detected by history, physical examination and ECG. Therefore some specialists have suggested that an an echocardiography should be included. This may sometimes be the only way to detect disorders like for example hypertrophic cardiomypathy.

In 2008 the UEFA (The Union of European Football Associations) put forward new rules concerning medical examination of players participating in European competition. Apart from history, physical examination and blood tests an ECG and an echocardiography should be performed.

In my opinion the inclusion of echocardiography, although not included in AHA and ESC guideline, would be an important step forward in athletes participating in high intensity competitive sports. My opinion is that echocardiography should be performed at regular intervals of 1-2 years in such athletes. This is a relatively simple and inexpensive procedure that gives a lot of information about the heart chambers, the heart muscle and the heart valves.

The second question is what restrictions should be placed upon athletes who on screening turn out to have signs of heart disease. The devastating impact of sudden death incidents justifies restriction of athletes from athletic competition if they have heart disease. The question is who should make the decision. In my opinion, informing the athlete about the increased risk and let himself decide whether to continue participating in competitive sports is hard to justify. However, it can be very hard for an athlete to accept being banned from competitive sports due to signs of heart disease. Although there may be increased risk for sudden death for that particular athlete, the absolute risk may indeed be very low. These are all difficult questions that have to be addressed. Although the answers may be difficult to deal with, these issues can not be left unsolved.

Axel F Sigurdsson is a cardiologist, PhD and a Fellow of the American College of Cardiology, The Icelandic Society of Cardiology and The Swedish Society of Cardiology.

He runs his own website, http://www.docsopinion.com, dedicated to health, nutrition, healthy lifestyle and prevention of disease.

Source: http://toddsblogs.com/healthandfitness/2012/08/17/sudden-death-in-athletes/

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