Comparison of the Frequency of Sudden Cardiovascular Deaths in Young Competitive Athletes Versus Nonathletes: Should We Really Screen Only Athletes?

doi:10.1016/j.amjcard.2016.01.026

The American Journal of Cardiology

Volume 117, Issue 8, 15 April 2016, Pages 1339-1341

https://doi.org/10.1016/j.amjcard.2016.01.026 Get rights and content

The issue of sudden death in young athletes and consideration for the most practical and optimal strategy to identify those genetic and/or congenital heart diseases responsible for these tragic events continues to be debated. However, proponents of broad-based and mandatory national preparticipation screening, including with 12-lead electrocardiograms have confined the focus to a relatively small segment of the youthful population who choose to engage in competitive athletic programs at the high school, college, and elite-professional level. Therefore, lost in this discussion of preparticipation screening of athletes is that the larger population of young people not involved in competitive sports (and, therefore, a priori are excluded from systematic screening) who nevertheless may die suddenly of the same cardiovascular diseases as athletes. To substantiate this hypothesis, we accessed the forensic Hennepin County, Minnesota registry in which cardiovascular sudden deaths were 8-fold more common in nonathletes (n = 24) than athletes (n = 3) and threefold more frequent in terms of incidence. The most common diseases responsible for sudden death were hypertrophic cardiomyopathy (n = 6) and arrhythmogenic right ventricular cardiomyopathy (n = 4). These data raise ethical considerations inherent in limiting systematic screening for unsuspected genetic and/or congenital heart disease to competitive athletes.

Section snippets

Methods

We accessed the case records of the Medical Examiner of Hennepin County, the largest of the 87 Minnesota counties, representing the Minneapolis metropolitan area. Hennepin County includes 1,198,778 residents (23% of the state); all sudden deaths <40 years of age undergo complete autopsy and toxicologic studies. The database was assessed to identify naturally occurring sudden cardiovascular deaths, age 14 to 23 years, 2000 to 2014. In addition to the Medical Examiner evaluation, gross and

Results

During the 15-year study period, 39 cases of sudden death with virtually instantaneous collapse2, 3 were identified. Twelve were excluded because of confounding toxicology results or a known history of congenital heart disease. Therefore, 27 sudden deaths due to a variety of cardiovascular diseases constitute the final study group (Table 1). Ages were 14 to 23 years; 22 (81%) were men. Seventeen decedents were white, 8 were black, and one each was Hispanic or Asian.

Of the 27 deaths, only 3

Discussion

The ongoing debate concerning preparticipation cardiovascular screening for competitive athletes (ie, history and physical examination with or without 12-lead electrocardiograms)1, 2, 8, 11, 12 to date has failed to address a fundamental issue, that is, the frequency of sudden deaths occurring in young people in the general population who are not engaged in competitive sports. Indeed, an ethical dilemma has emerged in this regard because nonathletes may die suddenly of the same genetic and/or

Disclosures

The authors have no conflicts of interest to disclose.

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Causes of sudden cardiac death in young athletes and non-athletes: systematic review and meta-analysis: Sudden cardiac death in the young
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The etiology of sudden cardiac death (SCD) in young people continues to attract much attention. This meta-analysis aimed to identify the most frequent causes of SCD in individuals aged ≤35 years, the differences between athletes and non-athletes and geographic areas.
Studies published between 01/01/1990 and 01/31/2020 and evaluating post-mortem the aetiology of SCD in young individuals (≤35 years) were included. Individuals were divided into athletes and non-athletes. Studies that did not report separate data between athletes and non-athletes were excluded.
Thirty-four studies met the inclusion criteria, and a total population of 5,060 victims of SCD were analyzed (2,890 athletes, 2,170 non-athletes). Comparing the causes of SCD between athletes and non-athletes, non-ischemic left ventricular scar (NILVS) (5.1% vs. 1.1%, p=0.01) was more frequent in the former, while coronary artery disease (CAD) (19.6% vs. 9.1%, p=0.009), arrhythmogenic cardiomyopathy (ACM) (11.5% vs. 4.7%, p=0.03) and channelopathies (8.4% vs. 1.9%, p=0.02) were more frequent in the latter. In studies published in the last decade, hypertrophic cardiomyopathy (HCM) (p=0.002), dilated cardiomyopathy (p=0.047), and anomalous origin of coronary arteries (AOCA) (p=0.009) were more frequently the causes of SCD in athletes while aortic dissection (0.022) was the cause in non-athletes. HCM (p=0.01) and AOCA (p=0.004) were more frequently the causes of SCD in the US while ACM (p=0.001), structurally normal heart (p=0.02), and channelopathies (p=0.02) were more frequent in Europe.
Among the causes of SCD, NILVS was the more frequent cause in athletes, while CAD, ACM and channelopathies were more frequent causes in non-athletes. The causes of SCD differ between the US and Europe.
ECG screening in the United States: Are we there yet?
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Canadian Cardiovascular Society Cardiovascular Screening of Competitive Athletes: The Utility of the Screening Electrocardiogram to Predict Sudden Cardiac Death
2019, Canadian Journal of Cardiology
Prevention of sudden cardiac arrest/death (SCA/D) among athletes is a universal goal, although the optimal strategy for its achievement is controversial, with the inclusion of the 12-lead electrocardiogram (ECG) at the center of the debate. The ECG exhibits superior sensitivity over history and physical examination to detect conditions associated with SCA/D. However, the identification of disease does not necessarily lead to a significant reduction in SCA/D. The “Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes” recommended against the routine performance of an ECG for the initial cardiovascular screening of competitive athletes. The incidence of SCA/D among athletes (<35 years of age), the risk of SCA/D during sport participation among individuals with abnormalities found on screening ECG, the efficacy of the ECG to identify conditions associated with SCA/D, and the positive predictive value of an abnormal ECG to predict SCA/D are critically examined. This review presents the evidence informing the panel’s recommendation.
La prévention de l’arrêt cardiaque soudain (ACS) et de la mort subite d’origine cardiaque (MSOC) chez l’athlète constitue un objectif universel, bien que la stratégie optimale pour sa réalisation soit controversée, l’inclusion de l’électrocardiogramme (ECG) à 12 dérivations se trouvant au centre du débat. Comparativement à l’anamnèse et à l’examen physique, l’ECG présente une sensibilité supérieure quand il s’agit de détecter les troubles associés à l’ACS et à la MSOC. Cependant, le dépistage d’un état pathologique ne se traduit pas nécessairement par une réduction significative des cas d’ACS et de MSOC. Dans l’énoncé de position conjoint de, la Société canadienne de cardiologie et de la Société canadienne de rythmologie sur le dépistage cardiovasculaire des athlètes de compétition, le recours systématique à un ECG pour le dépistage initial des troubles cardiovasculaires chez les athlètes de compétition est déconseillé. L’incidence de l’ACS et de la MSOC chez l’athlète (< 35 ans), le risque qu’ils surviennent pendant la pratique d’activités sportives chez les sujets présentant des anomalies qu’un ECG a permis de détecter, l’efficacité du dépistage par ECG des troubles associés à l’ACS et à la MSOC, de même que la valeur prédictive d’un résultat d’ECG anormal au regard de ces deux entités cliniques sont l’objet d’un examen critique. Le présent article de synthèse expose les données probantes sur lesquelles se fonde la recommandation du groupe.
Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes
2019, Canadian Journal of Cardiology
Citation Excerpt :
However, if a given institution/organization decides to administer a routine 12-lead ECG as part of the screening process towards tier 3 after achieving all previous steps, it must be accompanied by an interpretation by clinicians experienced in the assessment of an athlete’s ECG.13,61-63 The limitations of such programs must be appreciated.19,64-70 The capacity to provide expeditious access to further cardiac investigations must be in place.52
Sudden cardiac death (SCD), especially in a young seemingly healthy individual, is a tragic and highly publicized event, which is often followed by a strong emotional reaction from the public and medical community.” Although rare, SCD in the young is devastating to families and communities, underpinning our society’s desire to avoid any circumstances predisposing to the loss of human life during exertion. The Canadian Cardiovascular Society Position Statement on the cardiovascular screening of athletes provides evidence-based recommendations for Canadian sporting organizations and institutions with a focus on the role of routine electrocardiogram (ECG) screening in preventing SCD. We recommend that the cardiac screening and care of athletes within the Canadian health care model comprise a sequential (tiered) approach to the identification of cardiac risk, emphasizing the limitations of screening, the importance of shared decision-making when cardiac conditions are diagnosed, and the creation of policies and procedures for the management of emergencies in sport settings. Thus, we recommend against the routine (first-line or blanket mass performance of ECG) performance of a 12-lead ECG for the initial cardiovascular screening of competitive athletes. Organization/athlete-centred cardiovascular screening and care of athletes program is recommended. Such screening should occur in the context of a consistent, systematic approach to cardiovascular screening and care that provides: assessment, appropriate investigations, interpretation, management, counselling, and follow-up. The recommendations presented comprise a tiered framework that allows institutions some choice as to program creation.
La mort subite d’origine cardiaque (MSOC), en particulier chez une personne jeune et qui semblait être en bonne santé, est un événement tragique et hautement médiatisé qui engendre souvent de la part du public ou du milieu médical un « appel à l’action ». La MSOC chez les jeunes, si elle est rare, n’en a pas moins des conséquences dévastatrices sur les familles et les communautés, ce qui explique le désir de notre société d’éviter toute circonstance prédisposant à la perte d’une vie humaine durant un effort physique. L’énoncé de position de la Société canadienne de cardiologie sur le dépistage des troubles cardiovasculaires chez les athlètes présente, à l’intention des organisations et des institutions sportives canadiennes, des recommandations fondées sur des données probantes insistant plus particulièrement sur le rôle du dépistage par électrocardiogramme (ECG) de routine dans la prévention de la MSOC. Nous préconisons, pour le dépistage et les soins des troubles cardiovasculaires des athlètes au sein du modèle canadien de soins de santé, une approche séquentielle (par paliers) d’évaluation du risque cardiaque, tout en soulignant les limites du dépistage et l’importance de la prise de décision partagée lors du diagnostic d’une cardiopathie et l’élaboration de politiques et de procédures applicables à la gestion des situations d’urgence dans un contexte d’activité sportive. Par conséquent, nous déconseillons le recours à un ECG à 12 dérivations de routine (utilisation en première ligne ou généralisée) pour le dépistage initial des troubles cardiovasculaires chez les athlètes de compétition. Un programme de dépistage et de soins des troubles cardiovasculaires des athlètes axé sur l’institution et l’athlète est recommandé. Un tel dépistage devrait s’inscrire dans une approche uniforme et systématique du dépistage et du traitement des troubles cardiovasculaires comprenant les volets suivants : évaluation, examens appropriés, interprétation, prise en charge, counseling et suivi. Les recommandations présentées incluent un cadre à plusieurs paliers qui donne aux institutions une certaine latitude pour l’élaboration du programme.

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CardiomyopathyComparison of the Frequency of Sudden Cardiovascular Deaths in Young Competitive Athletes Versus Nonathletes: Should We Really Screen Only Athletes?

Section snippets

Methods

Results

Discussion

Disclosures

J Am Coll Cardiol

J Am Coll Cardiol

Mayo Clin Proc

Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in general healthy populations of young people (12-25 years of age)

Circulation

Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program

JAMA

Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006

Circulation

Cardiomyopathy
Comparison of the Frequency of Sudden Cardiovascular Deaths in Young Competitive Athletes Versus Nonathletes: Should We Really Screen Only Athletes?