Sudden Death in Competitive Athletes

Steven R. Neish, MD, SM


December 07, 2007

The sudden death of an elite athlete always warrants a headline. Recently, one of America's elite distance runners stumbled off the course at the Olympic trials marathon in New York. He died after attempts at resuscitation. He was 28 years old. His death seemed completely unexpected. When he was 14 years old, though, he was diagnosed with an enlarged heart when he had pneumonia, and a chest x-ray was performed. The autopsy is inconclusive at the time of this taping.

In the United States, the most common cause of sudden death in young athletes is hypertrophic cardiomyopathy.[1] With the right evaluation, hypertrophic cardiomyopathy is an easy diagnosis to make sometimes.[2]

In the US, all athletes are evaluated prior to competition.[3,4] Typically, physicians look for cardiac disease during this evaluation. The overwhelming majority of competitive athletes have normal hearts. In fact, our young athletes seem the healthiest members of our society.

There are clues, though, that should open the door to further testing. The history holds the most clues. Syncope with exercise is ominous. Palpitations with exercise or chest pain with exercise rarely lead to a diagnosis of heart disease in young athletes, but merit a careful physical examination, and an ECG at a minimum. Sudden death in childhood or early adulthood in a close relative can point to many important cardiac diagnoses. On physical examination, particularly when accompanied with worrisome symptoms, an abnormal-sounding heart murmur deserves attention. A diagnosis of hypertrophic cardiomyopathy may follow any of these revelations in the history and physical.

Mass screening of asymptomatic athletes with no clues on physical examination or during the history presents a more vexing question. Risks in diagnosis are abundant. Overall, the prevalence of diseases that cause sudden death is low. Elite athletes show cardiovascular adaptations that mimic findings in nonathletes with heart disease.[5] Some cardiologists have limited familiarity with the subtle differences between the normal changes that accompany extreme conditioning and the findings in diseases. Eventually, DNA testing may be a cost-effective way to screen for many cardiac diseases, including cardiomyopathies and many life-threatening arrhythmias.

That's my opinion. I'm Dr. Steven Neish, Director of the Pediatric Cardiology Fellowship Program at the Texas Children's Hospital and Editor-in-Chief of Pediatrics for eMedicine.




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