Risk of Sports-related Sudden Cardiac Death in Women

Deepthi Rajan; Rodrigue Garcia; Jesper Svane; Jacob Tfelt-Hansen


Eur Heart J. 2022;43(12):1198-1206. 

In This Article

Abstract and Introduction


Graphical Abstract

Diagram of incidence, pathophysiology, and causes of sports-related sudden cardiac death in women. The pie chart shows causes of 59 sports-related sudden cardiac deaths in women based on reported data from different studies.[7–9,23,24,26,27,29,38] SADS, sudden arrhythmic death syndrome; RV, right ventricular; LQTS, long QT syndrome; ARVC, arrhythmogenic right ventricular cardiomyopathy. The primary autopsy finding and stated cause of death in one of the hyponatraemia cases was hyponatraemia, yet additional clinical and autopsy data also showed the presence of myxomatous polyvalvular (mitral, tricuspid, aortic) heart disease.

Sudden cardiac death (SCD) is a tragic incident accountable for up to 50% of deaths from cardiovascular disease. Sports-related SCD (SrSCD) is a phenomenon which has previously been associated with both competitive and recreational sport activities. SrSCD has been found to occur 5–33-fold less frequently in women than in men, and the sex difference persists despite a rapid increase in female participation in sports. Establishing the reasons behind this difference could pinpoint targets for improved prevention of SrSCD. Therefore, this review summarizes existing knowledge on epidemiology, characteristics, and causes of SrSCD in females, and elaborates on proposed mechanisms behind the sex differences. Although literature concerning the aetiology of SrSCD in females is limited, proposed mechanisms include sex-specific variations in hormones, blood pressure, autonomic tone, and the presentation of acute coronary syndromes. Consequently, these biological differences impact the degree of cardiac hypertrophy, dilation, right ventricular remodelling, myocardial fibrosis, and coronary atherosclerosis, and thereby the occurrence of ventricular arrhythmias in male and female athletes associated with short- and long-term exercise. Finally, cardiac examinations such as electrocardiograms and echocardiography are useful tools allowing easy differentiation between physiological and pathological cardiac adaptations following exercise in women. However, as a significant proportion of SrSCD causes in women are non-structural or unexplained after autopsy, channelopathies may play an important role, encouraging attention to prodromal symptoms and family history. These findings will aid in the identification of females at high risk of SrSCD and development of targeted prevention for female sport participants.


Sudden cardiac death (SCD) is a major health issue and responsible for up to 13–20% of all deaths in Western societies, a proportion of which are related to sports activities.[1–3] Sports are defined, according to the Council of Europe, as all forms of physical activity which, through casual or organized participation, aim at expressing or improving physical fitness and mental well-being, forming social relationships, or obtaining results in competition at all levels.[4] Sports-related SCD (SrSCD) is the subset of SCD occurring in temporal relation to physical exercise. While some definitions of SrSCD allow a time interval between sports participation and the occurrence of SCD of 1 h, others allow up to 96 h. However, the most common definition of SrSCD is a non-traumatic SCD occurring during or within 1 h of moderate- to high-intensity exercise.[5–9]

Sports were previously viewed as beneficial in preventing leading causes of SCD such as coronary artery disease (CAD) and diabetes. CAD is the most common cause of SCD[3] and diabetes is a risk factor for SCD.[10]

SrSCD has been found to occur significantly more often in males than females.[1] While both short- and long-term exercise are known to be associated with a multitude of cardiac structural and functional changes to accommodate increased demand for cardiac output,[11–13] biological differences between males and females may result in distinct cardiac adaptations following exercise, leading to a disproportion in SrSCD incidence between the sexes.[14] Furthermore, sex differences in catecholamine release during exercise may be consequential.

Uncovering the role of female sex in lower SrSCD incidences could reveal underlying mechanisms and consequently how SrSCD can be prevented. Therefore, in this review, we focus on the epidemiology of SrSCD, characteristics and causes of SrSCD in females, and elucidate how and why cardiac adaptations to exercise vary between males and females (Graphical Abstract).