The sudden death of a competitive athlete inevitably becomes an occasion for local, if not national, publicity. On each occasion, the public and the medical community ask whether such events could be prevented by more careful or complete screening. Although each event is tragic, it must be appreciated that there are approximately 5 million competitive athletes at the high school level or above in any given year in the United States. The number of cardiac deaths occurring during athletic participation is unknown but estimates at the high school level range from one in 100,000 to one in 300,000 participants. Death rates among more mature athletes increase as the prevalence of CAD rises. These numbers highlight the problem of how best to screen individual participants. Even an inexpensive test such as an ECG would generate an enormous cost if required of all athletes, and it is likely that only a few at-risk individuals would be detected. Echocardiography, either as a routine test or as a follow-up examination for abnormal ECGs, would be prohibitively expensive except for the elite professional athlete. Thus, the most feasible approach is that of a careful medical history and cardiac examination performed by personnel aware of the conditions responsible for most sudden deaths in competitive athletes.
It is important to point out that sudden death is much more common in the older than the younger athlete. Older athletes will generally seek advice regarding their fitness for participation. These individuals should recognize that strenuous exercise is associated with an increase in risk of sudden cardiac death and that appropriate training substantially reduces this risk. Preparticipation screening for risk of sudden death in the older athlete is a complex issue and at present is largely focused on identifying inducible ischemia due to significant coronary disease.
In a series of 158 athletic deaths in the United States between 1985 and 1995, hypertrophic cardiomyopathy (36%) and coronary anomalies (19%) were by far the most frequent underlying conditions. LVH was present in another 10%, ruptured aorta (presumably due to Marfan syndrome or cystic medial necrosis) in 6%, myocarditis or dilated cardiomyopathy in 6%, aortic stenosis in 4%, and arrhythmogenic RV dysplasia in 3%. In addition, commotio cordis, or sudden death due to direct myocardial injury, may occur. More common in children, ventricular tachycardia or ventricular fibrillation may occur even after a minor direct blow to the heart; it is thought to be due to the precipitation of a PVC just prior to the peak of the T wave on ECG.
A careful family and medical history and cardiovascular examination will identify most individuals at risk. An update in 2014 recommends that all middle school and higher athletes undergo a medical screen questionnaire and examination. The 12 elements in the examination are outlined in Table 10–21.
Table 10–21.12-element AHA recommendations for preparticipation cardiovascular screening of competitive athletes.