Sudden Death in Athletes

What is Sudden Death in Athletes?

Sudden death in athletes is a terribly sad event that engages the areas of sports medicine, heart health, general care, and children’s health. The leading cause of unexpected death for a young athlete while competing often relates to heart disease, typically a birth defect or condition they were born with. However, heart disease in younger and middle-aged athletes can also come about due to the use of harmful substances like anabolic steroids, peptide hormones, and stimulants. On the other hand, sudden death in an older athlete is usually brought about by a condition connected to the hardening and narrowing of the arteries, known as atherosclerotic coronary artery disease.

There are many different heart conditions that people can be born with. Most of these fall into two categories: structural and non-structural. Structural heart disease affects the way blood flows in and out of the heart, with examples including hypertrophic obstructive cardiomyopathy (a disease where the heart muscle becomes abnormally thick), arrhythmogenic right ventricular dysplasia (a rare type of cardiomyopathy), and abnormal coronary arteries. Non-structural heart disease, on the other hand, involve defects in how the heart’s electrical system works, which could trigger uneven and hazardous heart rhythms. Examples include long QT syndrome, Brugada syndrome, Wolff-Parkinson-White (WPW) syndrome, and catecholaminergic polymorphic ventricular tachycardia (irregular heart rhythms that can occur during exercise or emotional stress). There are other forms of these heart diseases, and harming substances like steroids and stimulants can lead to structural changes or trigger dangerous heart rhythms.

These health conditions can lead to symptoms like fainting or near-fainting, and in some cases, can result in sudden and unexpected death. This emphasizes the importance of early identification of heart disease in athletes. Many athletes with heart disease often do not show any signs or symptoms, with a sudden stoppage of the heart being the first sign of an underlying issue. It can be tough to identify these athletes because we want to avoid invasive tests as much as possible. However, a thorough sports physical examination, including an assessment of the athlete’s personal and family health history, a complete physical examination, and an electrocardiogram (a test measuring the electrical activity of the heart), can effectively screen for heart diseases in those who don’t show symptoms and those at lower risk. Athletes considered to be at a higher risk might need more detailed tests.

After a diagnosis, the athlete is assessed in terms of risk, followed by put on a long-term treatment plan to bring down the risk of sudden heart-related death. Medication is a common treatment method, while surgery is kept for particular cases. An implantable cardioverter-defibrillator (a device that can identify and stop dangerous heart rhythms) may be the best choice for those seen to be at risk for a heart arrest resulting from a lethal heart rhythm. The decision to continue participating in the sport or quit is a shared decision made between the doctors and the patient.

This article aimed to review the causes of sudden death in athletes, mainly focusing on the most common causes in younger athletes and how these conditions may initially present and be evaluated.

What Causes Sudden Death in Athletes?

Sudden unexpected death in athletes has typically been seen as mainly occurring because of heart-related causes.

Causes tied to heart issues can be divided into two categories – those related to physical abnormalities in the structure of the heart and those where the heart looks normal but has an electrical or chemical malfunction.

Physical abnormalities causing sudden unexpected deaths could be:
* Thickening of heart muscles obstructing blood flow (Hypertrophic obstructive cardiomyopathy or HOCM)
* Enlarged heart that can’t pump blood effectively (Dilated cardiomyopathy)
* Unusual formation of heart arteries (Coronary artery anomaly)
* Thickening of the heart’s main pumping chamber (Left ventricular hypertrophy)
* Narrowing and hardening of the heart’s major blood vessels (Atherosclerotic coronary artery disease)
* Abnormal formation of heart muscles (Left ventricular noncompaction)
* Abnormalities in the structure of the right ventricle (Arrhythmogenic right ventricular dysplasia)
* Disease of the aorta (Aortopathy)
* Narrowing of the aortic valve from birth (Congenital aortic stenosis)
* Unusual folding or bulging of the valve between the left atrium and the left ventricle (Mitral valve prolapse)

In some instances, the heart may look structurally normal, but electrical or chemical issues could still lead to sudden unexpected deaths. These can include:
* Rapid heartbeats because of an additional electrical pathway (Wolff-Parkinson-White syndrome)
* Delayed return of electrical signals after a heartbeat, present from birth (Congenital long QT syndrome)
* Delayed return of electrical signals after a heartbeat due to medication or certain medical conditions (Acquired long QT syndrome)
* Abnormal pattern of electrical activity that can lead to dangerous heart rhythms (Brugada syndrome)
* Issues with the electrical signals that coordinate the heart beats (Atrioventricular blocks)
* An inherited rhythm disorder which can cause fast, chaotic heartbeats (Catecholaminergic polymorphic ventricular tachycardia)
* Too quick return of the electrical signals after a heartbeat (Short QT syndrome)
* Abnormal heart rhythm due to a sudden increase in heart rate (Early repolarisation syndrome)
* Unexplained, life-threatening heart rhythm disturbances (Idiopathic ventricular fibrillation)
* Abnormal electrical activity due to faulty heart proteins (Mixed sodium channel disease)
* Electrical disturbances created by the athlete’s chest muscles
* Electrical disturbances created by static electricity in the environment

Other causes could include things like:
* Taking drugs that increase heart rate and blood pressure (Stimulant use)
* Drugs that mimic the effects of testosterone and enhance performance (Anabolic steroid use)
* Heart damage from a blow to the chest (Commotio cordis)
* Tearing of the major artery leaving the heart (Aortic rupture)
* Inflammation of the heart muscles (Myocarditis)

Risk Factors and Frequency for Sudden Death in Athletes

Sudden cardiac death in athletes varies in frequency, depending on the method of data collection. Generally, the range is from 1 in 40,000 to 1 in 80,000. However, some reports note rates as high as 1 in 3,000. This variation likely comes from different interpretations of what counts as sudden cardiac death, such as instances happening during exertion, rest, or if a person survived resuscitation.

The most common cause of sudden death in athletes is hypertrophic obstructive cardiomyopathy (a heart muscle disease) and severe thickening of the wall of the heart’s main pumping chamber. This condition is usually seen in about 1 in every 500 people, and is more frequent in men. Abnormalities in the heart’s arteries are the second most common cause of athlete sudden deaths, and occur in about 1.2% of people. Of these, around 20% could be life-threatening when found in athletes. Another cause is Arrhythmogenic right ventricular dysplasia (a type of cardiomyopathy), which happens in 1 in 2,000 to 5,000 people.

Hypertrophic obstructive cardiomyopathy is the most common cause of sudden death in athletes and is observed in about 1 in 500 people.
Coronary artery anomalies, the second most common cause, occur in 1.2% of the population.
Arrhythmogenic right ventricular dysplasia is another known cause, occurring in 1 in 2000 to 1 in 5000 people.

While these heart conditions are mostly genetic, using anabolic steroids is a known cause of severe left ventricular hypertrophy. The degree of this condition varies among users of these substances, depending on the specific substances used and other complex factors.

There are also non-structural causes of sudden cardiac death, mainly linked to electrical defects in the heart leading to deadly abnormal heart rhythms. For instance, congenital long QT syndrome occurs in about 1 in 2000 births, Wolff-Parkinson-White syndrome at a rate of 1.5 in 1000, Brugada syndrome at a rate of 0.15%, and catecholaminergic polymorphic ventricular tachycardia in approximately 1 in 10000 people.

Congenital long QT syndrome shows up in roughly 1 in 2000 births.
Wolff-Parkinson-White syndrome occurs in about 1.5 in 1000 people.
Brugada syndrome has an incidence of 0.15%.
Catecholaminergic polymorphic ventricular tachycardia occurs in around 1 in 10000 people.

While these conditions are not very common in the population, they collectively pose a significant health risk, especially for the large population of young athletes.

Signs and Symptoms of Sudden Death in Athletes

If you’re a young athlete planning to participate in competitive sports or intense physical activities, you need to get a thorough health checkup. This examination should include assessing any symptoms like feeling like you’re about to faint, dizziness, rapid heartbeat, chest pain, breathlessness, seizures, extreme exhaustion, and inability to feel your own pulse. Doctors will need to know if these symptoms occur during exercise or at rest.

Feeling like you’re about to faint or actually fainting are usually caused by a sudden drop in blood pressure or extreme heat, but in young people, they might indicate an existing heart disease. Rapid heartbeat might simply be caused by naturally occurring extra heartbeats known as ectopic beats, but if it happens frequently, it might indicate some sort of heart disease. Chest pain and breathlessness might indicate heart problems specifically known as obstructive cardiomyopathy. Seizures and the inability to feel one’s pulse might point to a condition known as torsades de pointes associated with long QT syndrome. This syndrome is featured by episodes of an unstable heart rhythm.

An assessment of family health history is equally important, as it aids in the detection of inherited heart conditions. These conditions might have gone undiagnosed in family members or relatives who might have unexpectedly passed away. Also, athletes should share any history of using performance-enhancing drugs (PEDs), especially anabolic steroids and stimulants, as these substances can cause sudden heart failure. Heavy usage of testosterone, growth hormones, and certain injectable drugs can lead to thickening of the heart muscle’s wall, a condition known as left ventricular hypertrophy. Moreover, the usage of stimulants can increase the likelihood of arrhythmias or irregular heartbeats, especially in those with existing heart diseases. Some pre-workout supplements containing certain compounds can also lead to a high occurrence of ectopic heartbeats and cause various symptoms.

For the physical examination part, a general full-body checkup should be done, including a neurological assessment, a musculoskeletal examination, and a comprehensive cardiovascular assessment. A thorough cardiac exam involves listening to the heart’s rate and rhythm, the presence of additional heart sounds known as S3 or S4, and/or any abnormal heart movements or sounds. Any suspicious heart murmurs should be further investigated%

Testing for Sudden Death in Athletes

If you’re an athlete getting checked for heart diseases or you’ve been fainting and we’re not sure why, the first test we might use is an electrocardiogram (or ECG for short). This test tells us how fast your heart is beating and whether it’s beating in a normal rhythm – it can also show us if there are any abnormalities in the structure of your heart. We’re looking for several different things in an ECG:

An unusually short or long time between the start of a heartbeat and the next (‘PR interval’ or ‘QTc interval’)
Whether there’s an unusual pattern of heartbeats (like a ‘Brugada type 1 pattern’)
Any ‘premature ventricular contractions’ (extra heartbeat), doublets or triplets (two or three heartbeats very close together)
Signs that the heart is not correctly conducting electrical impulses (like a ‘Mobitz type II atrioventricular block’ or ‘complete left bundle branch block’)
Unusual ‘T wave inversion’ (a change in the pattern of heart activity)
Abnormally long duration of each heartbeat (‘QRS greater than 140ms’)
‘Epsilon waves’ are a sign of certain heart conditions, including arrhythmogenic right ventricular cardiomyopathy (ARVC), a rare disease of the heart muscle.

Some ECG findings that you would consider unusual might actually be perfectly normal for an athlete. As an example, you might have a heart rate of fewer than 60 beats per minute (‘sinus bradycardia’) – it’s quite common in athletes and not a problem, though very low heart rates do need to be checked out.

Another test that might be used if you have unusual ECG results or symptoms like heart palpitations, is a ‘Holter monitor’. It’s worn for 24 or 48 hours and provides a more detailed look at your heart rhythm during that time.

A ‘stress test’ on a treadmill or exercise bike can also be used to identify possible heart problems that only show up when the heart is working harder.

If we need a detailed look at the structure of your heart, we might use an ‘echocardiogram’. This test uses ultrasound waves to create a picture of the heart, allowing us to see the size and shape of your heart chambers, how well your heart is pumping and the structure of your heart valves.

Given that Long QT syndrome is a known risk factor for fainting and sudden death, you might also be tested for this condition. The QT interval is the time it takes for the heart muscle to contract and then recover, ready for the next contraction. When this interval is unusually long, it can disrupt the heart’s rhythm. You’ll be given a score based on a range of factors, and a high score suggests you have a high chance of having Long QT syndrome.

Also, we pay attention to the thickness of the muscle on the left side of your heart (left ventricular hypertrophy). If it’s a little thicker than usual, it’s probably just a sign of your heart adapting to regular exercise. If it’s exceptionally thick, this could be due to a genetic condition, or it could be a sign that you’ve been taking certain performance-enhancing drugs.

If it falls into a ‘gray area’ (neither normal nor definitely abnormal) we will need to do further tests to determine whether it’s a sign of a serious condition called ‘hypertrophic obstructive cardiomyopathy’.

Apart from the tests mentioned, other methods like scanning your heart using an MRI (a type of scan that uses magnetic fields and radio waves to produce detailed images) and assessing your genetics might be used to provide a more in-depth and comprehensive evaluation of your heart condition.

Treatment Options for Sudden Death in Athletes

When an athlete is diagnosed with heart disease, their treatment plan usually involves a combination of general and specific adjustments. They may be advised to avoid strenuous physical activity and other factors that could potentially worsen their condition temporarily. This is because physical and emotional stress can strain the heart and potentially cause dangerous heart rhythm problems.

One of the crucial aspects of building a long-term treatment plan is deciding whether the athlete can return to their chosen sport. This decision is usually made after evaluating the athlete’s risk factors and understanding their probability of experiencing sudden cardiac arrest or other related issues. The decision also depends on the specific sport the athlete plays, as some sports may carry higher risks than others. Though in the past, it was common advice for athletes with heart disease to retire from their sport, recent research suggests that many athletes can go back to their sport safely after going through the correct treatment process.

In terms of specific medical treatments, the goal is usually to increase blood flow to the heart and prevent irregular heart rhythms. This can be achieved with medications like beta-blockers or calcium channel blockers. For structural defects in the heart, surgery might be necessary. Some examples of such procedures include surgical septal myomectomy or alcohol septal ablation, both used to treat a condition called hypertrophic obstructive cardiomyopathy (thickening of heart muscle). In cases where an athlete has inherited (congenital) heart rhythm problems, a procedure called ablation can be used to remove the source of the irregular rhythms.

An implantable cardioverter-defibrillator (a device implanted in the body to regulate heart rhythm) may be used in cases where there’s a high risk of sudden cardiac arrest. This device has greatly improved the prognosis for athletes with congenital heart problems, even allowing many to continue participating in their sports. In some severe cases, a heart transplant might be necessary.

For athletes with congenital heart disease, it’s important to stay hydrated, maintain healthy electrolyte levels, and regularly check in with a doctor. In some cases, the athlete might have to stop participating in their sport. However, this decision should be made together with the doctor, taking into account the athlete’s welfare and personal preferences.

When looking at causes of sudden death in athletes, it’s important not to forget about non-heart-related possibilities. These may include:

Physical injury from blunt force
Drowning (depending on the sport)
Heatstroke
Dehydration

Similarly, when examining a case where an athlete suddenly faints, several potential causes need consideration apart from heart-related issues. These potential reasons might include:

Vasovagal events, which are common causes of fainting in both the general population and athletes
Heatstroke
Dehydration
Anorexia and related electrolyte abnormalities among female athletes
Anemia
Seizures
Hyponatremia (low blood sodium)

What to expect with Sudden Death in Athletes

The outcome for athletes diagnosed with heart disease hugely depends on the specific illness, how severe it is, and the treatment plan.

For those with a condition called Hypertrophic Obstructive Cardiomyopathy, life expectancy is often near normal and many may also not experience any symptoms. Implantable Cardioverter Defibrillators (ICDs), devices placed under the skin to monitor heart rate, are highly effective in preventing sudden heart-related death in those at risk.

Coronary Artery Anomaly, an abnormality in one or more of the coronary arteries of the heart, can have risk factors that are not quite known. While some abnormalities might cause sudden death, others are harmless and do not shorten life expectancy.

Athletes with Arrhythmogenic Right Ventricular Dysplasia, a heart muscle disorder, often have a good long-term outcome if they receive treatment and if the left chamber of the heart is not affected. An ICD can massively improve their outcome. However, many athletes with this condition may need to stop playing sports.

Congenital Long QT Syndrome, a heart rhythm condition, presents a low risk of sudden death if treated suitably. Moreover, the risk decreases after the age of 40.

For those with Wolff-Parkinson-White Syndrome, sudden heart-related death is quite rare if treated.

With Brugada Syndrome, another heart rhythm disorder, an assessment is done to determine the need for treatment. Patients without symptoms have a nearly normal life expectancy, while those with symptoms can have a life expectancy as low as 40 years old. There is no significant direct link between this syndrome and athletics.

For athletes diagnosed with Catecholaminergic Polymorphic Ventricular Tachycardia, a condition causing fast and irregular heartbeats, the prognosis is poor if it isn’t diagnosed early as this often begins during childhood. However, ICDs and a group of medications called beta-blockers can greatly improve outcomes.

Certain other conditions might have unpredictable outcomes or their outcome could greatly vary based on how well the person’s body responds to treatment. Compliance with the treatment is another important factor, particularly among younger athletes. Many athletes may need to abstain from sports for a while until they undergo a complete evaluation and a treatment plan is in place. Following the recommended period of abstention from sports, sticking to the treatment plan, and avoiding factors that aggravate the condition are critical to the outcome.

Possible Complications When Diagnosed with Sudden Death in Athletes

The worst possible outcome for athletes with heart disease is experiencing sudden cardiac death. Symptoms such as fainting, near-fainting, and feeling dizzy are quite common, especially during strenuous activities. Shortness of breath and chest pains are also often reported by athletes.

Common Symptoms:

Sudden cardiac death
Fainting, or feeling like you’re about to faint
Feeling dizzy
Feeling short of breath
Chest pain

Frequently asked questions

The prognosis for sudden death in athletes depends on the specific heart condition and its severity. Here are some general prognoses for certain heart conditions: - Hypertrophic Obstructive Cardiomyopathy: Life expectancy is often near normal, and implantable cardioverter-defibrillators (ICDs) are highly effective in preventing sudden heart-related death in those at risk. - Coronary Artery Anomaly: The risk factors are not well known, and the prognosis varies. Some abnormalities may cause sudden death, while others are harmless and do not shorten life expectancy. - Arrhythmogenic Right Ventricular Dysplasia: The long-term outcome is good if the left chamber of the heart is not affected, and an ICD can greatly improve the outcome. However, many athletes with this condition may need to stop playing sports. - Congenital Long QT Syndrome: The risk of sudden death is low if treated properly, and the risk decreases after the age of 40. - Wolff-Parkinson-White Syndrome: Sudden heart-related death is rare if treated. - Brugada Syndrome: The prognosis varies based on symptoms. Patients without symptoms have a nearly normal life expectancy, while those with symptoms may have a lower life expectancy. There is no significant direct link between this syndrome and athletics. - Catecholaminergic Polymorphic Ventricular Tachycardia: Early diagnosis is crucial, and the prognosis is poor if not diagnosed early. However, implantable cardioverter-defibrillators (ICDs) and beta-blockers can greatly improve outcomes.

Sudden death in athletes can occur due to various causes, including heart-related issues such as physical abnormalities in the structure of the heart or electrical and chemical malfunctions. Other causes can include drug use, heart damage from a blow to the chest, tearing of the major artery leaving the heart, and inflammation of the heart muscles.

Signs and symptoms of Sudden Death in Athletes include: - Feeling like you're about to faint - Dizziness - Rapid heartbeat - Chest pain - Breathlessness - Seizures - Extreme exhaustion - Inability to feel your own pulse These symptoms may occur during exercise or at rest. It is important to note that these symptoms can be caused by various factors, such as a sudden drop in blood pressure, extreme heat, or existing heart diseases. Therefore, a thorough health checkup is necessary to assess and diagnose the underlying cause of these symptoms. Additionally, an assessment of family health history is crucial in detecting any inherited heart conditions that may have gone undiagnosed in relatives who have unexpectedly passed away. Athletes should also disclose any history of using performance-enhancing drugs, as these substances can cause sudden heart failure and other cardiac complications.

The types of tests that are needed for sudden death in athletes include: - Electrocardiogram (ECG): This test measures the heart's electrical activity and can detect abnormalities in heart rhythm and structure. - Holter monitor: This device is worn for 24 or 48 hours to provide a more detailed look at the heart's rhythm. - Stress test: This test is performed on a treadmill or exercise bike to identify heart problems that may only occur during physical exertion. - Echocardiogram: This test uses ultrasound waves to create images of the heart and assess its size, shape, and function. - Long QT syndrome test: This test evaluates the QT interval, which is the time it takes for the heart muscle to contract and recover. A high score suggests a higher chance of having Long QT syndrome. - MRI scan: This scan uses magnetic fields and radio waves to produce detailed images of the heart. - Genetic assessment: This involves evaluating an individual's genetics to determine if there are any underlying genetic conditions related to heart disease.

The doctor needs to rule out the following conditions when diagnosing Sudden Death in Athletes: - Physical injury from blunt force - Drowning (depending on the sport) - Heatstroke - Dehydration - Vasovagal events - Anorexia and related electrolyte abnormalities among female athletes - Anemia - Seizures - Hyponatremia (low blood sodium)

The side effects when treating sudden death in athletes can include fainting or feeling like you're about to faint, feeling dizzy, feeling short of breath, and chest pain. These symptoms are quite common, especially during strenuous activities.

A cardiologist.

Sudden death in athletes varies in frequency, depending on the method of data collection, generally ranging from 1 in 40,000 to 1 in 80,000, but some reports note rates as high as 1 in 3,000.

Sudden death in athletes can be treated through a combination of general and specific adjustments to the athlete's treatment plan. This may involve advising the athlete to avoid strenuous physical activity and other factors that could potentially worsen their condition temporarily. Medications like beta-blockers or calcium channel blockers can be used to increase blood flow to the heart and prevent irregular heart rhythms. In cases where there is a high risk of sudden cardiac arrest, an implantable cardioverter-defibrillator may be used. In severe cases, a heart transplant might be necessary. The specific treatment approach will depend on the individual athlete's condition and risk factors.

Sudden death in athletes refers to the unexpected death of a young athlete while competing. It is often caused by heart disease, either a birth defect or a condition they were born with. In older athletes, sudden death is usually caused by atherosclerotic coronary artery disease.