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Hearing about sudden cardiac death in an otherwise well-appearing athlete generates significant alarm for families and providers alike. Without systematic collection of data on deaths among young athletes, it has been difficult to determine the incidence of these rare, tragic events.
Using data from mandatory cardiac screening of over 11,000 adolescent soccer players in the U.K. between 1997 and 2017, researchers assessed screening findings and incidence and causes of sudden cardiac deaths during follow-up. Adolescents completed a health questionnaire and underwent a physical examination, 12-lead electrocardiography, and echocardiography.
Forty-two athletes (0.4%) had a cardiac diagnosis associated with sudden cardiac death. An additional 225 (2%) had a congenital or valvular cardiac abnormality. During a mean follow-up of 11 years, 23 deaths occurred from any cause, of which 8 (35%) were sudden cardiac deaths during exercise. Cardiomyopathy led to seven of the eight sudden cardiac deaths. Six athletes (75%) with sudden cardiac death had a normal cardiac screen. Based on over 118,000 person-years of data, the incidence of sudden cardiac death was 6.8 per 100,000 athletes.
Screening of athletes to prevent sudden cardiac death continues to be a divisive topic. This prospective study with long, excellent follow-up provides some of the best data to date. Despite screening with questionnaires, electrocardiograms, and echocardiograms, the incidence of sudden cardiac death remained high (6.8 per 100,000 athletes) compared with other young populations. And of the eight athletes with sudden cardiac death, six had undergone the thorough screening process and were found normal. In my mind, this study highlights the imperfection of screening, and we indeed should redirect our focus to resuscitation with CPR and automated external defibrillators.
Malhotra A et al. Outcomes of cardiac screening in adolescent soccer players. N Engl J Med 2018 Aug 9; 379:524. (https://doi.org/10.1056/NEJMoa1714719)
Comment — Pediatrics and Adolescent Medicine
Though the low incidence of overall cardiac pathology in these youth is reassuring, it is disheartening that most of the sudden cardiac deaths were due to cardiomyopathies that were not detected on screening. Electrocardiography and echocardiography were simply not sensitive enough to detect early disease. Preparticipation exams continue to be important, but following the athlete throughout the season is even more crucial, as is encouraging adolescent athletes and their parents to contact their primary care provider if they feel unusual fatigue, palpitations, or other symptoms. Although it might be challenging to persuade the invincible-feeling adolescent athlete to miss a practice to schedule a health appointment, these findings suggest that we should keep trying.