The Exercise Paradox: Sudden Cardiac Arrest in Athletes

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The long term benefits of exercise are well documented, but as sports cardiologists we know that these benefits must be balanced against the short term risk of sudden cardiac arrest (SCA) from ventricular tachycardia (VT) and ventricular fibrillation (VF) occurring during or after exercise. The incidence of SCA is 1 in 50,000 among NCAA athletes, with a higher incidence in males vs females and in African Americans. Division 1 male basketball players are at greatest risk with an incidence of 1 in 5,000. Among younger athletes the true incidence is less well defined, but it is estimated that in the U.S. a high school age athlete suffers SCA every three days.

In young athletes (< 35 years of age), the leading cause of SCA is Sudden Arrhythmic Death Syndrome (SADS), in which the heart is structurally normal; conditions in this category include Long QT (LQT), Wolf Parkinson White (WPW), and Brugada Syndrome. Among the causes of SCA associated with structural abnormalities are hypertrophic cardiomyopathy (HCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), congenital coronary artery anomalies, and myocarditis.

An ECG can detect 85% of the conditions associated with SCA in young athletes and has been endorsed by the IOC and the European Society of Cardiology. On the other hand, the Preparticipation Physical Evaluation (PPE) used in the U.S. consists of a history and physical and is able to detect no more than 15% of these conditions. ECG screening is not mandated in any state and has not been endorsed by the American Heart Association. The argument against ECG screening of athletes is that SCA is rare, resources are lacking, the cost is prohibitive, and the false positive rate is too high. The reality is that an ECG can be performed at a cost of $80/athlete with a false positive rate of only 3% if interpreted according to the 2017 International Criteria for ECG interpretation in athletes. And we must ask, what is the cost of not screening?

 

Photo by Markus Spiske on Unsplash

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