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A review of sudden death in athletes



Sudden death syndrome in athletes is a very unpleasant and affecting event. Basically, the deaths that lead to death within one hour after the initial heart attack are called sudden death. This event can occur in both amateur and professional athletes, both young and old. Although this is undesirable, fortunately, its incidence rate is rare, but due to its great impact on the sports community, it has received a lot of attention. In many cases, after this happens, the athlete cannot be kept alive, but emergency aid and cardiopulmonary resuscitation can bring him back to life in some cases.

History of sudden death in athletes

The first evidence of sudden cardiac death dates back to 490 BC, when Pheidippides, a Greek soldier, ran from Marathon to Athens to announce the military conquest of the Greek army and died immediately after completing the mission. In recent years, the sudden death of a number of high-level athletes, including Italian cyclist Marco Pantani, winner of the Tour de France (2004), Miklos Fehr, player of the Hungarian national football team and Benfica of Portugal (2004), Mark Vivian Fou, player of the national football team Cameron (2003), Olympic figure skating gold medalist Sergi Grinkov (1993), Olympic volleyball champion Floheyman (1986) and Majid Pashamqadam, the late national player of Iran’s national basketball team, have drawn public attention to these painful events, although they are not common. Is.

According to the research conducted in sports, it is likely that its occurrence rate is about 1 in 100,000 athletes per year. The average age of people who suffer from this condition is 17.1 years. which increases with age. It can occur in men and women. But the risk of sudden death in male athletes is 5 times higher than that of female athletes. It seems to be more common in football, running, cycling and basketball than other sports. Geographical location can also be influential.

For example, in North America, the most common cause of sudden death (SD) in athletes is hypertrophic cardiomyopathy (HCM). In Italy, the most common cause of SD is right ventricular cardiomyopathy, and in Germany, myocarditis, in China, the most common cause of SD is Marfan syndrome. 70% of the causes of sudden death in young athletes (under 35 years old) are cardiovascular diseases, and most of them occur during competitions and hard and intense sports. Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden death (about 90%) of young athletes, 10% of other cases are cardiovascular diseases.

Among the causes that are less, the following can be mentioned:

In people under 35 years old: Congenital structural disorder of the heart in the heart muscles or valves, disorder in the cruciate heart rhythm, vascular ruptures (in the context of dilatation or vascular aneurysm), cerebrovascular events such as cerebral hemorrhages, asthma attack, acquired structural heart disorder in the heart muscles or valves: enlargement and hypertrophy The disproportion of heart muscles in athletes, which has a genetic background, is called hypertrophic cardiomyopathy, and as mentioned, it is the most common cause of sudden death in athletes.

In people over 35 years old: Coronary heart vascular diseases: the most common cause of sudden death at this age in athletes, hypotrophic cardiomyopathy, rupture of vascular aneurysms such as rupture of the aorta, brain events such as rupture of cerebral vessels, pulmonary causes such as severe spasm of the airways in the context of asthma. Other causes include doping (abuse of drugs such as stimulants, anabolic steroids, drugs, etc.), spasm of the bronchi and airways, heatstroke, pulmonary embolism, and drowning.

Most athletes in which sports are involved in sudden death?

The first sudden death occurred in athletics and running, but the highest number of sudden deaths was in sports such as basketball, football, and athletics, and its prevalence is usually higher in men. In 80% of cases, there is an underlying disorder that has not been diagnosed. Disorders such as congenital heart disorders, heart rhythm disorders, rupture of blood vessels, vascular accidents and brain death, asthma attacks, etc. are among the things that can turn into brain death.

Looking for a needle in a haystack

It is estimated that 200,000 athletes should undergo full screening tests to identify an athlete who is likely to die during sports. Of course, it is not possible to do such a large-scale work from the operational and economic point of view. Therefore, it is suggested that a detailed history and appropriate medical examination should be carried out in the pre-competition evaluation program of all professional athletes, and if any of the risk factors are present, the next stage of screening should be performed using additional diagnostic methods such as electrocardiography, echocardiography, etc. to be

It is necessary to ask any person who wants to do sports the necessary questions about the danger signs and family history of this incident, and if the answer to each of the following questions is positive, the necessary additional investigations mentioned below should be done.

  • Does he have a positive family history of sudden death or not?
  • Is there a history of congenital heart disease in the family or not?
  • Is there a history of chest pain after exercise or not?
  • Does he have a history of feeling confused or momentary loss of consciousness following activity?
  • Is there a history of inappropriate shortness of breath with physical activity or not?
  • Has he had a history of severe heart palpitations during physical activities or not?
  • Is there a history of connective tissue diseases such as Marfal’s syndrome in the family or not?
  • Have you ever passed out during or after exercise?
  • Do you get tired of your friends while exercising?
  • Have you ever had high blood pressure?
  • Has any doctor ever prohibited you from participating in sports for heart reasons?

In case of a positive answer to any of the above questions, it should be subjected to more detailed examinations and more complete evaluations.

In addition, medical research has proven that the cause of about 85% of the sudden deaths of athletes in sports fields is due to congenital abnormalities that have been present in their heart and blood vessels since birth and gradually develop clinical symptoms during their teenage years.


If any abnormal findings are found in the cardiovascular examination of the athlete, he should be examined for further investigations.

Required examinations are:

  • Pulse control of four organs in terms of pulse synchronicity, pulse intensity and pulse pattern
  • Paying attention to general health and body fitness that are in natural proportion with each other or not?
  • Auscultation of the heart in terms of finding any abnormal or extra sounds in the auscultation of the heart
  • Control of blood supply to the organs
  • Abdominal examination to check for any pulsatile mass in the abdomen which, if present, indicates an abnormal dilatation or aneurysm of the aorta.

Additional reviews

  • ECG at rest; To check heart rhythm, heart rate and heart rate conduction
  • Performing an exercise test (cardiogram while performing physical activity); To check the blood supply to the heart during exercise and to identify areas with reduced blood supply
  • Echocardiography: to check the function of the ventricles, the size of the heart chambers, the anatomy of the heart and the function of the heart valve
  • Holter monitoring: In this method, a 24-hour ECG will be prepared from the person.
  • Plain chest radiograph
  • Sometimes an MRI is necessary.
  • In special cases, genetic testing or electrophysiological testing is also done.
  • Abdominal ultrasound is sometimes needed to find aneurysms of vessels, especially the aorta.


Since sudden death cannot be treated and revived in many cases, the best way to prevent it is to pay attention to the signs of its risk. The best way to prevent it is regular moderate exercise, which not only does not increase the incidence of sudden death, but also significantly reduces it. Very intense, irregular and long exercise, on the contrary, increases the incidence of this. It is necessary for every person who wants to start exercising recently to have a cardiovascular examination. People who have a family history or the risk symptoms we mentioned should also be examined before exercising.

Warning: Do not ignore warning signs. Many athletes who died due to sudden death underestimated symptoms such as severe chest pain, shortness of breath, dizziness, fatigue, and irregular heartbeat during exercise and continued to exercise.

New recommendations published in the European Journal of Cardiology regarding sudden death in athletes during exercise

Dr Michael Papadakis from St George’s, University of London, UK, said: “Genetic testing is more available for a variety of fatal conditions than ever before and this document focuses on when athletes should be tested.” Athletes should be counseled about possible outcomes prior to genetic testing, as it may mean disqualification or limitation of their athletic activity.

In most cases, clinical assessment dictates the need for preventive treatment such as a defibrillator (defibrillator) and advice on exercise and participation in competitive sports. “Even if a genetic abnormality is found, recommendations for treatment and return to normal activity depend on the clinical severity of the disease,” explained Dr. Papadakis. Does it cause symptoms like fainting? Is the heart too weak or thick? Are there many heart rhythm irregularities (arrhythmias) and do they get worse during exercise? If the answer is “yes” to any of these questions, the activity is likely to be limited in some way. ”

For example: Hypertrophic cardiomyopathy (HCM) is an inherited disease that can cause sudden cardiac death in athletes, in which the heart muscle is abnormally thick. “We used to be very conservative, but now our recommendations are more liberal,” noted Dr. Papadakis. Athletes with HCM should undergo a comprehensive clinical evaluation to assess the risk of sudden cardiac death and then be offered an exercise prescription. Genetic testing in these conditions does not affect management in most cases.

Asymptomatic low-risk athletes can potentially participate in competitive sports after informed discussion with their physician. Other at-risk individuals may be limited to moderate-intensity exercise. An exercise prescription should be as specific as possible, specifying how often, for how long, at what intensity, and which exercise or sports are safe.

However, in some cases, genetic testing can dictate management. For example: Long QT syndrome (LQTS) – (a congenital disorder that can cause angina and cardiac arrest).

Identifying different genetic subtypes can determine the risk of arrhythmias (heart rhythm disorders), identify potential triggers to avoid, and help target medical treatments and plan exercise recommendations. “For example, sudden immersion in cold water is more likely to cause life-threatening arrhythmias that cause the complications mentioned above,” said Dr. Papadakis. So swimmers who have this type of syndrome should be careful.

Only in a situation that leads to the reduction or cessation of sports activity, there is a disease of the heart muscle called arrhythmogenic cardiomyopathy (ARVC) in the results of the genetic test. Dr. Papadakis said, “Even if an athlete does not have clinical evidence of the disease but has the gene for the disease, they should avoid intense and competitive sports.” This is because studies show that people with this gene who exercise at a high level develop the disease earlier and are more likely to develop it, which can cause life-threatening arrhythmias during exercise. to be

Genetic counseling should be performed prior to testing to discuss the implications for athletes and their families. For example, the athlete’s mother is clinically diagnosed with ARVC and has the causative gene that can be transferred to the athlete, then the athlete himself is screened and all his clinical tests are normal. The athlete has two choices: 1) annual clinical surveillance for signs of disease or 2) genetic testing.
Dr. Papadakis said: “The athlete should be aware that if the test is positive, it may indicate the end of his career, even if there is no clinical evidence of the disease. On the other hand, if the genetic test is rejected, the situation may worsen.

In young children clinically diagnosed with an inherited disease, genetic testing may confirm the diagnosis and, in some cases, help predict the risk of sudden death during exercise. For example, having the gene for an electrical heart defect called catecholaminergic polymorphic ventricular tachycardia (CPVT) may lead to recommendations for preventive treatments such as beta-blockers (a heart drug), and inform decisions about exercise. “This is important because CPVT predisposes to arrhythmias during exercise and can cause sudden death at a very young age,” said Dr. Papadakis. In contrast, the timing of genetic testing in children with a family history of HCM (the deadliest heart muscle disease) is controversial because it rarely causes sudden death in childhood in the absence of clinical symptoms.

last word

It is very important and important if a child in a family is active in sports and there is a hereditary disease in that family, he should be under the supervision of a doctor to find out about his condition and at what level he can continue to do sports according to his family background. .


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