Heart Disease in the Young Athlete

Author: Michele D. Pescasio,M.D.

Sudden death in the young athlete is rare, estimated at one out of 100,000 to 300,000 per year. The occurrence is approximately 12 per year in high school athletes, with a male predominance. An underlying cardiovascular disease that is usually asymptomatic and undiagnosed is responsible for most of these tragic events.

The majority of sudden deaths are due to congenital cardiac malformations. Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden, unexpected cardiac death among 12-32 year olds on the athletic field. The risk of sudden death increases until the third decade of life. Unfortunately, there are usually no symptoms prior to sudden death. Diagnosis is difficult because heart-related changes due to HCM might not be present and identifiable until adolescence.

The second most common cause of sudden death is congenital coronary artery anomalies. These arteries supply blood to the heart. Sudden death may be the first sign of this condition and is usually precipitated by exercise. Approximately 25 percent may experience symptoms in the form of palpitations (heart flutter) and/or syncope (passing out).

Other causes of sudden death include:

Myocarditis
An inflammation of the heart.
Mitral valve prolapse (MVP)
Very common. Risk factors are:
- Family history,
- Recurrent syncopal or passing out episodes,
- Prolonged QT interval on EKG,
- Marked physical changes in the mitral valve and moderate-to-severe mitral regurgitation (leaky valve), and
- History of embolic events (throwing blood clots).
Wolff-Parkinson-White syndrome
A pre-excitation syndrome where individuals are susceptible to fast, irregular heart beats.
Arrhythmogenic right ventricular dysplasia
A rare muscle disorder of the right ventricle of the heart.
Marfan syndrome

Long QT syndrome
Is predominantly a hereditary disorder diagnosed by EKG changes. It usually occurs in patients with a history of recurrent syncope.
Undiagnosed sudden death
This condition requires comprehensive cardiovascular testing to exclude structural cardiac diseases that can lead to sudden death.

The athlete's personal and family history is of critical importance. Detection of some of the conditions known to cause sudden death in athletes is very difficult. Frequently, the family history is the only risk factor. Factors that would place an athlete at an increased risk for sudden death are a family history of premature death, significant health problems from cardiovascular disease in close relatives younger than 50 years of age, or if anyone in the family had these conditions. Parents should be responsible for completing the history forms for young athletes.

The personal history should include prior occurrences of chest pain on exertion, passing out during physical activity, and excessive shortness of breath or fatigue during exercise. A personal history of congenital or acquired heart disease, hypertension, murmurs or palpitations should be noted.

The cardiovascular exam should include, but is not limited to, blood pressure measurements, listening to the heart in at least two positions (sitting/lying or sitting/standing), assessing the femoral artery, and recognizing the physical signs of Marfan syndrome.

The American Heart Association recommends that both a history and a physical exam be performed before participation in organized high school and collegiate sports. It is also recommended that athletic screening be performed by a healthcare worker with the requisite training, medical skills, and background to reliably obtain a detailed cardiovascular history, perform a physical examination, and recognize heart disease. When cardiovascular abnormalities are identified or suspected, the athlete should be referred to a cardiovascular specialist for further evaluation or confirmation.

Finally, despite all of the precautions to prevent sudden cardiac death in young athletes, there are limitations to preparticipation screening. Due to the rarity of these conditions, mass screening is neither practical nor cost-effective. In conclusion, it is virtually impossible to achieve a zero-risk circumstance in competitive sports.