Towards safer sport: modern perspectives on cardiovascular screening for the prevention of sudden cardiac death in athletes
DOI:
https://doi.org/10.12775/QS.2025.47.66667Keywords
sudden cardiac death, athletes, screening, arrythmias, electrocardiography, cardiovascular preventionAbstract
Background: Sudden cardiac death (SCD), defined as an unexpected fatal event within 1 hour of symptom onset (witnessed) or 24 hours (unwitnessed), is a leading cause of sport-related mortality, even in apparently healthy athletes. True incidence remains unclear due to variable definitions, reporting heterogeneity, and diagnostic limitations. Understanding mechanisms and risk factors is essential for effective screening and prevention.
Aim: This review examines cardiac anomaly screening in athletes, focusing on optimal modalities, target groups, and economic considerations. It also synthesizes evidence on epidemiology, structural and physiological risk factors, prevention strategies, and knowledge gaps.
Methods: A narrative review of PubMed and Google Scholar included original research, reviews, meta-analyses, and guidelines. Studies were analyzed for epidemiology, risk factors, pathomechanisms, and prevention strategies to provide an integrated overview.
Results: SCD etiology and risk profiles are heterogeneous, limiting universal screening. ECG use remains debated due to cost and false results. Questionnaires and physical exams are widely recommended, but advanced diagnostics face financial and logistical constraints. Reporting inconsistencies, variable athlete definitions, and resource disparities complicate implementation.
Conclusions: SCD in athletes arises from diverse cardiovascular disorders, making universal screening difficult. Evidence supports context-dependent, targeted strategies that balance feasibility, equity, and risk reduction.
References
1. Kumar A, Avishay DM, Jones CR, et al. Sudden cardiac death: epidemiology, pathogenesis and management. Rev Cardiovasc Med. 2021;22(1):147-158. doi:10.31083/j.rcm.2021.01.207
2. Ghani U, Farooq O, Alam S, Khan MJ, Rahim O, Rahim S. Sudden Cardiac Death in Athletes: Consensuses and Controversies. Cureus. 2023;15(6):e39873. Published 2023 Jun 2. doi:10.7759/cureus.39873
3. Markwerth P, Bajanowski T, Tzimas I, Dettmeyer R. Sudden cardiac death-update. Int J Legal Med. 2021;135(2):483-495. doi:10.1007/s00414-020-02481-z
4. Harmon KG, Drezner JA, Wilson MG, Sharma S. Incidence of sudden cardiac death in athletes: a state-of-the-art review. Heart. 2014;100(16):1227-1234. doi:10.1136/heartjnl-2014-093872.rep
5. DeFroda SF, McDonald C, Myers C, Cruz AI, Owens BD, Daniels AH. Sudden Cardiac Death in the Adolescent Athlete: History, Diagnosis, and Prevention. Am J Med. 2019;132(12):1374-1380. doi:10.1016/j.amjmed.2019.05.025
6. Finocchiaro G, Westaby J, Sheppard MN, Papadakis M, Sharma S. Sudden Cardiac Death in Young Athletes: JACC State-of-the-Art Review. J Am Coll Cardiol. 2024;83(2):350-370. doi:10.1016/j.jacc.2023.10.032
7. Egger F, Scharhag J, Kästner A, Dvořák J, Bohm P, Meyer T. FIFA Sudden Death Registry (FIFA-SDR): a prospective, observational study of sudden death in worldwide football from 2014 to 2018. Br J Sports Med. 2022;56(2):80-87. doi:10.1136/bjsports-2020-102368
8. Banner J, Basso C, Tolkien Z, Kholova I, Michaud K, Gallagher PJ. Autopsy examination in sudden cardiac death: a current perspective on behalf of the Association for European Cardiovascular Pathology. Virchows Arch. 2021;478(4):687-693. doi:10.1007/s00428-020-02949-8
9. Petek BJ, Churchill TW, Moulson N, et al. Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A 20-Year Study. Circulation. 2024;149(2):80-90. doi:10.1161/CIRCULATIONAHA.123.065908
10. Corrado D, Basso C, Pavei A, Michieli P, Schiavon MTG. Trends in Sudden Cardiovascular Death in Young Competitive Athletes. JAMA (2006);296, 1593–1601.
11. Steinvil A, Chundadze T, Zeltser D, et al. Mandatory electrocardiographic screening of athletes to reduce their risk for sudden death proven fact or wishful thinking?. J Am Coll Cardiol.
12. Li L, Le Douairon Lahaye S, Ding S, Schnell F. Sex Differences in the Incidence of Sudden Cardiac Arrest/Death in Competitive Athletes: A Systematic Review and Meta-analysis. Sports Med. 2025;55(3):697-712. doi:10.1007/s40279-024-02163-5
13. Finocchiaro G, Westaby J, Bhatia R, et al. Sudden Death in Female Athletes: Insights From a Large Regional Registry in the United Kingdom. Circulation. 2021;144(22):1827-1829. doi:10.1161/CIRCULATIONAHA.121.055535
14. Finocchiaro G, Dhutia H, D'Silva A, et al. Effect of Sex and Sporting Discipline on LV Adaptation to Exercise. JACC Cardiovasc Imaging. 2017;10(9):965-972. doi:10.1016/j.jcmg.2016.08.011
15. Haukilahti MAE, Holmström L, Vähätalo J, et al. Sudden Cardiac Death in Women. Circulation. 2019;139(8):1012-1021. doi:10.1161/CIRCULATIONAHA.118.037702
16. Drici MD, Burklow TR, Haridasse V, Glazer RI, Woosley RL. Sex hormones prolong the QT interval and downregulate potassium channel expression in the rabbit heart. Circulation. 1996;94(6):1471-1474. doi:10.1161/01.cir.94.6.1471
17. Cavasin MA, Sankey SS, Yu AL, Menon S, Yang XP. Estrogen and testosterone have opposing effects on chronic cardiac remodeling and function in mice with myocardial infarction. Am J Physiol Heart Circ Physiol. 2003;284(5):H1560-H1569. doi:10.1152/ajpheart.01087.2002
18. Corrado D, Basso C, Schiavon M, Thiene G. Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med. 1998;339(6):364-369. doi:10.1056/NEJM199808063390602
19. Yanai O, Phillips ED, Hiss J. Sudden cardiac death during sport and recreational activities in Israel. J Clin Forensic Med. 2000;7(2):88-91. doi:10.1054/jcfm.2000.0374
20. Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden death in adolescents and young adults?. J Am Coll Cardiol. 2003;42(11):1959-1963. doi:10.1016/j.jacc.2003.03.002
21. Drezner JA, Rao AL, Heistand J, Bloomingdale MK, Harmon KG. Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation. 2009;120(6):518-525. doi:10.1161/CIRCULATIONAHA.109.855890
22. Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of sudden cardiac death in National Collegiate Athletic Association athletes. Circulation. 2011;123(15):1594-1600. doi:10.1161/CIRCULATIONAHA.110.004622
23. Pelliccia A, Maron BJ, Spataro A, Proschan MA, Spirito P. The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes. N Engl J Med. 1991;324(5):295-301. doi:10.1056/NEJM199101313240504
24. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation. 2009;119(8):1085-1092. doi:10.1161/CIRCULATIONAHA.108.804617
25. Maron BJ. Structural features of the athlete heart as defined by echocardiography. J Am Coll Cardiol. 1986;7(1):190-203. doi:10.1016/s0735-1097(86)80282-0
26. Sheikh N, Papadakis M, Schnell F, et al. Clinical Profile of Athletes With Hypertrophic Cardiomyopathy. Circ Cardiovasc Imaging. 2015;8(7):e003454. doi:10.1161/CIRCIMAGING.114.003454
27. Malhotra A, Sharma S. Hypertrophic Cardiomyopathy in Athletes. Eur Cardiol. 2017;12(2):80-82. doi:10.15420/ecr.2017:12:1
28. Kochi AN, Vettor G, Dessanai MA, Pizzamiglio F, Tondo C. Sudden Cardiac Death in Athletes: From the Basics to the Practical Work-Up. Medicina (Kaunas). 2021;57(2):168. Published 2021 Feb 14. doi:10.3390/medicina57020168
29. de Noronha SV, Sharma S, Papadakis M, Desai S, Whyte G, Sheppard MN. Aetiology of sudden cardiac death in athletes in the United Kingdom: a pathological study. Heart. 2009;95(17):1409-1414. doi:10.1136/hrt.2009.168369
30. Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G. Does sports activity enhance the risk of sudden death in adolescents and young adults?. J Am Coll Cardiol. 2003;42(11):1959-1963. doi:10.1016/j.jacc.2003.03.002
31. Gomez AT, Prutkin JM, Rao AL. Evaluation and Management of Athletes With Long QT Syndrome. Sports Health. 2016;8(6):527-535. doi:10.1177/1941738116660294
32. Schwartz PJ, Priori SG, Spazzolini C, et al. Genotype-phenotype correlation in the long-QT syndrome: gene-specific triggers for life-threatening arrhythmias. Circulation. 2001;103(1):89-95. doi:10.1161/01.cir.103.1.89
33. Kapplinger JD, Tester DJ, Salisbury BA, et al. Spectrum and prevalence of mutations from the first 2,500 consecutive unrelated patients referred for the FAMILION long QT syndrome genetic test. Heart Rhythm. 2009;6(9):1297-1303. doi:10.1016/j.hrthm.2009.05.021
34. Kastellanos S, Aznaouridis K, Vlachopoulos C, Tsiamis E, Oikonomou E, Tousoulis D. Overview of coronary artery variants, aberrations and anomalies. World J Cardiol. 2018;10(10):127-140. doi:10.4330/wjc.v10.i10.127
35. Han J, Lalario A, Merro E, et al. Sudden Cardiac Death in Athletes: Facts and Fallacies. J Cardiovasc Dev Dis. 2023;10(2):68. Published 2023 Feb 5. doi:10.3390/jcdd10020068
36. Bohm P, Scharhag J, Meyer T. Data from a nationwide registry on sports-related sudden cardiac deaths in Germany. Eur J Prev Cardiol. 2016;23(6):649-656. doi:10.1177/2047487315594087
37. Schulz-Menger J, Collini V, Gröschel J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J. 2025;46(40):3952-4041. doi:10.1093/eurheartj/ehaf192
38. Harmon KG, Asif IM, Maleszewski JJ, et al. Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review. Circulation. 2015;132(1):10-19. doi:10.1161/CIRCULATIONAHA.115.015431
39. Vassalini M, Verzeletti A, Restori M, De Ferrari F. An autopsy study of sudden cardiac death in persons aged 1-40 years in Brescia (Italy). J Cardiovasc Med (Hagerstown). 2016;17(6):446-453. doi:10.2459/JCM.0000000000000234
40. Eichhorn C, Bière L, Schnell F, et al. Myocarditis in Athletes Is a Challenge: Diagnosis, Risk Stratification, and Uncertainties. JACC Cardiovasc Imaging. 2020;13(2 Pt 1):494-507. doi:10.1016/j.jcmg.2019.01.039
41. Bhatia A, Sra J, Akhtar M. Preexcitation Syndromes. Curr Probl Cardiol. 2016;41(3):99-137. doi:10.1016/j.cpcardiol.2015.11.002
42. Molinari M, Setti S, Brunetti ND, Di Nunno N, Alberta Cattabiani M, Molinari G. Different patterns of pre-excitation in a large Italian cohort of asymptomatic non-competitive athletes evaluated by telecardiology screening: Prevalence and ECG features. Int J Cardiol Heart Vasc. 2024;55:101553. Published 2024 Nov 12. doi:10.1016/j.ijcha.2024.101553
43. Obeyesekere MN, Leong-Sit P, Massel D, et al. Risk of arrhythmia and sudden death in patients with asymptomatic preexcitation: a meta-analysis. Circulation. 2012;125(19):2308-2315. doi:10.1161/CIRCULATIONAHA.111.055350
44. Tester DJ, Ackerman MJ. The role of molecular autopsy in unexplained sudden cardiac death. Curr Opin Cardiol. 2006;21(3):166-172. doi:10.1097/01.hco.0000221576.33501.83
45. Mont L, Pelliccia A, Sharma S, et al. Pre-participation cardiovascular evaluation for athletic participants to prevent sudden death: Position paper from the EHRA and the EACPR, branches of the ESC. Endorsed by APHRS, HRS, and SOLAECE. Eur J Prev Cardiol. 2017;24(1):41-69.
46. Ljungqvist A, Jenoure P, Engebretsen L, et al. The International Olympic Committee (IOC) Consensus Statement on periodic health evaluation of elite athletes March 2009. Br J Sports Med. 2009;43(9):631-643. doi:10.1136/bjsm.2009.064394
47. Maron BJ, Levine BD, Washington RL, Baggish AL, Kovacs RJ, Maron MS. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol. 2015;66(21):2356-2361. doi:10.1016/j.jacc.2015.09.034
48. Drezner JA, O'Connor FG, Harmon KG, et al. AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current evidence, knowledge gaps, recommendations and future directions. Br J Sports Med. 2017;51(3):153-167. doi:10.1136/bjsports-2016-09678
49. Sarto P, Zorzi A, Merlo L, et al. Value of screening for the risk of sudden cardiac death in young competitive athletes. Eur Heart J. 2023;44(12):1084-1092. doi:10.1093/eurheartj/ehad017
50. Corrado D, Migliore F, Bevilacqua M, Basso C, Thiene G. Sudden cardiac death in athletes: can it be prevented by screening?. Herz. 2009;34(4):259-266. doi:10.1007/s00059-009-3236-3
51. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation. 2007;115(12):. doi:10.1161/CIRCULATIONAHA.107.181423
52. Bille K, Figueiras D, Schamasch P, et al. Sudden cardiac death in athletes: the Lausanne Recommendations. Eur J Cardiovasc Prev Rehabil. 2006;13(6):859-875. doi:10.1097/01.hjr.0000238397.50341.4a
53. MacDonald J, Schaefer M, Stumph J. The Preparticipation Physical Evaluation. Am Fam Physician. 2021;103(9):539-546.
54. Maron BJ, Friedman RA, Kligfield P, et al. Assessment of the 12-lead electrocardiogram as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology. J Am Coll Cardiol. 2014;64(14):1479-1514. doi:10.1016/j.jacc.2014.05.006
55. Madsen NL, Drezner JA, Salerno JC. Sudden cardiac death screening in adolescent athletes: an evaluation of compliance with national guidelines. Br J Sports Med. 2013;47(3):172-177. doi:10.1136/bjsports-2012-091670
56. Harmon KG, Zigman M, Drezner JA. The effectiveness of screening history, physical exam, and ECG to detect potentially lethal cardiac disorders in athletes: a systematic review/meta-analysis. J Electrocardiol. 2015;48(3):329-338. doi:10.1016/j.jelectrocard.2015.02.001
57. Lawless CE, Erickson C, Kugler J, Albers L, Lawton D., Marx D, & Krueger S. UNDER-UTILIZATION OF MAJOR ATHLETE SCREENING AND PARTICIPATION GUIDELINES: AN OPPORTUNITY FOR IMPROVEMENT. Journal of the American College of Cardiology, 2014; 63(12S), A1665-A1665.
58. Emery MS, Kovacs RJ. Sudden Cardiac Death in Athletes. JACC Heart Fail. 2018;6(1):30-40. doi:10.1016/j.jchf.2017.07.014
59. Dhutia H, MacLachlan H. Cardiac Screening of Young Athletes: a Practical Approach to Sudden Cardiac Death Prevention. Curr Treat Options Cardiovasc Med. 2018;20(10):85. Published 2018 Aug 28. doi:10.1007/s11936-018-0681-4
60. Sharma S, Pelliccia A, Gati S. The 'Ten Commandments' for the 2020 ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease. Eur Heart J. 2021;42(1):6-7. doi:10.1093/eurheartj/ehaa735
61. Corrado D, Pelliccia A, Bjørnstad HH, et al. Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005;26(5):516-524. doi:10.1093/eurheartj/ehi108
62. Maron BJ, Levine BD, Washington RL, et al. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 2: Preparticipation Screening for Cardiovascular Disease in Competitive Athletes: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation. 2015;132(22):e267-e272. doi:10.1161/CIR.000000000000023.
63. Mavrogeni SI, Bacopoulou F, Apostolaki D, Chrousos GP. Sudden cardiac death in athletes and the value of cardiovascular magnetic resonance. Eur J Clin Invest. 2018;48(7):e12955. doi:10.1111/eci.12955
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Copyright (c) 2025 Maria Sudomir, Maciej Michałowski, Krystyna Wilkowska, Wojciech Kaczorowski, Karol Knysak, Alicja Maj, Mateusz Szczerba, Aleksandra Hejnosz, Michał Jastrzębski, Maja Piątek
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