VIEWPOINT Sudden Cardiac Death in Sports: Not a Fatality!

Sudden cardiac death in sports is still controversial. Despite being a rare event, the death of an apparently healthy young athlete causes a major impact on the media. On the other hand, for being a rare event, it is clearly undervalued. Sports preparticipation cardiological assessment is one of the most effective preventive medical actions for professional and amateur endurance athletes. The regular and supervised practice of physical exercise does not kill. We believe that deaths are triggered by excessive physical training and use of drugs, in individuals with not diagnosed or undervalued heart diseases. It is necessary to make health professionals and athletes aware of the athletes’ physiological limits, in addition to preparing the athletes properly when they try to overcome human limits.


Introduction
Sudden death in sports is still a controversial topic among those who consider the death of an apparently healthy young individual a severe fact, with a strong media repercussion, and those who consider it a less relevant fact from the epidemiological viewpoint. That discussion is common among physicians and even among other health professionals.
We consider the sudden death of a young athlete a paradox: the symbol of health and physical vitality, experienced in a certain sports modality, suffers a cardiac arrest followed by sudden death when is not recovered. 1 We cannot agree that it is a mere fatality, a condition mainly dependent on environmental factors such as accidents, lightening and floods, not on diseases.
In 2006, the International Olympic Committee, in Lausanne, Switzerland, reported data about sudden cardiac death in young athletes (< 35 years) from 1966 to 2004: 1,101 deaths were officially recorded worldwide, an incidence average of 29 athletes per year. 2 At the beginning of 2018, the incidence of sudden death in professional and amateur athletes increased, taking everyone by surprise. Thirteen deaths were confirmed and 9 occurred in Brazil, including those of a 15-year-old soccer player and of a 37-year-old triathlete.
Among these deaths, only 3 had a definitive diagnosis after postmortem examination and DNA gene profile testing: 1 arrhythmogenic death syndrome (probable Brugada syndrome), 1 obstructive hypertrophic cardiomyopathy and 1 early coronary atherosclerotic disease. The other cases evidenced no macroscopic findings, but microscopy and laboratory tests to define the diagnosis are still pending. Some hypotheses are being analyzed and myocardial fibrosis due to high intensity and volume training leading to malignant arrhythmias may be a possible cause of death.
In order to prevent sudden cardiac death in athletes, in the 1970s-1980s the Medical Section of Sports Cardiology of the Instituto Dante Pazzanese de Cardiologia (IDPC-USP) initiated pre-participation evaluation of professional and amateur athletes of the major teams in São Paulo such as soccer, basketball and volleyball players, street runners and martial arts fighters, following a routine that is currently part of the Brazilian guidelines of Sports Cardiology for competitive athletes: personal and family history, physical examination, blood tests, exercise test and echocardiography. 3  Professional and amateur athletes of competitive sports should undergo preparticipation cardiovascular screening, an effective preventative strategy to avoid sudden death in sports, an event considered paradoxical because it occurs in a trained individual, a symbol of health, an example to the entire society. To corroborate our statement, we have statistical data from our Service of Sports Cardiology of the IDPC with approximately 14,000 athletes and ex-athletes cared for in the past 40 years, in addition to those from the Sports Medicine Clinic (ex-Sport Check-up HCor) of the Hospital do Coração (HCor), with approximately 1,000 athletes assessed in 10 years, mainly from 4 São Paulo State premier league teams. 4