The sudden death of a competitive athlete inevitably becomes an occasion for local if not national publicity. On each occasion, the public and the medical community ask whether such events could be prevented by more careful or complete screening. Although each event is tragic, it must be appreciated that there are approximately 5 million competitive athletes at the high school level or above in any given year.

The number of cardiac deaths occurring during athletic participation is unknown, but estimates at the high school level range from one in 300,000 to one in 100,000 participants. Death rates among more mature athletes increase as the prevalence of coronary artery disease rises. These numbers highlight the problem of how to screen individual participants. Even an inexpensive test such as an ECG would generate an enormous cost if required of all athletes, and it is likely that few at-risk individuals would be detected. Echocardiography, either as a routine test or as a follow-up examination for abnormal ECGs, would be prohibitively expensive.

Thus, the most feasible approach is that of a careful medical history and cardiac examination performed by personnel aware of the conditions responsible for most sudden deaths in competitive athletes.

In a series of 158 athletic deaths in the United States between 1985 and 1995, hypertrophic cardiomyopathy (36%) and coronary anomalies (19%) were by far the most frequent underlying conditions. Left ventricular hypertrophy was present in another 10%, ruptured aorta (presumably due to Marfan’s syndrome or cystic medial necrosis) in 6%, myocarditis or dilated cardiomyopathy in 6%, aortic stenosis in 4%, and arrhythmogenic right ventricular dysplasia in 3%.

It is likely that a careful family and medical history and cardiovascular examination will identify some individuals at risk. A family history of premature sudden death or cardiovascular disease or of any of these predisposing conditions should mandate further workup, including an echocardiogram and ECG. Symptoms of chest pain, syncope, or near-syncope also warrant further evaluation. A Marfan-like appearance, significant elevation of blood pressure or abnormalities of heart rate or rhythm, and pathologic heart murmurs or heart sounds should also be investigated before clearance for athletic participation is given. Such an evaluation is recommended before participation at the high school and college levels and every 2 years during athletic competition. Selective use of routine electrocardiography and stress testing is recommended in men above age 40 years and women above age 50 years who continue to participate in vigorous exercise and at earlier ages when there is a positive family history for premature coronary artery disease or multiple risk factors.

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