An estimated 0.2 to 2 per 100,000 apparently healthy young athletes die suddenly during exercise each year (1). Males are affected up to 10 times more often than females (1). Basketball and football players in the United States and soccer players in Europe may be at highest risk (1, 2). It is estimated that in athletes ≤ 35 years old, 1 in 300 have a condition associated with sudden cardiac arrest and death.
Etiology
In young athletes (typically those < 35 years of age), sudden cardiac death has many causes (see table ). Data show that the majority of sudden cardiac deaths occur in patients whose hearts are found to be structurally normal during autopsy (1, 3, 4), representing in many cases an inherited arrhythmia syndrome (eg, long QT syndrome, Brugada syndrome).
Some Causes of Sudden Cardiovascular Death in Young Athletes
Commotio cordis |
Coronary artery anomalies (eg, anomalous left main coronary artery origin, anomalous right coronary artery origin, coronary arterial hypoplasia) |
Ruptured aortic aneurysm |
Tunneled left anterior descending coronary artery |
Premature atherosclerotic coronary artery disease |
Myxomatous degeneration of mitral valve |
Wolff-Parkinson-White syndrome (anterograde conduction only) |
Right ventricular outflow tract tachycardia |
Cardiac trauma |
Ruptured cerebral artery aneurysm |
Commotio cordis (sudden ventricular tachycardia or fibrillation after a blow to the precordium) is a risk in athletes with thin, compliant chest walls even when no cardiovascular disorder is present. The blow may involve a moderate-force projectile (eg, baseball, hockey puck, lacrosse ball) or impact with another player during a vulnerable phase of myocardial repolarization.
Structural heart disease with an arrhythmogenic component (eg, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) are also important causes of sudden cardiac death (3). Some young athletes die of aortic aneurysm rupture (in Marfan syndrome).
In older athletes, sudden cardiac death is typically caused by:
Occasionally, hypertrophic cardiomyopathy or valvular disease is involved.
In other conditions underlying sudden death in athletes (eg, asthma, heatstroke, complications related to use of illicit or performance-enhancing drugs), the development of ventricular tachycardia or ventricular fibrillation is a terminal, not a primary, event.
Presentation
Symptoms and signs are those of cardiovascular collapse; diagnosis is obvious.
Treatment, prognosis, and prevention
Immediate recognition and treatment of cardiac arrest are critical; with prompt cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, survival rates are currently in the range of 80 to 90% range (1).
For survivors, treatment is management of the underlying condition. In some cases, an implanted cardioverter-defibrillator may ultimately be required.
Prevention of sudden cardiac death is with a multi-pronged and community-based approach, including comprehensive pre-participation screening, CPR training, AED availability, and emergency action plans for athletic venues (4).
References
1. Lampert R, Harmon KG. Sudden Cardiac Arrest in Athletes. N Engl J Med. 2026;394(3):268-280. doi:10.1056/NEJMra2312555
2. Maron BJ, Haas TJ, Ahluwalia A, et al. Demographics and epidemiology of sudden deaths in young competitive athletes: From the United States National Registry. Am J Med. 2016;129(11):1170-1177. doi: 10.1016/j.amjmed.2016.02.031
3. Kim JH, Martinez MW, Guseh JS, et al. A contemporary review of sudden cardiac arrest and death in competitive and recreational athletes. Lancet. 2024;404(10468):2209-2222. doi:10.1016/S0140-6736(24)02086-5
4. Kim JH, Baggish AL, Levine BD, et al. Clinical Considerations for Competitive Sports Participation for Athletes With Cardiovascular Abnormalities: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation. 2025;151(11):e716-e761. doi:10.1161/CIR.0000000000001297
Key Points
Sudden cardiac death during exercise is rare but impactful.
In athletes ≤ 35 years, autopsy-negative sudden unexplained death is the most common cause.
In athletes > 35 years, coronary artery disease is the prominent cause.
