The issue of sudden death in young athletes and consideration for the most practical and optimal strategy to identify those genetic and/or congenital heart diseases responsible for these tragic events continues to be debated. However, proponents of broad-based and mandatory national preparticipation screening, including with 12-lead electrocardiograms have confined the focus to a relatively small segment of the youthful population who choose to engage in competitive athletic programs at the high school, college, and elite-professional level. Therefore, lost in this discussion of preparticipation screening of athletes is that the larger population of young people not involved in competitive sports (and, therefore, a priori are excluded from systematic screening) who nevertheless may die suddenly of the same cardiovascular diseases as athletes. To substantiate this hypothesis, we accessed the forensic Hennepin County, Minnesota registry in which cardiovascular sudden deaths were 8-fold more common in nonathletes (n = 24) than athletes (n = 3) and threefold more frequent in terms of incidence. The most common diseases responsible for sudden death were hypertrophic cardiomyopathy (n = 6) and arrhythmogenic right ventricular cardiomyopathy (n = 4). These data raise ethical considerations inherent in limiting systematic screening for unsuspected genetic and/or congenital heart disease to competitive athletes.
Screening healthy general populations for cardiovascular disease has become a topic of considerable interest, triggered by the high visibility afforded sudden deaths in young competitive athletes. Attention directed toward these often highly visible and public events may have created the misconception that sudden deaths in high school and college-aged subjects occur predominantly (or even exclusively) in student-athletes.
A debate has emerged concerning the most effective strategy for identifying the unsuspected genetic and/or congenital diseases responsible for these tragic events. Should systematic screening be confined to those who choose to engage in competitive sports, or should nonathletes (who can harbor the same potentially lethal cardiovascular diseases as athletes) be included in this process? We have addressed this highly relevant issue for the ongoing preparticipation screening conversation by interrogating a large forensic database for the frequency of genetic and/or congenital cardiovascular diseases causing sudden death in trained athletes versus young people not engaged in organized sports programs.
Methods
We accessed the case records of the Medical Examiner of Hennepin County, the largest of the 87 Minnesota counties, representing the Minneapolis metropolitan area. Hennepin County includes 1,198,778 residents (23% of the state); all sudden deaths <40 years of age undergo complete autopsy and toxicologic studies. The database was assessed to identify naturally occurring sudden cardiovascular deaths, age 14 to 23 years, 2000 to 2014. In addition to the Medical Examiner evaluation, gross and histopathologic cardiac examinations were conducted by expert cardiovascular pathologists at the Jesse E. Edwards Registry (Saint Paul, Minnesota; ERD, AMB, SM-B).
A competitive student-athlete in organized high school and college sports programs was defined as: one who participates in an organized team or individual sport that requires regular competition against others as a central component, places a high premium on excellence and achievement, and requires some form of systematic (and usually intense) training.
To calculate the relative incidence of competitive athlete versus nonathlete events, we constructed the size of at-risk populations within Hennepin County, 2000 to 2014, from publically available data. Specifically, this included total student enrollment in those high schools (n = 131) and colleges (n = 4) with athletic programs that practice some measure of preparticipation screening for athletes, usually history and physical examination. In Hennepin County, athlete participation rates for individual colleges and high schools were estimated by using combined data from the National Center for Educational Statistics and the Minnesota State High School League Sponsored Activity Participation Survey.
Results
During the 15-year study period, 39 cases of sudden death with virtually instantaneous collapse were identified. Twelve were excluded because of confounding toxicology results or a known history of congenital heart disease. Therefore, 27 sudden deaths due to a variety of cardiovascular diseases constitute the final study group ( Table 1 ). Ages were 14 to 23 years; 22 (81%) were men. Seventeen decedents were white, 8 were black, and one each was Hispanic or Asian.
| No. | Age/Gender | Race | Diagnosis | Circumstances of Death |
|---|---|---|---|---|
| NON-ATHLETES | ||||
| 1 | 22 M | W | CAD – LAD 75% | After coaching |
| 2 | 21 M | B | CAD – proximal LAD 75% | Sedentary (bed) |
| 3 | 20 M | B | CAD – LAD 75% (thrombus) | Sedentary (home) |
| 4 | 23F | B | RCA thrombus with posterior LV infarct | Home |
| 5 | 21 F | W | Fibromuscular dysplasia | Sedentary (home) |
| 6 | 21 F | W | HC; 405g/LV: 18 mm ∗ | After bath |
| 7 | 19 M | W | HC; 520g/LV: 19 mm | Driving |
| 8 | 23 M | H | HC; 440g/LV: 17 mm ∗ | Sedentary (home) |
| 9 | 23 M | W | HC; 530g/LV: 18 mm | Sedentary (bed) |
| 10 | 23 M | B | Probable HC; 400 g; LV: 16mm | Sedentary (bed) |
| 11 | 20 M | W | Morbid obesity; 640g/LV: 17 mm † | Sedentary (bed) |
| 12 | 14 M | W | ARVC | Sedentary (home) |
| 13 | 23 M | W | ARVC | Home |
| 14 | 22 M | B | ARVC | Standing at bus stop |
| 15 | 21 M | W | ARVC | Bathroom after practice |
| 16 | 15 F | B | Anomalous origin of LCA from right sinus | Sedentary |
| 17 | 19 M | W | Structurally normal heart: 346 g | Carrying luggage |
| 18 | 23 F | W | Structurally normal heart: 266 g | Bedroom |
| 19 | 23 M | W | Structurally normal heart: 450 g | Bedroom |
| 20 | 22 M | A | Structurally normal heart: 375 g | Bedroom |
| 21 | 21 M | W | Structurally normal heart: 340 g | Bedroom |
| 22 | 23 M | W | Ruptured aorta (dissection) | Sedentary (at work) |
| 23 | 22 M | W | Ruptured aorta (coarctation) | Sedentary (bed) |
| 24 | 19 M | W | Acute myocarditis | Bathroom |
| ATHLETES | ||||
| 25 | 22 M | B | HC; 510g; LV: 19 mm | Sedentary (dormitory) |
| 26 | 17 M | B | Anomalous origin of LCA from right sinus | Playing basketball |
| 27 | 19 M | W | Structurally normal heart: 448 g | In bed |
∗ Histopathology shows myocyte disarray.
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