new england journal
Sudden Death in Young Athletes
Barry J. Maron, M.D. The time you won your town the race We chaired you through the market-place; Man and boy stood cheering by, And home we brought you shoulder-high. To-day, the road all runners come, Shoulder-high we bring you home, And set you at your threshold down, Townsmanof a stiller town. — A.E. Housman, “To an Athlete Dying Young” (1895)
From the Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis. Address reprint requests to Dr. Maron at the Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, 920 E. 28th St., Suite 60, Minneapolis, MN 55407, or at hcm. firstname.lastname@example.org. N Engl J Med 2003;349:1064-75.Copyright © 2003 Massachusetts Medical Society.
oung athletes have come to be regarded as a special part of society, owing to their unique lifestyle and the widely held perception that they epitomize health and invulnerability, capable as they are of admirable and sometimes extraordinary physical achievements.1-3 Indeed, the possibility that young, highly trained high-school, college, or evenprofessional athletes may harbor potentially lethal heart disease or be susceptible to sudden death under a variety of circumstances4-26 seems counterintuitive. Nevertheless, such sudden cardiac catastrophes continue to occur, usually in the absence of prior symptoms, and they have a considerable emotional and social impact on the lay public and physician community. Attempts to understand the causesof such events have triggered considerable interest in differentiating physiologic athlete’s heart from structural cardiovascular disease,27 as well as in developing preparticipation screening strategies14 and formulating disqualification criteria15 aimed at preventing sudden death in young athletes.
the magnitude of the problem
The precise frequency with which sudden death occurs inyoung athletes (those under 35 years of age) remains unresolved. In Minnesota, the annual incidence of sudden death due to undiagnosed cardiovascular disease is reported to be about 1 in 200,000 high-school athletes participating in organized sports.16 However, such data are limited, and the magnitude of this public health problem may be considerably underestimated. Regardless of prevalence, when anathlete dies suddenly, the substantial social and emotional effect on the community is largely due to the youth, apparent good health, and lost potential of the athlete. Once regarded as personal and family tragedies, the unexpected death of an athlete now often becomes part of the public discourse and is fueled by media.
n engl j med 349;11
september 11, 2003Downloaded from www.nejm.org on September 15, 2003. This article is being provided free of charge for use in Argentina: NEJM Sponsored. Copyright © 2003 Massachusetts Medical Society. All rights reserved.
cardiovascular causes of sudden death
Although the overall population of athletes is at generally low risk for sudden death,5,16 a number of largely congenital but clinicallyunsuspected cardiovascular diseases have been causally linked to sudden death in young trained athletes, usually in association with physical exertion.3-12,17 In large autopsy-based surveys of populations of athletes in the United States, hypertrophic cardiomyopathy has consistently been the single most common cardiovascular cause of sudden death (Table 1), accounting for about one third of theseevents in prior reports.6 Hypertrophic cardiomyopathy, characterized by an asymmetrically hypertrophied and nondilated left ventricle, is a relatively common genetic cardiac disease (with an incidence of 1 in 500 persons in the general population),29 with heterogeneous clinical, morphologic, and genetic expression29-31 (Fig. 1A). Sudden death is probably a consequence of an electrically...