Current Concepts Cardiovascular Disease in Athletes

As a physician, coach, or trainer, we see athletes as healthy, physically fit, and able to tolerate extremes of physical endurance. It seems improbable that such athletes may have, on occasion, underlying life-threatening cardiovascular abnormalities. Regular physical activity promulgates cardiovascular fitness and lowers the risk of cardiac disease. However, under intense physical exertion and with a substrate of significant cardiac disease—whether congenital or acquired— athletes may succumb to sudden cardiac death. The deaths of high-profile athletes receive much attention through the national news media, but there are also deaths of other athletes. With repetitive, intense physical exercise, the heart undergoes functional and morphologic changes. Knowledge of those changes may help one identify cardiovascular abnormalities that can cause sudden death from the heart known as an “athlete’s heart.” This article will review cardiovascular diseases that may limit an athlete’s participation in sports and that may put an athlete at risk for sudden cardiac death. It also reviews the extent and limitations of the cardiovascular preparticipation screening examination. Team physicians, coaches, and trainers must understand the process of evaluation of a symptomatic athlete that may indicate significant cardiac abnormalities. Finally, guidelines to determine eligibility of athletes with cardiovascular disease to return to sports will be reviewed. SUDDEN CARDIAC DEATH The death of an athlete from sudden cardiac collapse is a tragic event and has great impact on the family, the community, and the medical establishment. The deaths of Hank Gathers, a college basketball player, of Sergei Grinkov, a former Olympic gold medal skater, of Reggie Lewis, a professional basketball player, and of Jim Fixx, a long-distance runner and fitness advocate, have great public interest and have generated public debate. Sudden cardiac death related to sports can involve any athlete from the older, highly trained, elite athlete to the young, school-aged athlete. In each instance, the question always arises as to how someone who is physically fit and who has seemingly been screened to participate in sports can die from a cardiac abnormality. “Sudden death is defined as a witnessed or unwitnessed natural death resulting from sudden cardiac arrest occurring unexpectedly within 6 hours of a previously normal state of health.” Other definitions limit the time frame of sudden cardiac death in athletes, such as during or 1 hour after supervised or unsupervised exercise. For the purpose of this discussion, a competitive athlete is considered to be a person who participates in an organized team or individual sport in which regular competition is a component. A high priority is placed on excellence and achievement in the sport. Vigorous training in a systematic fashion is required for the sport.