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Courtney Moore March 17, 2014 Professor Wolcott ENC 1102 Annotated Bibliography: Sudden cardiac death among athletes Ive decided to look into is a typical controversial topic of death that can take place among athletes. This occurrence is referred to as sudden cardiac death (SCD) and is usually rare. Although rare, it is none the less a frightening event to witness. This conversation is important because with the addition of existing technology and eventually future improvements and further d advances into the medical field perhaps one day we can prevent SCD from happening at all. It is also important because it is informational to many people including but not limited to: patients, athletes, doctors, coaches, trainers, and parents. It may also be helpful to any college students who may take an interest in the cardiovascular subject and want to gather further information about sudden cardiac death in athletes. SCD can be due to a number of pre-existing cardiac disease and underlying heart defects. Physicians have thought to have narrowed down the causes to two specific diseases: hypertrophic cardiomyopathy disease (HCM) and congenital coronary artery disease (CAA). Since SCD is such a rare occurrence among the population, when it does eventually happens to an athlete it can most likely be found on the news. Its a media frenzy and the population and surrounding community are in shock. Coaches and trainers want to prevent their athletes from being affected by this occurrence and therefore require mandatory physicals prior to the start of the season to that specific sport. Surprisingly most SCD cases have taken place in start-stop sports such as, but not limited, to football and basketball. The combination of the momentum it takes to propel their bodies forward on the start and the chance of being slammed into by another player significantly increases the athletes risk for SCD. Another factor that actually increases SCD in athletes is by

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exercise. Exercise, as it is already, increases the heart rate which causes the heart to work twice as hard to pump and circulate the blood throughout your body. If a pre-existing heart disease or abnormality is present and goes undiagnosed, the athlete is likely to put their health and heart at risk during exercise or training for competitive sports. Due to the rarity of SCD, the athlete is often asymptomatic (not exhibiting any known symptoms) and death is unfortunately the first sign. In fact, pre-existing heart diseases and abnormalities can be treated if caught in time by the use of an EKG or electrocardiogram. An EKG is a test that is administered through the use of a 12-lead machine which records and monitors the electrical activity of the heart. It allows the physician or cardiologist to detect any electrical abnormalities or defects that may be present in an individuals heart. Usually if a severe defect is detected the diagnosing doctor may recommend the discontinuance or disqualification of participation in a competitive sport. Another action the physician may take if the defect is severe enough is through cardiovascular surgery where the surgeon implants a defibrillator that sends impulses or shocks to the heart when an arrhythmia is detected. The following annotations are chosen due to the recent studies that have been conducted. The medical field has changed over the years and will continue to advance, therefore the more recent the study the more reliable and relatable it can be. For my annotations I only decided to look into recent studies and articles that were conducted from 2012 to 2014. I did so primarily for the fact for relevance due to the amount of technology we now have available today versus what we had back then.

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Angelini, Paolo, Mladen Vidovich, Christine Lawless, Macarthur Elayda, J. Alberto Lopez, Dwayne Wolf, and James Willerson. "Preventing Sudden Cardiac Death in Athletes. "Forthcoming Clinical Investigation 2nd ser. 40 (2013): 148-55. Print.

Recent studies have discovered that sudden cardiac death (SCD) can be diagnosed by screening with modern imaging techniques. The Center for coronary artery anomalies at the Texas heart institute are dedicated in looking for studies and procedure which could in time prevent SCD from occurring among young athletes and non athletes. Exercise is very beneficial to our health and it is highly recommended by our physicians, however, exercise can increase heart rate and blood pressure which may in turn increase SCD in people who may have undiscovered and silent heart defects. The mortality rate for individuals who suffer from heart disease or cardiac arrest outside of the hospital is seemingly higher than it should be at 70%-95% in the population today. (Angelini, et.al 148) The two main causes of SCD seem to be consistent throughout studies that have been conducted. These causes are cardiomyopathy and coronary artery anomalies (CAA). The American College of Cardiology and the American Heart Association are working hand in hand and have produced guidelines which state that most SCD in young athletes is primarily due to structural heart disease which can be congenital. They have also concluded that many of these cases can be recognized ahead of time via screening processes such as a cardiovascular magnetic resonance (CMR). Studies conducted have resulted in the findings that of the athletes being tested, only 3% had structurally normal hearts. Another reoccurring factor of SCD is hypertrophic cardiomyopathy which may cause the left ventricular wall of the cardiac muscle to thicken greater than 1.5cm or 2

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standard deviations above the normal mean.( Angelini, et.al 149) Since this disease is so rare, it actually only takes place in 2-3% of the population and poses a high risk in competitive sports. Scientists expect to validate the CMR by comparing the screenings to that of the deceased with normal hearts at the same age. (Angelini, et.al 150) In fact, the CMR is said to be highly reliable in diagnosing and finding anomalous coronary artery origin from the opposite sinus (ACAOS). And can also be useful in determining left and right ventricular wall thickness. (Angelini, et.al 152)

Balady, G. J., and J. A. Drezner. "Tackling Cardiovascular Health Risks in College Football Players." Circulation 128.5 (2013): 477-80. Print.

As we go more in depth into this journal article, we begin to see it takes a closer look into football. Unfortunately, sudden cardiac death (SCD) is the leading medical cause of death during exercise in the National Collegiate Athletic Association (NCAA). Fortunately for many athletes it is rare occurring in 1 of every 38497 players per year. (Balady, et. al 477) A medical exam was given to 113 first year football players from the Harvard University football team. At post season (after the football season) it resulted in the findings of 46% of the players to have demonstrated prehypertension and 14% to have stage 1 hypertension. The study was conducted on both lineman and non-lineman and it concluded that lineman displayed higher blood pressure at preseason (before the football season) than non-linemen. At postseason however, 83% of studied and tested linemen were displaying signs of either prehypertension or hypertension. (Balady, et. al 478)

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While observing competitive athletes, arterial hypertension is the most common cardiovascular condition. Arterial hypertension is abnormally high blood pressure in the pulmonary artery and occurs when the arteries that go to the lungs narrow in diameter and supply and insufficient amount of blood into the lungs. For reference, linemen exhibit an intense amount of force when a play is started and is often combined with holding their breath. The players are often susceptible to heavy blows to the thoracic cavity during each play. Since linemen have a higher body mass index than most nonlinemen, they actually carry twice the risk of heart disease. Approximately 42% of defensive linemen are at a higher risk than most for a heart disease related death and are at a greater risk for hypertension. (Balady, et. Al 479)

Bar-Cohen, Yaniv, and Michael J. Silka. "The Pre-Sports Cardiovascular Evaluation: Should It Depend on the Level of Competition, the Sport, or the State?" Pediatric Cardiology 33.3 (2012): 417-27. Print.

Sudden cardiac death (SCD) among athletes is a tragic event and a plethora of controversy exists regarding the most effective method to define the individuals at the highest risk for SCD. The American Heart Association (AHA) requires that a history and physical examination to be used for a preparticipation screening with further screening if an abnormality is detected. The guidelines constructed by the AHA also state that such screening as the electrocardiogram (ECG) is optional and not required. These guidelines apply to all competitive sport athletes however there is results that may indicated that

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there are subgroups of athletes based on age, level of competition, sports and state of residence in which a mandatory ECG would be sensible. Screening higher risk individuals would in fact be more reasonable than not screening at all. Although rare, when SCD does occur it is reported all over the news. Since coaches and trainers want to do the best in preventing such a tragic event from happening, they suggest that some type of screening should be conducted prior to participation in a sport. However, sometimes even with the presence of screening results are not always available for a prognosis of an examination. Even though such screening would result in huge financial and resource expenditures it could have an overall benefit of survival rate. (Bar-Cohen, et al. 417) If studies could be done to narrow down to a specific group of athletes with an increased risk of SCD, more intensive preparticipation screenings could be matriculated into the groups and deemed appropriate. (Bar-Cohen, et al. 418) A factor that could in fact increase the risk for SCD in an athlete may be their age and level of competition. Both factors go hand in hand because the athletes age often defines the level of intensity of competition. For example, if the athlete is younger than 12 years of age they are most likely to be involved in club sports such as soccer or basketball. Yet, if the athlete is in college and in the NCAA we can see there would be an extremely high level of competition. Therefore, there is a higher sudden death rate amongst the NCAA athletes. (Bar-Cohen, et al. 423) Unfortunately at this current time there is no screening program that will completely eliminate the risk of SCD in athletes. The electrocardiogram remains an option and is not a mandatory screening that is required to participate in a competitive sport. If an ECG was mandatory for the at least a small sub group of athletes within a specific age, level, race and gender it would be less costly and perhaps would be able to

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narrow down the typical individual who could have such a disease. (Bar-Cohen, et al. 426)

Basso, Cristina, Barbara Bauce, Domenico Corrado, and Gaetano Thiene. "Pathophysiology of Arrhythmogenic Cardiomyopathy." Nature Reviews Cardiology (2011): n. pag. Print.

A heterogeneous disorder of the heart muscle is known as arrhythmogenic cardiomyopathy (AC) which can most likely be associated with ventricular arrhythmias and can increase patients risk of sudden cardiac death. AC is a mutation in five genes which encode major components of the desmosomes. (Basso, et al. 223) Studies of the AC have shown that AC is more prevalent in men who are affiliated within an affected family and may experience an onset of ventricular arrhythmias and the occurrence if sudden cardiac death. During any physical exercise and activity in a competitive sport there is an indication of an increased risk for a ventricular arrhythmia and sudden cardiac death of patients who are likely to suffer from AC. In fact, any physical activity that the patient or athlete may participate in can actually accelerate the progression of the disease phenotype. Patients with atrial fibrillation, the irregular and rapid heart rate which causes poor blood flow to the body, can be indictated with anticoagulation (when the blood does not clot). in these cases studies do not support the use of prophylactics such as the use of anticoagulants in patients with right ventricular aneurysms or other forms of AC. (Basso, et al. 230) Data collected from studies have indicated that various events, signs, and symptoms such as previous cardiac arrest, tachycardia, and syncope (fainting), to name a

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few coincide with potential prognosis of sudden cardiac death. There has been frequent observations of AC which scientists think may lead to the usage of anti-inflammatory drugs to decrease the inflammation of the disease. (Basso, et al. 231)

Batra, Anjan S., and Seshadri Balaji. "Prevalence and Spectrum Diseases Predisposing to Sudden Cardiac Death: Are They the Same for Both the Athlete and the Nonathlete?" Pediatric Cardiology 33.3 (2012): 379-86. Print.

Sudden cardiac death (SCD) is usually due to an undiagnosed case of congenital or a cardiovascular disease. Two most frequent causes of cardiovascular disease and SCD are hypertrophic cardiomyopathy (HCM) or congenital coronary artery disease. Cardiac death is extremely rare and if present usually takes place during or immediately after an exercise or activity occurring 1 in every 100,000 people per year. SCD is primarily due to the presence of cardiac disease but can also been seen due to blunt force trauma which could result in structural and electrical damage to the heart or even heat stroke if not well hydrated. (Batra, et al. 380) Over time as athletes continue to exercise for the competitive sport, conditioning (working out) often, they experience an increase on cardiac mass caused by the thickening of the left ventricular wall or cavity dimension. HCM has seen to be a genetic disease and has mutated among genes for quite some time now in encoding proteins of the sacromere. (Batra, et al. 381) When diagnosing a patient with HCM, the physician usually uses an exercise stress test which measures the hemodynamic responses to stress, shows presence of ischemia as well as left ventricular

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outflow tract obstruction and arrhythmia. After the diagnosis of HCM the athlete is usually restricted from participating in competitive sports which can lead to SCD. With the presence of myocarditis, the risk of cardiovascular collapse is heightened with the increase of exercise and physical activity in the patient. Marfans syndrome is more prevalent in individuals with taller structured people with longer limbs that participate in sports such as basketball and volleyball. Approximately 70% of patients die due to increased blood pressure and stroke volume which could increase the aortic enlargement and making the athlete more vulnerable to aortic rupture. (Batra, et al. 383)

Chandra, Navin, Rachel Bastiaenen, Michael Papadakis, and Sanjay Sharma. "Sudden Cardiac Death in Young Athletes." Journal of the American College of Cardiology61.10 (2013): 1027-040. Print.

Sudden cardiac death (SCD) in athletes is caused by cardiovascular abnormalities in typically the right ventricle of the heart. The mechanism is usually due to ventricular arrhythmia induced by electrical surges from heavy exercise. In addition to exercise, mechanisms also include dehydration, hyperpyrexia (extremely high fever), electrolyte imbalances, and increased platelet clusters. In the article, the authors define an athlete as an individual who is engaged in regular physical training. (Chandra, et al. 1027) Researchers have found that the prevalence of SCD is mainly dominant amongst males and in the African/afro-Caribbean ethnicity. During autopsy of the deceased, data has been collected that reported higher rates of hypertrophic cardiomyopathy in blacks (20%)

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than in whites (10%). Scientists hypothesize that the right ventricular defect that may lead to sudden death under extreme cases may be genetic and a phenotype amongst black males.(Chandra, et al. 1028). Since sudden death is so rare, death due to ventricular tachycardia and/or ventricular fibrillation is usually the first manifestation of the disease. Studies have also shown that the sports in the US that most likely lead to SCD is startstop sports such as basketball and football. To diagnose such disease, doctors conduct tests using an electrocardiograph (ECG) which records the electrical activity of the athletes heart and translates the recordings onto a line on paper that signifies the PQRST waves your heart makes when beating. It is shown that more than 90% of the affected athletes have an abnormal resting ECG. SCD has also been associated with congenital coronary artery disease in many births and has reportedly caused sudden cardiac death in 12-13% of athletes. (Chandra, et al. 1029) Recommended treatment for a congenital artery abnormality is through surgical correction. Studies are still being conducted but since SCD is so rare its often difficult to detect early on.

Choi, Kristal, Yann Ping Pan, Michelle Pock, and Ruey-Kang R. Chang. "Active Surveillance of Sudden Cardiac Death in Young Athletes by Periodic Internet Searches." Pediatric Cardiology 34.8 (2013): 1816-822. Print.

Researchers have recently confirmed that systematic internet searches could give us more insight of sudden cardiac death (SCD) in athletes in which would be useful for establishing a system of active surveillance. A group of researchers conducted weekly

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advanced Google searches of cases of SCD over a 12 month period. Included in the study were athletes that were between the ages of 11-30 years old who collapsed during a game, practice, or within an hour of exercising. Anyone who was known to have a preexisting heart condition or event outside of the United States was excluded for this study. At the beginning of the study, 71 cases were identified over a 12 month period from April 2007 to March 2008. Reports from the coroner and death certificates were available for 45 out of the 71 cases. 43 of the 45 cases were confirmed to be due to SCD. As mentioned throughout the other annotations, the most common cause of SCD is hypertrophic cardiomyopathy and the second common cause is coronary artery abnormality. Such cardiac pathology is seen to be genetic and often congenital however, it goes undiagnosed for some time. A complied set of data indicates that approximately 50-100 SCD can occur in the U.S each year due to any participation in an athletic sport. (Choi, et al. 1816) Out of the 71 cases that were researched via Google as previously mentioned, 69 were the focal point of analysis. Out of those 69 cases, 54 of them pertained to the cause of death of a cardiovascular disease. Approximately 55 occurred in males and 14 occurred in females of the original 69 cases. (Choi, et al. 1818) further research and in depth analysis revealed that of the 69 cases, 45 occurred at school, 23 occurred in the track and field area, and the remained took place at the gym, basketball court, etc. The conclusion to the study was that internet searches combined with the coroners reports and death certificates were actually very helpful in determining approximately how many cases were reported. Unfortunately most of the cases of SCD go unreported but with the help of internet searches and active surveillance, results could

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be efficient and less costly in developing and refining public health recommendations and policies. (Choi, et al. 1822).

Halkin, Amir, Arie Steinvil, Raphael Rosso, Arnon Adler, Uri Rozovski, and Sami Viskin. "Preventing Sudden Death of Athletes With Electrocardiographic Screening." Journal of the American College of Cardiology 60.22 (2012): 2271-276. Print.

One of the largest controversies is the conversation about the use of the electrocardiogram (ECG) to prevent sudden cardiac deaths (SCD). The European Society of Cardiology makes the screening of all competitive athletes by the ECG mandatory, while the American Heart Association does not. Researchers we curious to see approximately how much money it would cost to screen all high school and college athletes with the ECG to detect heart defects or a presence of any disease. With the help of a cost-projection model they were able to estimate the approximate national annual expenditure related to mandatory ECG screening of athletes in competitive sports as well as the prediction of the cost of saving a single athletes life. (Halkin, et al. 2271) During a typical year, approximately 8.5 million athletes will undergo ECG screening. Each year, about 91% of the 8.5 million will show negative screenings and will be allowed to compete in sports. They will be rescheduled for a follow up in a year. However, 2% would screen positive and would be disqualified for competitive sports and will have to undergo additional tests. Results for the cost projection model concluded that with the presence of approximately 8.5 million athletes over a 20 year screening process will

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result in about 170 million ECG screenings. That being said, it would cost around $2.5 to $3.4 billion dollars per year just to screen high school and college athletes. (Halkin, et al. 2273) The number of lives saved however over a course of a 20 year span is 4,813 lives with the cost per life saved ranging from $10.6 to $14.4 million. (Halkin, et al. 2274) The controversy that ties into this research is that due to the limited resources made available to the healthcare in the U.S, mandating such a process of mandatory ECG screening and spending all this money to do so will in the long run hinder other preventable measures that could have been taken for other cardiac arrest patients. (Halkin, et al. 2275)

Law, Ian H., and Kevin Shannon. "Implantable Cardioverter-Defibrillators and the Young Athlete: Can the Two Coexist?" Pediatric Cardiology 33.3 (2012): 387-93. Print.

One of the treatments for sudden cardiac death (SCD) is through the use of an implantable cardioverter-defibrillator (ICD) to be used for life threatening arrhythmias (problem with the rate or rhythm of the heartbeat). The implantation has now been allowed to be implanted in younger and smaller patients who exhibit irregular heartbeats. A majority of these young patients who have the ICD surgically placed show signs of electrical cardiac disease. (Law, et al. 387) Research has been conducted which indicates that vigorous activities actually increase the life threatening arrhythmia through the increase of heart rate. Also, arrhythmias can increase due to repetitive training and high levels of exertion, such as pushing or pulling things, can in fact decrease the durability of the ICD in the patient/athlete. The article compares recreational sports, such as jogging or

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playing catch, which can be noncompetitive and sports, such as football, tennis, etc, which can be competitive. Since sports require more strength, stamina and energy, the patient is often at a higher risk for SCD and a life threatening arrhythmia due to the larger strain the activity puts on the heart. The American heart association conducted a study back in 1996 which stated that patients who have hypertrophic cardiomyopathy (a condition in which a part of the heart muscle becomes thicker than others) are at the highest risk for sudden cardiac death (SCD). (Law, et al. 388) An interesting fact in this article is that adrenaline can actually trigger an arrhythmia. Ventricular arrhythmias can also be triggered by cold water immersion such as in competitive swimming which leads us to the conclusion that SCD can be seen in more activities other than start-stop sports such as football and basketball. Through the placement in ICDs studies can conclude that it is for the most part successful. However, for an ICD to administer the appropriate shock necessary for the therapy it must be able to detect an arrhythmia in the hearts pulse. If damaged due to an electromechanical noise, lead short, wire break, or generator failure, the ICD may administer an inappropriate shock. (Law, et al. 390)

McClaskey, David, Daniel Lee, and Eric Buch. "Outcomes among Athletes with Arrhythmias and Electrocardiographic Abnormalities: Implications for ECG Interpretation." Sports Medicine 43.10 (2013): 979-91. Print.

Normally, electrocardiogram (ECG) arrhythmias and changes are commonly seen amongst most athletes due to the increase in exercise. Some of the changes which can be reported varies and most likely includes structural or electrical remodeling within the

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cardiac muscle due to prolonged exercise or the presence of cardiovascular disease. A ventricular arrhythmia is more or less common among an athlete and may be seen during the ECG screening. However, sometimes the presence of this arrhythmia can warrant concern and may increase risk for sudden cardiac death in which case the athlete is likely to be disqualified from and competitive sports. (McClaskey, et al. 979) Ventricular arrhythmias (VA), scientists deduce, represent a benign expression of the athletes heart. In any statement there is always controversy and in this case others often argue that VA is instead a structural disorder that can lead to sudden cardiac death. Two well known structural defects seen within the cardiac muscle are hypertrophic cardiomyopathy and congenital coronary artery anomalies. Since sudden cardiac death is rare and often doesnt occur that often in the U.S death may be the first sign of an abnormality. Sports activities are known to trigger such episodes and therefore pre-participation tests are required to be conducted to check the athletes physical health. This test is usually done during a physical and an ECG screening. If the structural defect is caught early enough there are a few treatment options which are further examined upon each new case. During a longitudinal study that was conducted on the arrhythmia and cardiac event which highlighted the existence of 20 uses of prophylactic procedures: 11 were through the implantation of a cardioverter-defibrillator which sends shocks to the heart when an arrhythmia is indicated and 9 cases of catheter ablation. The scientists concluded that through the placement of these devices, it most likely decreased an incident of sudden cardiac death. (McClaskey, et al. 988)

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Morse, Emily, and Marjorie Funk. "Preparticipation Screening and Prevention of Sudden Cardiac Death in Athletes: Implications for Primary Care." Journal of the American Academy of Nurse Practitioners 24.2 (2012): 63-69. Print.

Sudden cardiac arrest can be diagnosed by the use of an electrocardiogram (ECG) which is able to detect subtle abnormalities throughout the heart muscle. It has been reported and strongly studied that ventricular arrhythmias in pre-diagnosed patients with cardiac disease can be triggered by intense exercise and a great amount of exertion. Unfortunately, a majority of sudden cardiac deaths (SCD) are undiagnosed and are usually asymptomatic underlying cardiovascular conditions. Since the guidelines for participation in competitive sports is not mandatory by law and only limited to family history and physical examinations there is a limited amount of data for sudden death in young athletes. (Morse, et al. 63) SCD is prevalent in black males rather than among other races or females and is usually seen in football or basketball players due to the amount of force and energy they exert at one time. SCD is likely to occur during exercise or immediately after. If an athletes routine requires extensive conditioning, the heart often show signs of remodeling, such as the thickening of the left ventricular wall. It can affect the rhythm as well as the electrical conduction produced. The thickening of the left ventricular wall can mimic Hypertrophic cardiomyopathy (HCM) which causes concern to the physician. As we see in the other journal articles we can see that HCM is the leading genetic cause of SCD in the U.S among competitive athletes and this can predispose the athletes heart to fatal arrhythmias eventually leading to death. Unfortunately however, preparticipation screening does not wholeheartedly meet the

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standards of the world health organization due to the fact of its rarity and SCD is usually the first sign that there was a cardiac disease present in the athlete. (Morse, et al. 68)

Roston, Thomas M., Astrid M. Souza, George G. S. Sandor, Shubhayan Sanatani, and James E. Potts. "Physical Activity Recommendations for Patients With Electrophysiologic and Structural Congenital Heart Disease: A Survey of Canadian Health Care Providers."Pediatric Cardiology 34.6 (2013): 1374-381. Print.

A physician is faced with many challenges throughout their career but one that is often misconstrued is the determination of a safe level of physical activity for a patient present with a cardiac disease such as structural congenital heart disease (CHD). The Bethesda conference has come up with guidelines for athletes who are pursuing competitive sports. The guidelines determine the eligibility of the athlete or their disqualification due to the severity of their disease. The sad part is that due to the lack of evidence and data for the specific disease, in this case we will look at congenital heart disease, physicians often are incorrect about the type of activities they restrict. (Roston, et al. 1375) A study was conducted with a survey designed to determine the pattern of maximum exercise involvement that should be allowed for patients with structural of arrhythmic heart disease. The researchers had to keep in mind that there had to be certain considerations during the study such as the intensity of the activity, the duration of such, and the frequency. The risks that were considered were limited exercise capacity and the time from when the last episode or procedure took place. (Roston, et. al 1376) The results

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of the study for CHD as well as electrophysiologic disease were through the restrictions of competitive sports, weight training, contact sports, and recreational sports. A later discussion prompted researchers to conclude that Canadian cardiac care providers were in fact only partially implementing the guidelines for physical activity by either over or under restricting exercise for patients with a heart arrhythmia. (Roston, et al. 1377)

Sarquella-Brugada, Georgia, Oscar Campuzano, Anna Iglesias, Josep Snchez-Malagn, Myriam Guerra-Balic, Josep Brugada, and Ramon Brugada. "Genetics of Sudden Cardiac Death in Children and Young Athletes." Cardiology in the Young 23.02 (2013): 159-73. Print.

Sudden cardiac death (SCD) is categorized as an unexpected cardiac event in seemingly healthy individuals. It is one of the most common deaths among adults and in the elderly. SCD can be correlated to heart disease but is most likely seen in adults. Studies have indicated that SCD in children is extremely rare, however it counts for about 10% of pediatric deaths during the first year of life. (Sarquella-Brugada, et al. 159) Sudden cardiac deaths in young adults are shown to have a congenital heart defect and may inhibit other cardiac defects such as right ventricular cardiomyopathy, occasionally a case will be presented of a young adult having electrical disorders through the cardiac muscle without the presence of any structural defect visible. Since SCD is so rare, it is expected that it affects every 1 in 50,000 to 200,000 per year. (Sarquella-Brugada, et al. 159) Researchers have found that athletes are possibly at more risk than any average human being due to the amount of physical energy their body exerts during one specific time and

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how much stress is being endured during that physical activity. Channelopathies, a syndrome that affect the cardiac electrical system and disrupts the ion channels that travel through your heart, can often be seen as mutations of the genes. The diagnosis is often discovered using an electrocardiograph which records the electrical activity throughout the heart. Treatment for this genetic disease is often through detraining, losing fitness when you cease physical activity, and through the use of a cardio-defibrillator which is implanted into the heart during surgery to regulate the electrical pulses sent through the heart.

Tanguturi, Varsha Keelara, Peter A. Noseworthy, Christopher Newton-Cheh, and Aaron L. Baggish. "The Electrocardiographic Early Repolarization Pattern in Athletes." Sports Medicine 42.5 (2012): 359-66. Print.

One of the most commonly used devices to detect irregular arrhythmias in athletes is through the use of a 12-lead electrocardiogram (ECG). A common finding amongst most athletes is the early repolarization pattern (ERP). Some scientists deduce that the ERP findings directly correlate to the sudden cardiac death (SCD). The definition of early repolarization pattern is characterized by the J point elevation manifested either as QRS slurring or notching associated with concave upward ST-segment elevation or prominent T waves in at least two contiguous leads. The J point is seen as the junction between the QRS complex and the ST segment. (figure 1) (Tanguturi, et al. 359) Researchers have seemed to have pinpointed that the ERP occurs within the inferior leads attached to the

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thoracic cavity. Studies conducted by Hassaguerre and colleagues in 2008 found that the ERP was higher in patients with idiopathic ventricular fibrillation (VF) than among the control subjects. (Tanguturi, et al. 361) Studies showed that if the ERP was isolated to the inferior leads then that patient had the greatest risk of death which deemed that inferior ERP was associated with cardiac mortality. However, if it was isolated to the lateral leads then that person had a lower risk of death. Another study was conducted on ERP which indicated that it could be genetic and associated with SCD. (Tanguturi, et al. 362) These studies conducted also show a prevalence of ERP in the black male race that have a lower heart rate and increased QRS wave. The ERP rate is recorded to have increased significantly from before the exercise at 37.2% to after the exercise at 52.7%. (Tanguturi, et al. 362) The horizontal/descending ST segment is closely related with an increased risk of cardiac death whereas an ascending ST segment shows no increase in risk of cardiac death. Since the ERP morphology in athletes shows an ascending ST segment, scientists cannot correlate in the increased risk of SCD. The ERP is shown to increase after a period of intense physical training and is associated with lower resting heart rates which can be found in athletes. (Tanguturi, et al. 364) The ERP is believed to be triggered by exercise and is usually higher during the post-exercise than seen during or prior to the workout. The American heart association and American college of cardiology only recommend that screening for ERP be conducted upon prevalence in family history and physical examination. If an athlete presents abnormalities then the physician will conduct an ECG. (Tanguturi, et al. 364) Fortunately for athletes as well as the general population, further studies are being planned for the future in hopes that one day we can confirm the correlation between ERP and the risk of SCD.

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(FIGURE 1: Recording of heart beat including the J point in the PQRST wave)

Vaseghi, Marmar, Michael J. Ackerman, and Ravi Mandapati. "Restricting Sports for Athletes With Heart Disease: Are We Saving Lives, Avoiding Lawsuits, or Just Promoting Obesity and Sedentary Living?" Pediatric Cardiology 33.3 (2012): 407-16. Print.

Sudden cardiac death is extremely rare amongst athletes and is often due to an undiagnosed cardiovascular disease. Due to the risk of unsuspected disease, physicians usually disqualify athletes from participating in competitive sports. However, due to the controversy of the problem the community faces today with obesity, physicians often allow patients with inherited arrhythmias and congenital heart disease to participate in low/moderate activity to maintain a healthy lifestyle. The American heart association, American college of cardiology, and the European society of cardiology have devised a consensus with a series of recommendations on restriction from the participation in competitive sports for trained athletes affected by both genetic and nongenetic cardiovascular diseases. (Vaseghi, et al. 407) The issue with this consensus is that through the restriction of competitive activities being participated in may lead to an increase in inactivity, obesity, and coronary artery disease amongst athletes. (Vaseghi, et

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al. 407) Possible precautions that could be acted upon should be the decrease of such physical activity and the athlete should be encouraged to pursue a more moderate level of activity which would fall in the spectrum of safety of the disease. Sudden cardiac death can occur due to either mechanical or electrical malfunctions. A mechanical malfunction could be described as a pump failure due to pulmonary embolism or an aortic rupture. They are arrhythmic due to ventricular fibrillation. One of the leading causes of reported cases of sudden cardiac death is due to hypertrophic cardiomyopathy (HCM) which can be diagnosed by asymmetric left ventricular hypertrophy and can be inherited in a mutated dominant gene. (Vaseghi, et al. 409)