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Spanish footballer Nacho Barbera has died after suffering a cardiac arrest during a recent match. Barbera had been playing in the 13–14 year-old age group of Valencia-based side UD Alzira and was the captain of his team., 4 February 2018

The sudden death of a young athlete on the playing field is a most devastating event. Sudden cardiac death (SCD) is the leading cause of mortality in young athletes during exercise and typically is the result of undiagnosed structural or electrical cardiovascular disease.15 Sudden cardiac death is always tragic and it profoundly impacts the community, school and team where it occurs.

Athletes are viewed as the healthiest members of our society, and exercise and sport are widely encouraged to prevent illness and promote health. However, intense exercise and physical conditioning also may trigger an acute cardiovascular event or sudden cardiac arrest (SCA) in young individuals harbouring silent hereditary or congenital heart disease. This ‘exercise paradox’ is highlighted by the sudden death of a young athlete during training or competition.

Because of the importance of this topic and the large number of recent advances, SCD has a dedicated chapter. The clinical approach to other cardiac symptoms (such as chest pain, syncope, dyspnoea) is addressed in Chapter 10. The main goals of this chapter are to:

  • review the incidence of SCD in young athletes—this is not a rare occurrence

  • clarify the aetiology of SCD—sports physicians should have a detailed understanding of the various pathologies that underpin SCD, and all clinicians should be interested in the various ways the heart can fail:

    • – structural

    • – electrical

    • – acquired

  • outline how to evaluate an athlete for conditions that may cause SCD

  • address three common diagnostic conundrums that need practical solutions

  • briefly review the purpose of pre-participation cardiovascular screening (see also Chapter 46, ‘Periodic medical assessment of athletes’, in Clinical Sports Medicine Volume 1: Injuries)

  • discuss the contemporary approach to primary and secondary prevention of SCD in sport.


The true incidence of SCD in young athletes is widely debated. Accurate calculation of the incidence of SCD in athletes requires a precise numerator (number of deaths per year) and an exact denominator (number of athlete participants per year) in the population studied. Variability in either of these accounts for unreliable estimates of incidence. The reported incidence of SCD in young competitive athletes (aged 12–35 years) varies widely, and it is challenging to compare studies with heterogeneous case identification methods that originate from different geographic regions (Table 9.1).

Early estimates of SCD in the USA range from 1:160 000 to 1:300 000 deaths per year in young competitive athletes.57 Passive collection methods, using retrospective review of media reports, electronic databases and insurance claims, in these early ...

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