Skip to Main Content


Once you’re into the race, your heart isn’t in rhythm, oxygen is running out and you lose power and become weaker and weaker as the race goes on. It feels like you’re dragging something behind the boat.

Nathan Cohen, Olympic double sculls rowing gold medallist, London 2012

As discussed in Chapter 9, sudden cardiac death is the leading cause of death in young athletes during sport and is typically the result of undiagnosed structural or electrical cardiovascular disease.14 Some athletes present with symptoms that can alert the clinician to underlying cardiac pathologies. However, identifying the athlete with symptoms representing a sinister pathological condition can be extremely difficult. For example, syncope during exercise is an important ‘red flag’ symptom, yet for athletes suffering these events, a benign explanation is far more likely. This chapter will provide a logical framework for working through these difficult clinical scenarios. We will discuss symptoms and clinical signs that can indicate serious pathology, as well as commonly encountered symptoms that may not represent a serious disorder.

In this chapter we:

  • discuss the management of five key symptoms:

    • – syncope and exercise-related collapse

    • – syncope mimics (e.g. seizure and exertional collapse)

    • – exertional chest pain

    • – palpitations

    • – excessive fatigue/dyspnoea

  • discuss physical examination findings that may be relevant to cardiovascular health

  • provide an overview of contemporary investigations for cardiovascular disease, which include electrocardiography, cardiac imaging (echocardiography, cardiac magnetic resonance and CT coronary angiography) and, occasionally, specialised investigations such as electrophysiological studies and genetic testing

  • discuss the approach to temporary and permanent disqualification from sport because of cardiac diagnoses.

Abbreviations used in this chapter


The incidence of sudden death in young athletes (≤35 years) is 0.6–3.6 per 100 000 athletes per year and the majority of deaths are due to cardiovascular causes.1, 2, 58 For reasons that remain unexplained, the risk is approximately 3- to 10-fold greater among males than females and is higher among competitive athletes than non-athletes.5, 7, 9 Although considerable attention has focused on young athletes, the risk of sudden cardiac death is considerably higher among athletes older than 35 years of age.7, 10 In general, inherited cardiomyopathies are the most frequent identified cause of sudden cardiac death in young athletes, while acquired heart disease, principally coronary artery disease, is most frequent in athletes of middle age and older.1, 5, 7, 1113 However, there is considerable overlap, particularly ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.