On a cool Ithaca night in March 2004, a Cornell University lacrosse player died suddenly after being stuck in the chest with a lacrosse ball during a game against Binghamton University. Sudden cardiac death in athletes is a rare and tragic event. Recently, an article published in the Heart Rhythm Journal revealed that only one in 10 U.S. student athletes who suffers sudden cardiac arrest survives.

The incidence of sudden cardiac death (SCD) is uncommon, estimated at one in 50,000 to 300,000 U.S. competitive athletes over a 20-year period. It tends to strike young and otherwise well appearing individuals and is almost universally fatal. As the stakes are so high in the young, there has been a great impetus to detect those at risk for SCD. Ultimately, the questions are what are the causes of SCD, how can it be detected, and if undetected, how can the risk be minimized.

SCD is most commonly due to lethal arrhythmias, or electrical storms within the heart. Most arrhythmias are due to ventricular tachycardia and ventricular fibrillation, some of which have a genetic basis and others occur spontaneously. In addition to cardiac arrhythmias, certain heart muscle disorders called cardiomyopathies can causes SCD.

Although rare in young athletes, heart attacks or myocardial infarction can occur and if not treated in time can result in SCD. Another relatively rare condition is a group of born heart defects broadly classified as congenital heart disease. This includes abnormal heart muscle development, abnormal valves and even malrotation and position of the heart chambers.

A somewhat more common condition is an abnormal connective tissue disorder called Marfan's Syndrome, in which the valves and blood vessels develop incorrectly and ultimately increase the risk of SCD. An even more rare etiology of SCD is a condition called Commotio cordis. This is due to sudden impact to the chest with a fast traveling blunt object that seems to trigger a life threatening arrhythmia. Most commonly, Commotio cordis is due to chest trauma with a ball, puck or fist.

In addition to the characteristics of the patient, there are also the risks of the sport. As compared to purely recreational sports, competitive sports have a higher risk of SCD. As the intensity level of competition increases with advancement of one's athletic career, the stress on the body tends to increase with subsequent increases of the risk of SCD. Additionally, sports with potential high velocity chest contact such as hockey, baseball, lacrosse and judo have a slightly higher risk of SCD. Although any competitive sport can result in SCD in athletes, it is well established certain sports can cause SCD in a select few patients.

As SCD is a tragic event, there has been a high emphasis placed on detecting those at high risk of SCD before they engage in athletics. Some of the causes of SCD can be detected with routine screening tests. Those deemed to have a high risk of SCD could be accurately risk stratified with EKGs, transthoracic echocardiograms and stress testing. In those with an unfavorable family history of SCD, certain genetic testing can be performed for known markers of SCD. However, there is logistical problem in testing only those deemed to be high risk, when in fact the majority of SCD victims have no obvious clues of their condition.

Recent census in the United States estimate that there are roughly four million high school-age athletes, half a million college athletes, and some 5,000 professional athletes. The cost, complexity and consequences of an incorrect test result, either positive or negative, would be devastating. In a region of Italy where there is a preponderance of SCD, the government instituted a mandatory EKG screening policy for athletes. After 25 years of follow-up data, the screening EKG policy demonstrated a significant reduction in SCD. Unlike the United States, this was a uniform population with very high rates of SCD and a government supported health care system. Currently, the American Heart Association has published guidelines stating that athletes have a pre-participation screening exam, and comprehensive review of personal and family medical history.

This leads to the question of what can be done in the United States. The most essential step is to follow the AHA recommendation of uniform health screening and exams of all athletes. This will hopefully detect those at higher risk for SCD and trigger appropriate cardiac testing. An essential next step is to increase prevalence of defibrillators, which are devices used to detect and ultimately shock a life threatening arrhythmia. It is thought that successful defibrillation of a lethal arrhythmia within three to five minutes could be life saving and increase the chances of successful neurological recovery. Implicit in this “chain of life#” is increased availability of an Automatic External Defibrillator (AED) at all sporting events, large public gatherings and government buildings. Increased presence of AEDs at sports competition can save lives.

The good news is that SCD is a rare event, and having thorough pre-participation health care screening tests can reduce this risk. Ultimately, young people participating in athletics will be better served by a well-designed emergency preparedness plan and having AEDs at all sporting events. When a young life is at stake, these measures can truly make a world of difference.

Dr. David M. Donaldson is an Auburn native and currently a cardiologist at Massachusetts General Hospital in Boston.