Herz © Urban & Vogel 2006
Exercise and the Risk of Sudden Cardiac
Death
Domenico Corrado1, Federico Migliore1, Cristina Basso1, Gaetano Thiene2
Abstract
Sports activity may precipitate acute fatalities in both
adults and young competitive athletes with concealed
heart diseases. However, the risk-benefit ratio of physi-
cal exercise differs among these two age groups. In ad-
olescents and young adults, competitive physical exer-
cise is associated with a significant increase of the risk
of sudden death. Sports is not “per se” cause of the en-
hanced mortality in this age group; rather, it acts as a
trigger of cardiac arrest in those athletes who are af-
fected by silent cardiovascular conditions, mostly car-
Sport und das Risiko des plötzlichen Herztodes
Zusammenfassung
Sportliche Aktivitäten können sowohl bei jugendlichen
als auch adulten Leistungssportlern mit verborgenen
Herzerkrankungen akute, fatale Ereignisse induzieren.
Allerdings differiert die Risiko-Nutzen-Relation in bei-
den Altersgruppen. Bei Adoleszenten und jungen Er-
wachsenen sind kompetitive körperliche Aktivitäten
mit einem signifikanten Anstieg des Risikos eines
plötzlichen Herztodes assoziiert. Der Sport ist hier
nicht „per se“ die Ursache der gesteigerten Mortalität
in dieser Altersgruppe; vielmehr wirkt er als Trigger für
einen Herzstillstand bei Athleten, die von unentdeck-
ten kardiovaskulären Störungen, insbesondere Kardio-
Introduction
Regular physical exercise is recommended by the
medical community because it offers the potential to
reduce the incidence of coronary events [1, 2]. On the
other hand, vigorous exertion may act as a trigger of
acute myocardial infarction and sudden cardiac death
in susceptible individuals [3–12].
The risk-benefit ratio of physical exercise differs
between young competitive athletes and adults [5].
This may be explained by the different nature of car-
diovascular substrates underlying sports-related sud-
den death (SD) in the two populations. As reported
in Table 1, the causes of SD reflect the age of partici-
pants. Although in young athletes a broad spectrum
of cardiovascular substrates (including congenital
and inherited heart disorders) underlies sudden car-
Herz 31 · 2006 · Nr. 6 © Urban & Vogel
Department of
1
Cardiac, Thoracic
and Vascular
2
Sciences, Universi-
ty of Padova, Italy,
Institute of Pa-
thologic Anatomy,
University of
Padova, Italy.
diomyopathy, premature coronary artery disease and Key Words:
congenital coronary anomalies, which predispose to Athletes · Cardio-
life-threatening ventricular arrhythmias during physi- myopathy · Corona-
cal exercise. In adults, on the other hand, physical activ- ry artery disease ·
ity can be regarded as a “two-edged sword”: vigorous Sudden death · Ven-
tricular fibrillation
exertion increases the incidence of acute coronary
events in individuals who did not exercise regularly,
whereas habitual physical activity reduces the overall
risk of myocardial infarction and sudden coronary death Herz 2006;31:553–8
by preventing development of coronary artery disease DOI 10.1007/
and progression of coronary atherosclerotic lesions. s00059-006-2885-8
myopathien, vorzeitig auftretender koronarer Herz- Schlüsselwörter:
krankheit und kongenitale koronare Anomalien, be- Athleten · Kardiomyo-
troffen sind, die zu lebensbedrohenden ventrikulären pathie · Koronare Herz-
Arrhythmien prädisponieren. Andererseits kann kör- krankheit · Plötzlicher
perliche Aktivität bei Erwachsenen als „zweischnei- Herztod · Kammerflim-
mern
diges Schwert“ betrachtet werden: Intensive Anstren-
gung erhöht das Risiko akuter koronarer Ereignisse bei
Personen, die nicht regelmäßig trainieren; demgegen-
über reduziert regelmäßige körperliche Aktivität das
Gesamtrisiko bezüglich Myokardinfarkt und plötz-
lichen Herztodes, indem die Entstehung und Progressi-
on einer atherogenen koronaren Herzerkrankung ver-
hindert werden.
diac arrest [13–25], in older athletes (adults > 35 years
of age) atherosclerotic coronary artery disease ac-
counts for the vast majority of fatalities [26–28].
This review article will focus on the risk of car-
diovascular events during sports activity in either
young competitive athletes or adults, with emphasis
on the different underlying pathologic substrates/
mechanisms and the different risk-benefit ratio.
Risk of Sudden Death in Young Competitive
Athletes
SD in young athletes usually occurs either during or
immediately after athletic activity, suggesting that
participation in competitive sports increases the like-
lihood of cardiac arrest [13–17]. We recently studied
553
Corrado D, et al. Exercise and the Risk of Sudden Cardiac Death

Table 1. Age-relat-

SD per 100,000 person-years

Young competitive athletes (age ≤ 35 years) 4 a Athletes
ed cardiovascular
• Hypertrophic cardiomyopathy 3.5 RR = 2.5 RR = 2.8 Nonathletes
causes of sudden CI = 1.8−3.4 CI = 1.9−3.7
death during • Arrhythmogenic right ventricular cardiomyopathy 3 p < 0.001 p < 0.001
sports activity. • Congenital anomalies of coronary arteries 2.5
Tabelle 1. Alters- • Myocarditis 2
bezogene kardio- 1.5
• Aortic rupture RR = 1.7
vaskuläre Ursa- CI = 0.32−5.7
• Valvular disease 1
chen des plötzli- p = 0.39 (NS)
chen Herztodes • Preexcitation syndromes and conduction diseases 0.5
während sportli- • Ion channel disease 0
cher Aktivität. Total Cardiovascular Noncardio-

SD per 100,000 person-years

• Congenital heart disease, operated or unoperated 2 vascular
b
Adults (age > 35 years)
• Atherosclerotic coronary artery disease 1.5

the impact of sports activity on the risk of SD in ado-
lescents and young adults. We examined the inci-
dence and causes of SD in the athletic and nonath-
letic young population (12–35 year old) of the Veneto
region of Italy. From 1979 to 1999, there were 300
cases of SD in adolescents and young adults, produc-
ing an overall cohort incidence rate of 1 per 100,000
persons per year. 55 SDs occurred among athletes
(2.3 per 100,000 per year) and 245 among nonathletes
(0.9 per 100,000 per year), with an estimated relative
risk (RR) of SD from all causes of 2.5 (CI [confidence
interval] 1.8–3.4; p < 0.001; Figure 1a). The RR of
SD among athletes versus nonathletes was 1.95 (CI
1.3–2.6; p = 0.0001) for men and 2.02 (CI 0.6–4.9;
p = 0.15) for women.
The rates of SD by cardiovascular diseases were
2.1 in 100,000 athletes per year, compared with 0.7 in
100,000 nonathletes per year (RR 2.8, CI 1.9–3.7; p <
0.001; Figure 1a). The estimated RR of cardiovascu-
lar SD was 2.0 for male (CI 1.4–2.8; p = 0.0001) and
2.6 for female athletes (CI 0.8–6.4; p = 0.06). The car-
diovascular causes at highest risk of sports-related
SD were anomalous origin of coronary artery from
the wrong coronary sinus (RR = 79), arrhythmogenic
right ventricular cardiomyopathy (ARVC; RR = 5.4),
and premature coronary artery disease (RR = 2.6;
Figure 1b).
By Poisson multivariate regression analysis, the
estimated RRs of sports activity for total SD and car-
diovascular SD were 1.95 and 2.1, respectively, while
the estimated RR of male gender was 2.5 and 2.8, re-
spectively. The interaction between sports involve-
ment and gender, for both total and cardiovascular
SD, was not significant.
The Veneto region study is the first to quantitate
the hazard of physical exercise in adolescents and
young adults. The major finding is that competitive
sports activity enhances by 2.5 the risk of total SD and
by 2.8 the risk of cardiovascular SD in young individu-
als. Sports is not itself the cause of the enhanced mor-
tality, but it triggers SD in those athletes who are af-
RR = 5.4
1 CI = 2.5−11.2 RR = 2.6
CI = 1.2−5.1
p < 0.001
p = 0.008
RR = 79.0
CI = 10−3,564
0.5 p < 0.001
0
ARVC/D CAD CCA
Figures 1a and 1b. Incidence and relative risk (RR) of sudden
death (SD) from total, cardiovascular and noncardiovascular
causes among young athletes and nonathletes (a). Incidence
and RR of SD from specific cardiovascular causes among
young athletes and nonathletes (b).
ARVC/D: arrhythmogenic right ventricular cardiomyopathy/
dysplasia; CAD: coronary artery disease; CCA: congenital cor-
onary artery anomalies; CI: confidence interval; NS: not sig-
nificant.
Abbildungen 1a und 1b. Häufigkeit und relatives Risiko (RR)
des plötzlichen Herztodes (SD; Gesamt-, kardiovaskuläre und
nichtkardiovaskuläre Ursachen) bei jungen Athleten und
„Nichtathleten“ (a). Häufigkeit und RR des SD (spezifische
kardiovaskuläre Ursachen) bei jungen Athleten und „Nich-
tathleten“ (b).
ARVC/D: arrhythmogene rechtsventrikuläre Kardiomyopa-
thie/Dysplasie; CAD: koronare Herzkrankheit; CCA: kongeni-
tale Koronararterienanomalie; CI: Konfidenzintervall; NS:
nicht signifikant.
fected by cardiovascular conditions, such as ARVC,
premature coronary artery disease and anomalous cor-
onary artery origin, which predispose to life-threaten-
ing ventricular arrhythmias during physical exercise.
Epidemiology of SD in Young Competitive
Athletes
The assessment of the precise frequency with which
SD occurs in young athletes during organized com-
petitive sports encounters a number of practical ob-
stacles and results in limitations mostly related to
retrospective analysis. Studies in the USA probably
resulted in underestimation of the true prevalence of
sports-related SD because they relied on reporting
from individual schools and institutions, or on media

554 Herz 31 · 2006 · Nr. 6 © Urban & Vogel