Incidence and etiology of sports-related sudden cardiac death

in Denmark—Implications for preparticipation screening

Anders Gaarsdal Holst, MD,*† Bo Gregers Winkel, MD,*† Juliane Theilade, MD, PhD,*†
Ingrid Bayer Kristensen, MD,‡ Jørgen Lange Thomsen, MD, DMSc,§ Gyda Lolk Ottesen, MD,㛳
Jesper Hastrup Svendsen, MD, DMSc,*†¶ Stig Haunsø, MD, DMSc,*†¶ Eva Prescott, MD, DMSc,#
Jacob Tfelt-Hansen, MD, DMSc*†#
From the *Danish National Research Foundation Centre for Cardiac Arrhythmia (DARC), University of Copenhagen,
Denmark; †Laboratory of Molecular Cardiology, Department of Cardiology, The Heart Centre, Copenhagen University
Hospital Rigshospitalet, Copenhagen, Denmark; ‡Department of Forensic Medicine, Aarhus University, Aarhus, Denmark;
§
Institute of Forensic Medicine, University of Southern Denmark, Odense, Denmark; 㛳Department of Forensic Medicine,
University of Copenhagen, Copenhagen, Denmark; ¶Department of Medicine and Surgery, Faculty of Health Science,
University of Copenhagen, Copenhagen, Denmark; and #Department of Cardiology, Copenhagen University Hospital
Bispebjerg, Copenhagen, Denmark.

BACKGROUND Studies on incidences of sports-related sudden
cardiac death (SrSCD) are few and data are needed for the discus-
sion of preparticipation screening for cardiac disease.
OBJECTIVE We sought to chart the incidence and etiology of
SrSCD in the young in Denmark (population 5.4 million) and to
compare this to the incidence of sudden cardiac death (SCD) in the
background population.
METHODS All 5,662 death certificates for decedents in the period
2000 to 2006 in the age group 12 to 35 years in Denmark were read
independently by 2 physicians to identify cases of SCD. Informa-
tion from autopsy reports, selected hospital records, and multiple
registries was used to identify cases of SCD and SrSCD. SrSCD was
defined as SCD occurring during or within 1 hour after exercise in
a competitive athlete. The size of the athlete population was
estimated from national survey data.
RESULTS Fifteen (range 0 to 5 per year) cases of SrSCD were
found, 8 of which had antecedent symptoms. The incidence rate
was 1.21 (95% confidence interval [CI]: 0.68 to 2.00) per 100,000
athlete person-years. The most common autopsy findings were
arrhythmogenic right ventricular cardiomyopathy (n ⫽ 4), sudden
unexplained death (n ⫽ 4), and coronary artery disease (n ⫽ 2).
The incidence of SCD in the general population age 12 to 35 was
3.76 (95% CI: 3.42 to 4.14) per 100,000 person-years.
CONCLUSION In Denmark, SrSCD is a rare occurrence and the
incidence rate is lower than that of SCD in the general population.
This may imply a low value of preparticipation screening of ath-
letes in Denmark.
KEYWORDS Sudden cardiac death; Athletes; Preparticipation
screening; Epidemiology
ABBREVIATIONS ARVC ⫽ arrhythmogenic right ventricular car-
diomyopathy; CI ⫽ confidence interval; HCM ⫽ hypertrophic car-
diomyopathy; SCD ⫽ sudden cardiac death; SrSCD ⫽ sports-re-
lated sudden cardiac death
(Heart Rhythm 2010;7:1365–1371) © 2010 Heart Rhythm Society.
All rights reserved.

Introduction the merits and timeliness of preparticipation screening of

Sports-related sudden cardiac deaths (SrSCDs) are tragic
occurrences that in most cases receive significant media
attention. A proportion of these deaths are potentially pre-
ventable, which has fuelled an ongoing scientific debate on
Supported by the Foundation of 17-12-1981, the John and Birthe Meyer
Foundation, the Arvid Nilsson Foundation, the Danish National Research
Foundation, the Danish Heart Foundation (07-10-R60-A1751-B743-
22412), the Research Foundation at the Heart Centre, Rigshospitalet, the
Research Foundation of Bispebjerg Hospital, and Bønnelykkefonden. Ad-
dress reprint requests and correspondence: Dr. Anders G. Holst, De-
partment of Cardiology, Section 2142, Copenhagen University Hospital,
Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark. E-mail
address: anders@kanten.dk. (Received April 19, 2010; accepted May 12,
2010.)
competitive athletes. Preparticipation screening has already
been implemented on different levels in many countries,
with the most extensive preparticipation screening program
mandatory in Italy since the early 1980s.1
Proponents for preparticipation screening argue that
screening saves many lives,2 but also emotional and societal
arguments such as the devastating effect of each SrSCD on
a community and the problems that the death of a perceived
healthy athlete as a role model present. Opponents empha-
size the high number of disqualifications (false positives),3,4
the impact on quality of life that a disqualification can have
for the athlete, the loss of beneficial effects of sport on
health, and the economic costs, and also question whether
there is a proven effect of preparticipation screening.5– 8

1547-5271/$ -see front matter © 2010 Heart Rhythm Society. All rights reserved. doi:10.1016/j.hrthm.2010.05.021
1366
A randomized study of preparticipation screening has
never been reported and would be very hard to carry out
because of the scale required. As a consequence, the evi-
dence regarding the efficacy of preparticipation screening is
based on observational studies. The most convincing data in
favor of preparticipation screening are the significant de-
cline in sudden cardiac death (SCD) cases among athletes in
the Veneto region in Northern Italy after the implementation
of the screening program.1
Few studies have provided numbers for SrSCD. The
most accurate numbers probably also stem from Veneto,
where the mandatory preparticipation screening with regis-
tration of all competitive athletes together with a prospec-
tive clinicopathologic investigation of SCD has allowed
Corrado et al1 to provide numbers for SCD among athletes.
Based on 14 cases, they have reported an overall annual
incidence rate of 4.19 per 100,000 athlete person-years in
the prescreening period of 1979 to 1981. In contrast, inci-
dence rates from U.S. data have been consistently lower.9–11
The causes of SCD among athletes also differ among stud-
ies, with a high proportion being caused by hypertrophic
cardiomyopathy (HCM) in the United States9 and by ar-
rhythmogenic right ventricular cardiomyopathy (ARVC) in
the screened population in Italy.12
In Denmark, no systematic screening of athletes has been
in place during or before the study period, but due to
requirements from among others the Union of European
Football Associations screening of a small group of elite
athletes has been carried out recently.
Before implementing preparticipation screening of a
wide array of elite athletes in Denmark, we wanted to
investigate the magnitude of the problem and the potential
effect of screening. We thus undertook a retrospective na-
tionwide analysis of all deaths to estimate incidence and
etiology of SrSCD among individuals ages 12 to 35 years
who died in Denmark in 2000 to 2006. Furthermore, we
compared our national data with data from the United States
and Italy.
Methods
The design of the study was a nationwide retrospective
study. The death certificate contains 1) Cause of death
section consisting of 4 lines listing a chain-of-events of
diseases and/or injuries that caused the death. 2) Other
significant diseases contributing to the death. 3) Mode of
death section. 4) Operation performed and autopsy status.
Autopsy status can be ticked as forensic autopsy, hospital
autopsy, no autopsy (forbidden) or no autopsy, other reason.
5) Supplemental information field describing the circum-
stances surrounding the death including interview with eye-
witnesses and relatives, previous medical conditions, an
external examination of the body, and the preliminary con-
clusion before autopsy. This field is mandatory in all
medico-legal examinations, regardless of whether an au-
topsy is performed. 6) The result of the macroscopic au-
topsy (both forensic and hospital). All death certificates for
deceased subjects ages 12 to 35 years dying in the period
Heart Rhythm, Vol 7, No 10, October 2010
2000 to 2006 in Denmark were retrieved as scanned com-
puter files and reviewed independently by 2 physicians for
possible SCD. The high level of information available on
Danish death certificates allowed us to use these as a pri-
mary screening tool for the identification of possible SCD.
For cases found to be possible SCD, further information
was retrieved from the Cause of Death Registry, where all
deaths in Denmark are recorded with a cause of death, and
the National Patient Registry, where all inpatient and out-
patient activity is recorded with corresponding International
Classification of Diseases, versions 8 to 10, diagnosis codes.
Furthermore, all autopsy reports and selected hospital charts
were reviewed. Using this information, a decision was made
among the 2 physicians regarding whether or not to classify
the case primarily as SCD and secondly as a subcategory of
SCD or SrSCD.
When a case was classified as SrSCD, further informa-
tion on antecedent symptoms and diseases, prodromal
symptoms, place, circumstances, and cause of death was
retrieved using the sources noted above. To investigate
whether being an athlete conferred an increased risk of
SCD, we compared the incidence of SrSCD in the athlete
population with the incidence of all SCD in the general
population of the same age.
Definitions
We defined SCD in autopsied cases as the sudden, natural
unexpected death of either unknown cause (sudden unex-
plained death) or cardiac cause (definite SCD); in unwit-
nessed cases as a person last seen alive and functioning
normally fewer than 24 hours before being found, and in
witnessed cases as an acute change in cardiovascular status
with time to death being less than 1 hour.
In nonautopsied deaths, we used the same criteria as
earlier in cases presumed to be of cardiac cause based on the
circumstances relating to the death. A prior medical history
was not an exclusion criterion, but was taken into account in
every single case. If concurrent disease was considered to be
a potential or likely causative explanation of death, the case
was not considered an SCD.
SrSCD was defined as nontraumatic SCD occurring dur-
ing or within 1 hour after moderate- to high-intensity exer-
cise in a competitive athlete. The deceased was considered
a competitive athlete if he or she did physically demanding
sports and took part in competitions.
We chose only to report SrSCD and not SCD among
athletes in general because we could not be sure if infor-
mation on whether the decedent was an athlete would be
mentioned in the sources of information we had access to
when death was not exercise-related. Conversely, the cir-
cumstances of the death were nearly always mentioned,
allowing us to identify SrSCD.
Media search
To validate our method of identifying SrSCD among ath-
letes, an extensive retrospective media search was per-
formed as a supplement to the main approach. The Danish
Holst et al Sports-Related SCD in Denmark
media surveillance database Infomedia (www.infomedia.
dk), a database of approximately 400 printed, 2,200 web-
based, and the major radio and television Danish media, was
used. All national and most regional media are included in
the database.
Medicolegal examination and autopsy in Denmark
In Denmark, if a death is sudden and unexpected, a medi-
colegal examination is carried out by the police and a
medical officer of public health (a certified physician). A
small number of medical officers of public health/forensic
pathologists (in total, 34 persons nationwide) perform the
medicolegal examinations, which include a standardized
death scene investigation with particular focus on circum-
stances of the death supplemented with data from hospital
records and interviews with relatives and witnesses. A sum-
mary of the medicolegal examination is written in the sup-
plemental information field on the death certificate, ensur-
ing a high degree of information on this.
A forensic autopsy is to be performed if the death is
sudden and unexpected. In Denmark there are 3 Depart-
ments of Forensic Medicine, which together conduct ap-
proximately 1,500 autopsies per year. All autopsies are
performed by 2 forensic pathologists and follow a standard-
ized protocol, in which all organ systems are examined.
Histopathology on the heart is done routinely in all cases,
except when an obvious noncardiac cause of death is estab-
lished at the macroscopic autopsy. Toxicology screenings
are performed on all deaths in which concern has been
raised of whether the person could have been intoxicated by
alcohol and/or drugs, and in all cases in which cause of
death remains unexplained after the macroscopic autopsy.
Alongside forensic autopsies, autopsies are also conducted
at local hospital pathology departments. These hospital au-
topsies are usually conducted if the police did not request an
autopsy and it is requested by the relatives or the treating
physician.
Athlete population
To estimate the size of the competitive athlete population
(the at-risk population) in Denmark, we used data derived
from the National Danish Health and Morbidity Study from
the year 2005. This is an interview study of 3,848 people
ages 16 to 35 years stratified on geographic as well as on
socioeconomic parameters.13 Because the age range in the
study did not match ours (12 to 35 years), the assumption
was made that we could extrapolate information about the
percent of people participating in competition-level sports
from the population ages 16 to 35 years to the population
ages 12 to 35 years.
Data from Veneto, Minnesota, and the entire
United States
We extracted data for Veneto, Minnesota, and the entire
United States from recent reports.1,9,12,10 We used data from
the period best matching ours available in the literature,
although also taking into account the necessity of covering
1367
a sufficient number of person-years, and thus used the pe-
riod 1993 to 2004 for Veneto and Minnesota, and 2001 to
2006 for the entire United States. In Veneto, reliable data
for the number of screened athletes evidently equaling the
number of competitive athletes is at hand, but in both
Minnesota and the entire United States this number is esti-
mated using, among many other data, the number of high
school and college students participating in different
sports.9,10
Information on population demographics was retrieved
from the U.S. Census Bureau (http://www.census.gov/) and
the Italian National Institute of Statistics, ISTAT (http://
demo.istat.it/), and used, where appropriate, as the denom-
inator for incidence rate calculations and for estimating the
percentage of athletes in the population.
Statistical methods
We used Stata 11 (StataCorp, College Station, Texas) for
our analyses. Incidence rates were calculated using the
mean age group population as a denominator when avail-
able, and if not the median year population was used.
Confidence intervals for incidence rates were calculated
using the Poisson distribution. The study was approved by
the local ethics committee (KF 01 272484), The Danish
Data Protection Agency (2005-41-5237), and the Danish
National Board of Health (7-505-29-58/1-5).
Results
Review of death certificates
During the study period, there were 5,865 deaths within the
age group, but in 203 cases, concerning either foreigners or
Danish citizens dying outside of Danish borders, no death
certificates were issued. We thus received 5,662 death cer-
tificates, and after excluding 53 death certificates due to
missing data, 5,609 death certificates were reviewed. A flow
chart of the process is shown in Figure 1.
Athlete background population
According to the National Danish Health and Morbidity
Study, 10.9% of the Danish population in the age group 16
to 35 years old reported participating in competition-level
sports.13 The mean 12- to 35-year-old population in the
period was 1,624,499,14 corresponding to a mean competi-
tive athlete population of 177,070 or 1,239,493 person-
years for the 7-year study period.
SrSCDs in Denmark by review of death certificates
Fifteen cases of SrSCD were found in the 7-year period,
corresponding to a median of 2 cases per year (range of 0 to
5 cases per year). The crude incidence rate of SrSCD in the
age group (athletes and nonathletes) was 0.13 (95% confi-
dence interval [CI]: 0.074 to 0.22) per 100,000 person-
years, whereas the incidence rate was 1.21 (95% CI: 0.68 to
2.00) per 100,000 athlete person-years.
Descriptive information on the 15 cases is given in Table 1.
The median age of death was 28 years (range 15 to 35 years,
mean 26.4 years), and the deceased subjects were all male.
1368 Heart Rhythm, Vol 7, No 10, October 2010

Prodromal symptoms, defined as symptoms in the minutes

leading up to the death, were observed in 2 of 12 (17%) of
the witnessed cases, and antecedent symptoms, defined as
symptoms in the year to months leading up to the death,
were reported in 8 of 15 (53%) of the cases. Autopsy was
performed in 14 of 15 cases (autopsy ratio 93%). After
review of the autopsy reports, 4 deaths were found to be
caused by ARVC; 4 were sudden unexplained death, 2 were
caused by coronary artery disease, and 1 was caused by each
of the following: myocarditis, cardiac sarcoidosis, possible
HCM, and congenital coronary artery anomaly. The con-
genital coronary artery anomaly was in the form of a ste-
notic left coronary artery departing from the posterior aortic
cusp. In the case of possible HCM, left ventricular hyper-
trophy was found, but no definite diagnosis could be made
because the histopathology showed no signs of disarray of
myofibrils.

Figure 1 Flowchart of the process used to identify SrSCD. SCD ⫽
sudden cardiac death; SrSCD ⫽ sports related sudden cardiac death.
The predominant sports were running (n ⫽ 5) and soccer
(n ⫽ 5). The site of death was in 11 of 15 (73%) cases a
sport arena; in 12 of 15 (80%) cases the death was wit-
nessed, all cases of deaths in a sport arena being witnessed.
Media reports
By searching the national media database, we identified and
read 1,129 articles, resulting in the finding of 3 cases of
SrSCD. All 3 cases were identified by the review of death
certificates.
All SCDs in Denmark
When including both cases of nonautopsied presumed SCD
(n ⫽ 142) and autopsied definite SCD (n ⫽ 286), we found
a total of 428 SCDs (including SrSCD) in Denmark in the
age group and period (Figure 1). The incidence rate of SCDs
was 3.76 (95% CI: 3.42 to 4.14) per 100,000 person-years.

Table 1 Cases of sports-related sudden death in Denmark, 2000 to 2006

Age at Sport Autopsy Prodromal Body Heart

death Sport arena Witnessed results symptoms Antecedent symptoms weight (kg) weight (g)
15 Running Yes Yes CCAA None Chest pain, no relation to 72 454
exercise
17 Soccer Yes Yes No autopsy None Dyspnea, treated as asthma N/A N/A
18 Running No No ARVC None None 70 360
18 Soccer Yes Yes ARVC None None 77 500
26 Soccer Yes Yes Sarcoidosis None None 83 500
27 Running Yes Yes SUD None None 82 395
27 Soccer Yes Yes SUD None Dyspnea, treated as asthma 76 332
28 Cycling No Yes ARVC None Exercise-related syncope 81 535
29 Aerobics Yes Yes SUD Syncope minutes None 78 460
before
30 Running No No Pos-HCM None Exercise-related syncope 106 680
diagnosed with athletes
heart
30 Handball Yes Yes SUD None Presyncope 1 week before 104 530
during training
31 Boxing Yes Yes CAD None None 92 510
32 Running Yes Yes CAD None Exercise-related syncope 70 400
33 Handball Yes Yes ARVC Dizziness 2 admissions because of chest 86 615
pain in preceding year
35 Soccer No No Myocarditis Dizziness None 83 359
All decedents were male. Prodromal symptoms was defined as symptoms in the minutes leading up to the death, and antecedent symptoms was defined
as symptoms in the year to months leading up to the death.
ARVC ⫽ arrhythmogenic right ventricular cardiomyopathy; CAD ⫽ coronary artery disease; CCAA ⫽ congenital coronary artery anomaly; LV ⫽ left
ventricular; N/A ⫽ not available; Pos-HCM ⫽ possible hypertrophic cardiomyopathy; SUD ⫽ sudden unexplained death.
Holst et al Sports-Related SCD in Denmark
Table 2 Comparison of data from Denmark, Veneto (Italy), Minnesota (United States), and the entire United States
Denmark
Observation period 2000–2006
Age group 12–35
Total population, in thousands* 5,427
Age group population, in thousands* 1,624
Athletes in age group, %† 10.9%
Incidence rate per 100,000 person-years (denominator)
SCD, general population (general population) 3.76
SCD, athletes (athletes) 1.21‡
SCD, athletes (general population) 0.13‡
Gender distribution, % women athletes 27%
Mean age of cases, yrs 26
N/A ⫽ not available.
*Retrieved from the U.S. Census bureau (http://www.census.gov/) and the Italian National Institute of Statistics, ISTAT (http://demo.istat.it/).
†Based on the number of athlete person-years retrieved from the references listed.
‡Sports-related sudden cardiac death.
Data from Veneto, Minnesota, and the entire
United States
The data from Denmark, Veneto, Minnesota, and the entire
United States are summarized in Table 2. The incidence
rates of SCD among athletes per 100,000 athlete person-
years were: entire United States, 0.61 (2001 to 2006);
Veneto, 0.87 (1993 to 2004); Minnesota, 0.93 (1993 to
2004). The rates for SCD among athletes per 100,000 per-
son-years in the general population in the corresponding age
group were: entire United States, 0.050 (2001 to 2006);
Veneto, 0.079 (1993 to 2004); and Minnesota, 0.072 (1993
to 2004).
Discussion
We report a study of all deaths for decedents ages 12 to 35
years in the period 2000 to 2006 in Denmark with the aim
of identifying all cases of SrSCD. We thoroughly examined
a total of 5,662 death certificates and found 15 cases of
SrSCD, amounting to an incidence rate of 1.21 per 100,000
athlete person-years.
We used a novel approach to chart the incidence of
SrSCD compared with other studies; instead of relying on
reporting either in the media (U.S.9) or from hospitals and
pathological departments (Veneto1), we examined all death
certificates of decedents in the period and age group to
identify possible SCDs. Danish death certificates allow for
extensive additional information compared to, for example,
those from the United States, thereby making the Danish
death certificates suitable as a primary screening tool for
identification of possible SCD in the young. We then gath-
ered additional data through autopsy reports, electronic reg-
istries, and in some cases hospital charts. We believe that
using this approach we missed only very few cases of
SrSCD, if any. In addition, we carried out a comprehensive
retrospective media search, and surprisingly we identified
only 3 (20%) cases of SrSCD using this method; all 3 cases
had been identified using our main approach. We cannot
dismiss the possibility of sampling bias and misclassifica-
tion of cases, but by using 2 independent reviewers of all
1369
Veneto1,12 Minnesota10 Entire United States9
1993–2004 1993–2004 2001–2006
12–35 12–31 8–39
4,530 4,919 291,652
1,385 1,383 131,313
8.1% 5.9% 8.1%
0.79 N/A N/A
0.87 0.93 0.61
0.079 0.072 0.050
20%12 40%19 N/A
23 17 18
death certificates and clear definitions, we believe we kept
this to a minimum.
We compared incidence rates in our study with those
from the entire United States, the state of Minnesota, and
Italy. However, a number of limitations in regard to this
should be emphasized. The numbers from the United States
and Minnesota included cases of aborted SCD, whereas the
Italian and our numbers did not. The athlete population
gender distribution among the studies differed significantly
(range 27% to 40% female) (Table 2), and as the SCD
incidence rate for male athletes is much higher than for
female athletes,11 this significantly influences the incidence
rates reported. The same issue concerns the age distribution,
which also varies among studies (Table 2), because risk of
SCD increases steeply with increasing age.11 Furthermore,
in our study, we were unable to identify SCD that occurred
in an athlete outside of training or competition, but accord-
ing to data from the United States and Veneto, 80% to 90%
of all SCDs in athletes occur during sports activity,1,9 thus
minimizing the problem. The main problem in comparing
the incidence rates, however, is the denominator, i.e., the
proportion of the general population involved in competi-
tive sports. In Veneto, athletes are registered because of the
mandatory screening; thus they have reliable numbers for
size of the athlete population.1 In our study as well as the
studies originating from United States,9 –11 these numbers
are estimated using different approaches. To try to circum-
vent this problem, we also calculated the incidence rate of
SrSCD using the whole population of the corresponding age
(athlete ⫹ nonathlete) as the denominator; this ensures
better comparability between studies when comparing inci-
dence rates if one assumes that all SrSCD occurs among
athletes and the proportion comprised by athletes is similar
across populations.
Taking into account the abovementioned limitations, we
find that our incidence rate of 1.21 per 100,000 athlete
person-years is in close alignment to what has been found in
other studies (range 0.61 to 0.93) (Table 2). We chose to
focus on the study from Veneto because our populations
1370
match well, as we examined the same age group (12 to 35
years old) and had comparable mean age (26 vs. 23 years
old) and gender distribution (27% vs. 20% female) of cases.
In Veneto, the postscreening era incidence rate was 0.87 per
100,000 athlete person-years or 0.079 per 100,000 person-
years in the general population, compared with ours, 1.21 or
0.13. Although the Danish incidence rates of SrSCD are
somewhat higher than the postscreening era ones reported
from Veneto, they are far from the incidence rate of 4.19 per
100,000 athlete person-years reported from the prescreening
era in Veneto. The value of preparticipation screening may
thus be limited in Denmark because we already have an
incidence rate of SrSCD comparable to the postscreening
era rate in Veneto. A comparison between Minnesota and
Veneto by Maron et al10 recently led to similar conclusions
regarding the United States, although the 2 populations
differed in respect to gender and age distribution.
The incidence rate of 4.19 per 100,000 athlete person-
years reported from the prescreening era in Veneto is much
higher than what has been reported in other studies, includ-
ing the present one,9 –11 and it could point to it being either
a spurious finding or a finding representative of another
genetic background/environment.
To study whether being a competitive athlete conferred
an increased risk of SCD in comparison to the general
population, we reported the incidence rate of SCD in the
general population (athletes and nonathletes) and found this
to be 3.76 per 100,000 person-years. Because of the inclu-
sion of nonautopsied cases, this is a high estimate, and the
true incidence rate is probably a bit lower, but this rate is
considerably higher than the incidence of SrSCD for ath-
letes (1.21 per 100,000 athlete person-years), indicating that
being a competitive athlete does not confer an increased risk
of SCD. This is in contrast to the findings from the pre-
screening era in Veneto.12
In regard to the activity at time of death, 33% of SrSCDs
occurred while running and 33% while playing soccer. The
distribution of cases according to sports was proportional to
the popularity of the sports in Denmark. The data thus do
not give any further information on risk of SrSCD in rela-
tion to type of sport. All cases were male. From reported
gender ratios in other studies,1,9,11,15 we expected only a
few female cases and not finding any was probably due to
chance. In regard to the distribution of causes of death in our
cohort, it is hard to draw any solid conclusions due to the
small numbers, but ARVC was found in a high proportion
of the cases (27%). In the United States, this was only found
in 2% of the cases in white athletes,9 but in screened athletes
in Veneto, ARVC was found in 22% of cases,12 and in a
recent study from Britain in a slightly older population the
proportion was 14%.15 We found no cases of definite HCM
in our population, but one case of possible HCM, which
may clinically have been diagnosed as HCM.16,17
Most deaths (73%) occurred in a sports arena and were
witnessed, and hence some of these deaths could potentially
have been prevented by an automatic external defibrillator
Heart Rhythm, Vol 7, No 10, October 2010
placed in sport arenas. A recent study showed that among
190 major soccer arenas in Europe only 72% had an auto-
matic external defibrillator and only 64% a medical action
plan for cardiovascular emergencies, however,18 highlight-
ing the potential for improvement in this area.
In more than half of the cases (53%) the decedents had
experienced probable cardiac symptoms such as dyspnea and
chest pain in the weeks, months, or years leading up to their
death, and in 4 of these cases (27%) even exercise-related
syncope and presyncope. This underlines the importance of a
thorough investigation by specialists in sports cardiology in all
cases of athletes experiencing probable cardiac symptoms,
especially if symptoms present during exercise.
Using data from Veneto, Elston and Stein4 recently cal-
culated that 38,151 athletes must be screened to prolong 1
life, and in the process 791 athletes would be disqualified
for each life prolonged. Raising awareness among athletes
and coaches about the importance of investigating probable
cardiac symptoms may present an alternative strategy for
preventing SrSCD, reducing costs and likely also reducing
the rate of false-positive results.
Conclusion
In Denmark, SrSCD in the young is a rare occurrence, with
an incidence rate of 0.13 per 100,000 person-years in the
general population and 1.21 per 100,000 athlete person-
years. This is comparable to the Italian postscreening era
incidence rate of 0.87 per 100,000 athlete person-years, and
lower than the Danish incidence rate of SCD of 3.76 per
100,000 person-years in the general population. These data
imply that preparticipation screening of athletes is likely to
be of low value in Denmark.
References
1. Corrado D, Basso C, Pavei A, et al. Trends in sudden cardiovascular death in
young competitive athletes after implementation of a preparticipation screening
program. JAMA 2006;296:1593–1601.
2. Corrado D, Thiene G. Protagonist: routine screening of all athletes prior to
participation in competitive sports should be mandatory to prevent sudden
cardiac death. Heart Rhythm 2007;4:520 –524.
3. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and consid-
erations related to preparticipation screening for cardiovascular abnormalities in
competitive athletes: 2007 update: a scientific statement from the American
Heart Association Council on Nutrition, Physical Activity, and Metabolism:
endorsed by the American College of Cardiology Foundation. Circulation 2007;
115:1643–1655.
4. Elston J, Stein K. Public health implications of establishing a national pro-
gramme to screen young athletes in the UK. Br J Sports Med 2009. Available at:
http://bjsm.bmj.com/content/early/2009/07/20/bjsm.2009.061184.abstract.
5. Thompson PD. Preparticipation screening of competitive athletes: seeking sim-
ple solutions to a complex problem. Circulation 2009;119:1072–1074.
6. Viskin S. Antagonist: routine screening of all athletes prior to participation in
competitive sports should be mandatory to prevent sudden cardiac death. Heart
Rhythm 2007;4:525–528.
7. Thompson PD, Levine BD. Protecting athletes from sudden cardiac death.
JAMA 2006;296:1648 –1650.
8. Corrado D, Basso C, Schiavon M, Pelliccia A, Thiene G. Pre-participation
screening of young competitive athletes for prevention of sudden cardiac death.
J Am Coll Cardiol 2008;52:1981–1989.
9. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in
young competitive athletes: analysis of 1866 deaths in the United States, 1980-
2006. Circulation 2009;119:1085–1092.
Holst et al Sports-Related SCD in Denmark
10. Maron BJ, Haas TS, Doerer JJ, Thompson PD, Hodges JS. Comparison of U.S.
and Italian experiences with sudden cardiac deaths in young competitive athletes
and implications for preparticipation screening strategies. Am J Cardiol 2009;
104:276 –280.
11. Van Camp SP, Bloor CM, Mueller FO, Cantu RC, Olson HG. Nontraumatic
sports death in high school and college athletes. Med Sci Sports Exerc
1995;27:641– 647.
12. Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G. Does sports activity
enhance the risk of sudden death in adolescents and young adults? J Am Coll
Cardiol 2003;42:1959 –1963.
13. The Health and Morbidity Study. The National Institute of Public Health. Available
at: http://susy2.si-folkesundhed.dk/susy.aspx. Accessed January 30, 2009.
14. Danmarks Statistik—statistikbanken.dk. Available at: http://www.statistikbanken.
dk/statbank5a/default.asp?w⫽1680. Accessed January 30, 2009.
1371
15. de Noronha SV, Sharma S, Papadakis M, et al. Aetiology of sudden cardiac death
in athletes in the United Kingdom: a pathological study. Heart 2009;95:1409 –1414.
16. McLeod CJ, Bos JM, Theis JL, et al. Histologic characterization of hypertrophic
cardiomyopathy with and without myofilament mutations. Am Heart J 2009;
158:799 – 805.
17. Fabre A, Sheppard MN. Sudden adult death syndrome and other non-ischaemic
causes of sudden cardiac death. Heart 2006;92:316 –320.
18. Borjesson M, Dugmore D, Mellwig K, et al. Time for action regarding cardio-
vascular emergency care at sports arenas: a lesson from the arena study. Eur
Heart J 2010. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20197422.
Accessed April 19, 2010.
19. Maron BJ, Gohman TE, Aeppli D. Prevalence of sudden cardiac death during
competitive sports activities in Minnesota High School athletes. J Am Coll
Cardiol 1998;32:1881–1884.