Unfortunately, it is all too common to read about cases of sudden cardiac death in well-conditioned young athletes. This also strongly highlights the need for athletic recovery programmes and for this to be taken seriously when it comes to athletics as a sport. Insurers see many cases of high-face-amount applications to insure large money contracts and to protect teams against economic loss. These policies, written on young and ostensibly healthy individuals, are very low premium cases relative to the net amount at risk; thus, companies have to be very careful to get enough information in order to accurately underwrite these high amount cases.
Sudden cardiac death (SCD) is defined as death that occurs within one hour of symptoms in someone without a previously recognized cardiovascular abnormality. It excludes other causes of sudden death including respiratory (e.g., life-threatening asthma) and drug-related overdoses. The estimate is that 300,000 cases a year of sudden cardiac death occur in the United States population each year, and 1 to 2 percent of those are in people under the age of 35. The risk is five times greater for males than females, three times higher for young athletes when compared to non-athletes, and twice the average for African Americans.
There are three main categories of sudden cardiac deaths for young athletes.
• The first is structural heart disease. This includes coronary artery disease (premature), abnormalities of the blood vessels themselves, myocardial bridges (where the electrical system jumps and short circuits), and hypertrophic cardiomyopathy (enlarged heart).
Hypertrophic cardiomyopathy (HCM) makes up the largest part of these categories-almost 40 percent. The annual mortality with this condition is about 1 percent per year, half of it presenting as sudden cardiac death. Athletes generally have larger hearts than non-athletes because of their increased conditioning and the heart’s need to pump larger amounts of blood at increased heart rate during maximal exercise. However, the pattern of HCM is generally marked and has unique features that allow it to be differentiated from the normal athlete’s heart in most cases.
• The second category of SCD involves primary cardiac electrical deficits. They have names such as long QT syndrome (a measurement of the time between the start of the Q-wave and the end of the T-wave in the heart’s electrical cycle), Brugada syndrome, and catecholinergic polymorphic ventricular tachycardia. Most are genetic, and unfortunately do not cause marked symptoms until sudden death. During exercise in particular, these patterns may present themselves, and screening should be done for any athlete who complains of abnormal tiring, fatigue or lightheadedness during normal exercise.
• The last category is caused by external factors such as trauma. Commotio cordis is the second most common cause of SCD in athletes and depends on a projectile striking the chest at a critical point in ventricular repolarization, meaning wrong hit at the wrong time. Quick cardio-pulmonary resuscitation can reverse this, unlike other causes which may have structural problems that prove more difficult to treat.
A major challenge to insurance companies comes with requirements at younger ages. For the convenience of higher end athletes, as well as the fact that they are assumed to be in superior physical shape at younger ages, requests to waive exercise testing and even a basic resting EKG are often encountered. While EKGs are frequently abnormal in athletes, who have larger hearts and slower pulse rates due to their increased conditioning, the fact is that an EKG picks up many etiologies for sudden cardiac death (including hypertrophic cardiomyopathy, the long QT syndrome, Brugada syndrome and conduction abnormalities).
Most athletes are in quite pristine cardiac condition and will qualify for best available rates. Insurers look at family history, personal history (for things like a murmur, chest pain, palpitations, or fainting) and any physical examinations done as part of team sports. Indeed, many teams now put their athletes through extensive cardiac testing to protect the investment of a large multi-year contract just as an insurer must insist on a little more cardiac information for an athlete before issuing a policy. The risk certainly warrants going the extra step in evaluation.
