In order to bring you the best possible user experience, this site uses Javascript. If you are seeing this message, it is likely that the Javascript option in your browser is disabled. For optimal viewing of this site, please ensure that Javascript is enabled for your browser.
Did you know that your browser is out of date? To get the best experience using our website we recommend that you upgrade to a newer version. Learn more.

How do you prevent “sudden death” during sports activities?

Although sport is associated with a lower level of all-cause mortality, exercise may paradoxically trigger sudden cardiac death (SCD) in individuals, especially those with cardiovascular disease. Therefore, pre-participation screening and consultation aimed at the detection of disorders associated with SCD are essential.

This risk differs according to the age of athletes and the presence of cardiovascular disease. While SCD is due mainly to atherosclerotic coronary artery disease in athletes >35 years of age, genetic or structural cardiac disorder is the main aetiology in young athletes.

Each age group should have strict recommendations concerning the type, duration and strength of the practised sport.

Sports Cardiology


ACM:     arrhythmogenic cardiomyopathy

AOCA:   anomalous origin of coronary arteries

BP:        blood pressure

CAD:      coronary artery disease

CACS:    coronary artery calcium scoring

CHD:      congenital heart disease

CTCA:    computed tomography coronary angiography

CVD:      cardiovascular disease

ECG:       electrocardiogram

HCM:      hypertrophic cardiomyopathy

MVP:      mitral valve prolapse

PA:         physical activity

SCA:      sudden cardiac arrest

SCD:      sudden cardiac death

SVT:       supraventricular tachycardia



Despite the importance of sports, exercise may paradoxically trigger sudden cardiac arrest (SCA) in individuals with cardiovascular disease (CVD), particularly those who were previously sedentary or have advanced CVD [1].

At the same time, sudden cardiac death (SCD) is the main cause of sports- and exercise-related mortality in athletes [2].

CV safety and avoiding of fatal events during the practice of sports is imperative and has become a common goal in many sports institutes [3].

Screening strategies should be tailored to the specific population groups and the different  cardiac disorders [4].

Special emphasis should be applied to high-risk groups during their pre-participation screening as well as during their follow-up.

Prevention of SCD requires certain eligibility conditions before practising sport.

In addition to pre-participation screening, special equipment should be available in clubs for prevention of SCD and management of SCA.


SCA in athletes could be defined as sudden collapse due to any cardiac aetiology in which cardiopulmonary resuscitation (CPR) and/or direct current (DC) shock is applied to an athlete regardless of the survival outcome [2].

SCD is defined as a sudden unexplained death due to any cardiac aetiology, or sudden death with a structurally normal heart post mortem with no other explanation for death and a history suggesting cardiac-related death [2].

SCD in athletes can be categorised according to the time of occurrence as that occurring during the exercise, within the first hour post exercise, or between 1 and 24 hours post exercise. The practice of sport at the time of SCD can be further classified as occurring during ordinary training or during competitive games [5].

Incidence of SCD in athletes

Current reports about the incidence of SCD in competitive athletes range from almost 1 in a million to 1 in 5,000 athletes per year [2,6].

The incidence of cardiac arrest increases acutely with vigorous exercise, especially in those who do not exercise regularly.

Previous reports show that 56-80% of SCA in young athletes occurs during exercise [2]. Some variables including sex, race and type of sport may increase the risk of SCA [2,6]. Relative risk increases in male athletes compared to female athletes, with a range from 3:1 to 9:1 (male:female) [2]. Black athletes also have a higher risk than white athletes (1 in 21,000 vs 1 in 68,000) [2].

Genetic and congenital structural cardiac disorders are usually the cause of SCD in young athletes [2,7]. However, in older athletes >35 years of age, SCD is due mainly to atherosclerotic coronary artery disease (CAD) in most cases, with increased risk with vigorous exercise. Athletes with little or no background in systematic training have the greatest risk [4].

Pre-participation screening programmes

A systematic pre-participation evaluation programme can significantly decrease SCD among athletes via identification of those with a cardiac disorder before licensing for sport practice, exercise modification and disease-related intervention [8]. For competitive or professional athletes, personal history, physical examination and a resting 12-lead electrocardiogram (ECG) are recommended [9].

Pre-participation screening allows application of appropriate measures to prevent SCD in athletes with clinically silent CVD through lifestyle modification, including restriction of competitive sports activity (if necessary), but also by prophylactic treatment with drugs and implantable defibrillators.

Screening for cardiovascular disease in young athletes

Pre-participation screening modalities in young athletes present specific challenges and limitations.

Despite low sensitivity, pre-participation history questionnaires show a high positive response rate. However, CV screening using ECG outperforms history and physical examination [10].

There are insufficient data to recommend an echocardiogram for routine screening without evidence of CV disorder warranting echocardiography performance.

Screening for cardiovascular disease in older athletes

The recommendations and evidence base for CV screening in athletes >35 years of age are limited. CV screening in senior athletes must be directed to atherosclerotic CAD.

ECG screening can uncover some latent cardiomyopathies as well as electrical disorders in older athletes. In addition, risk factor assessment for CVD may identify higher-risk individuals who need additional screening tests.

Despite CAD being the main aetiology of SCD in older athletes, routine screening for ischaemia with stress testing in asymptomatic individuals is not recommended. However, exercise ECG should be reserved for symptomatic or high-risk athletes based on the ESC Systematic Coronary Risk Evaluation (SCORE) system [11].

An exercise ECG test may also be important to evaluate the blood pressure (BP) response to exercise, the occurrence of exercise-induced arrhythmias, and to assess the functional capacity needed for exercise training. Exercise testing may also be helpful in the evaluation of CV functional capacity in elderly individuals who have recently engaged in moderate or severe exercise.

Prevention of scd in special populations

Anomalous origin of coronary arteries (AOCA)

SCD may result from ischaemic attacks due to the compression of the anomalous vessel coursing between the aorta and the pulmonary artery during exercise and/or the proximal intramural course of the anomalous coronary [12]. This frequent ischaemic episode may precipitate myocardial fibrosis and consequent ventricular arrhythmias during exercise.

Multislice contrast-enhanced computed tomography (CT), computed tomography coronary angiography (CCTA), or cardiac magnetic resonance (CMR) are the mainstays of diagnosis and should be considered together with an exercise test to identify high-risk individuals with AOCA. Participation in sports, more than low-intensity skill sports, is discouraged regardless of symptoms.

Valvular heart disease:

Mitral valve prolapse (MVP)

High-risk features for SCD are presented in Figure 1.

An exercise test and 24-hour Holter ECG should be considered in the evaluation of individuals with MVP. Individuals with high-risk features where myocardial fibrosis affecting the infero-basal wall is suspected should undergo a CMR imaging scan. Symptomatic patients with MVP and any of the high-risk features should not participate in recreational or competitive sports.


Figure 1. High-risk features of mitral valve prolapse. Adapted from  [13] Gati S, Malhotra A, Sharma S. Exercise recommendations in patients with valvular heart disease. Heart 2019;105:106-110 ( by permission of Oxford University Press on behalf of the European Society of Cardiology).

248_El Tahlawi_Figure 1_NEW.jpg


Hypertrophic cardiomyopathy (HCM)

Exercise carries a high risk of SCD/SCA for individuals with HCM. Consistently, all athletes with HCM have been recommended not to participate in competitive sports [9]. In addition, certain sports may carry a higher risk for SCD, such as highly dynamic, start-stop sports like basketball and football [2].

More recently, a more liberal approach to sports practice has been accepted in some individuals after careful evaluation [14]. This applies to amateur sports or leisure-time exercise to maintain physical and psychological well-being.

The baseline evaluation should include a detailed personal and family history, assessment of the clinical severity of HCM, and the presence of any other risk factors for SCD/SCA.

Individuals with a history of SCA or syncope and individuals with exercise-induced symptoms are recommended to engage in low-intensity recreational sports only. Holter ECG monitoring for 48 hours is recommended to detect ventricular and supraventricular arrhythmias.

Echocardiography should be used for risk stratification for SCD by assessing the following indices: (i) left ventricular (LV) wall thickness; (ii) LV outflow tract (LVOT) gradient at rest, during the Valsalva manoeuvre, on standing suddenly, and after light exercise; and (iii) left atrial diameter [15].

CMR imaging may be considered for confirming the diagnosis and for risk stratification in HCM.

Individuals with HCM who exercise on a regular basis should be followed up annually or biannually according to their vulnerability for exercise-related SCD. Follow-up should consider disease progression and the development of new symptoms that prompt interruption of exercise and re-evaluation.

Arrhythmogenic cardiomyopathy (ACM)

Regular and high-intensity exercise carries worse outcomes.

Competitive sports increase the risk of ventricular tachyarrhythmias or death twofold.

The baseline evaluation should include a detailed history of symptoms and family history of a similar disorder or SCD, clinical assessment of the severity of the ACM, and the presence of any traditional risk factors for SCD/SCA.

An ECG is important for risk stratification in ACM. The presence of extensive T-wave inversion in ≥3 precordial leads or T-wave inversion in two of the three inferior leads presents some additional risk for SCD/SCA [16].

Ambulatory ECG monitoring should include exercise periods to detect ventricular arrhythmias.

The presence of non-sustained ventricular tachycardia or high burden of ventricular ectopy (≥1,000/24 h), even in asymptomatic individuals, increases the risk of fatal arrhythmias [17].

Risk stratification for SCD in ACM includes echocardiography or CMR imaging assessment of the level of right ventricular (RV) and LV involvement.

Exercise testing should be part of the routine assessment of every individual with ACM who wants to exercise but away from “hot phases”, to assess the functional capacity and risk stratification.

An annual or biannual follow-up is recommended for ACM individuals who exercise on a regular basis according to SCD risk.

Dilated cardiomyopathy

Participation in high-intensity exercise as well as competitive sports may be allowed in asymptomatic individuals who fulfil certain low-risk criteria (Table 1).


Table 1. Low-risk criteria for SCD in dilated cardiomyopathy. Adapted from [4] (Pelliccia A, et al. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease: The Task Force on sports cardiology and exercise in patients with cardiovascular disease of the European Society of Cardiology (ESC). Eur Heart J. 2020;42:17-96) by permission of Oxford University Press on behalf of the European Society of Cardiology.

 Sports Cardiology and exercise in patients with cardiovascular disease Guidelines

Low risk criteria for SCD in dilated cardiomyopathy
  • mildly reduced LV systolic function (EF 45-50%)
  • absence of frequent and/or complex ventricular arrhythmias on ambulatory Holter monitoring or exercise testing
  • absence of LGE on CMR
  • ability to increase EF by 10-15% during exercise
  • no evidence of high-risk genotype (lamin A/C or filamin C).



A comprehensive evaluation after complete recovery to assess the risk of exercise-related SCD should include imaging studies, exercise stress test, and Holter monitoring.

Repeated evaluation including measurement of troponin and inflammatory biomarkers, echocardiography, and prolonged ECG monitoring should be carried out. Individuals without evidence of ongoing myocarditis should undergo an exercise stress test. CMR imaging should be repeated if myocardial oedema or late gadolinium enhancement (LGE) was present during the acute illness.

Asymptomatic individuals could return to sport when the troponin and inflammatory biomarkers return to normal, LV systolic function normalises, myocardial fibrosis on CMR disappears, and complex arrhythmias during exercise also disappear.

Pre-excitation and supraventricular tachycardia (SVT)   

Pre-excitation may be associated with SCD; therefore, athletes with paroxysmal SVT should stop exercise once palpitations occur. The responsible physician should educate individuals with SVT on how to perform vagal manoeuvres safely to terminate the arrhythmia. Exercise may be resumed after arrhythmia termination. Beta-blockers or calcium channel blockers could be used as a prophylactic treatment.

In competitive athletes with asymptomatic pre-excitation an electrophysiological (EP) study is warranted to evaluate the risk of SCD.

In the case of high-risk individuals, ablation of the accessory pathway is recommended.

Long QT syndrome (LQTS)

Symptomatic athletes are forbidden from engaging in competitive sports.

Special categories such as LQT1 should not engage in diving into cold water since this is associated with an increased risk of arrhythmias. Preventive measures include avoidance of QT-prolonging drugs, dehydration, and electrolyte imbalance. Beta-blocker drugs could be used effectively in LQT1.

Individuals who present with syncope or SCA despite beta-blocker therapy should be referred for an implantable cardioverter defibrillator (ICD).

Brugada syndrome

Arrhythmic syncope or SCA during exercise warrants ICD implantation in athletes. An EP study may play a role in detecting individuals at risk of SCD.

Complex congenital heart disease (CHD)

Many complex CHD patients with the highest risk of SCD have reduced exercise capacity and cannot usually practise a significant athletic activity. However, some groups, e.g., post tetralogy of Fallot repair, carry a risk of SCD but can still compete in low-intensity sport. SCD in CHD patients under 35 years was due to a presumed arrhythmia in 87% of cases in a large population-based study [18].

Pre-participation athletic screening including an ECG and echocardiography is important.

Pre-participation screening modalities

Pre-participation cardiovascular evaluation is recommended mainly by means of history (personal and family history) and physical examination alone. However, a 12-lead ECG improves the sensitivity of the screening process through early detection of CV disorders with specific ECG changes, such as cardiomyopathies, pre-excitation syndromes, and channelopathies [18]. These ECG changes are found in approximately two thirds of young competitive athletes with SCD.

Some authors consider ECG as a poor screening test in athletes, because of high false-positive results [20].

Role of ECG exercise test

Exercise testing is indicated in athletes during a pre-participation screening for the following purposes:

  • To diagnose CAD
  • Assess the blood pressure response to exercise
  • Detect the exercise-induced arrhythmias
  • Evaluate symptoms occurring during physical activity
  • Assess the physical fitness and functional capacity relative to training and type of sport
  • For diagnostic or therapeutic approach in some conditions, e.g., LQTS

Role of ambulatory ECG monitoring

The most important indications for ambulatory ECG monitoring are unexplained syncope and palpitations during or after exercise. It may also be used in the documentation of bradyarrhythmias or quantification of the burden of premature ventricular beats related to exercise. Holter ECG monitoring is considered also in specific cases such as LQTS.

Role of imaging modalities

Imaging modalities have been integrated in the pre-participation screening  of athletes who are suspected of having a cardiac disorder [17]. Transthoracic echocardiography and CMR will detect the majority of cardiomyopathies. CTCA and CMR are the non-invasive modalities of choice for coronary artery anomalies. Coronary artery calcium scoring (CACS), CTCA, and stress imaging are reserved for the evaluation of athletes with suspected atheromatous CAD.

Criteria for positive cases in pre-participation screening

Some criteria are considered positive and risk factors for SCD during initial screening and warrant further investigation before disqualification from competitive sport [21].

These criteria include the following.

Family history

  • Close relative(s) with premature MI or SCD at <50 years
  • Family history of cardiomyopathy, CAD, Marfan syndrome, LQTS, severe arrhythmias, or other disabling cardiovascular diseases.

Personal history

  • Syncope or pre-syncope
  • Exertional chest pain or shortness of breath or fatigue out of proportion to the degree of physical effort
  • Palpitations or irregular heartbeat

Physical examination

  • Musculoskeletal and ocular features suggestive of Marfan syndrome
  • Diminished and delayed femoral artery pulses
  • Mid- or end-systolic clicks
  • Abnormal second heart sound (single or widely split and fixed with respiration)
  • Heart murmurs (systolic grade ≥2/6 and any diastolic)
  • Brachial blood pressure ≥140/90 mmHg on more than one reading


  • Left and/or right atrial enlargement
  • Frontal-plane QRS axis deviation
  • Increased voltage
  • Abnormal Q-waves
  • Right or left bundle branch block
  • ST-segment depression or T-wave flattening or inversion in ≥2 leads
  • Prolonged corrected QT interval
  • Premature ventricular beats or more severe ventricular arrhythmia
  • Supraventricular tachycardia, atrial flutter, or fibrillation
  • Ventricular pre-excitation
  • First-degree, second-degree, or third-degree atrioventricular block

Other preventive strategies

The screening ability to detect young competitive athletes with either atherosclerotic or congenital coronary lesions is limited by the absence of baseline ECG changes in many cases with premature disease [18].

Moreover, SCD during sports may occur due to non-penetrating chest injury (commotio cordis) which cannot be prevented by screening. This requires the implementation of an additional prevention strategy based on early external defibrillation of SCA. The presence of a free-standing automated external defibrillator (AED) at sporting events is a valuable preventive measure for SCD in conditions undetected by screening.

However, the availability of an AED should neither replace a pre-participation evaluation programme nor justify engagement of high-risk athletes in competitive sports.


SCD can occur in athletes during competitive sports. The aetiology of SCD differs according to the age of athletes, associated cardiac disorder and type of sport. A pre-participation screening programme should be applied to all athletes before qualification. Baseline history and physical examination should be carried out as an essential part of screening. Other different modalities should be applied if needed according to different situations. The presence of positive criteria indicating a high risk for SCD requires disqualification or the modification of exercise practice.


  1. Marijon E, Uy-Evanado A, Reinier K, Teodorescu C, Narayanan K, Jouven X, Gunson K, Jui J, Chugh SS. Sudden Cardiac Arrest during Sports Activity in Middle Age. Circulation. 2015;131:1384-91. 
  2. Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, Zigman ML, Ellenbogen R, Rao AL, Ackerman MJ, Drezner JA. Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A Decade in Review. Circulation. 2015;132:10-9. 
  3. Hainline B, Drezner JA, Baggish A, Harmon KG, Emery MS, Myerburg RJ, Sanchez E, Molossi S, Parsons JT, Thompson PD. Interassociation Consensus Statement on Cardiovascular Care of College Student-Athletes. Am Coll Cardiol. 2016;67:2981-95. 
  4. Pelliccia A, Sharma S, Gati S, Bäck M, Börjesson M, Caselli S, Collet JP, Corrado D, Drezner JA, Halle M, Hansen D, Heidbuchel H, Myers J, Niebauer J, Papadakis M, Piepoli MF, Prescott E, Roos-Hesselink JW, Graham Stuart A, Taylor RS, Thompson PD, Tiberi M, Vanhees L, Wilhelm M; ESC Scientific Document Group. 2020 ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease. Eur Heart J. 2020;42:17-96. 
  5. Solberg EE, Borjesson M, Sharma S, Papadakis M, Wilhelm M, Drezner JA, Harmon KG, Alonso JM, Heidbuchel H, Dugmore D, Panhuyzen-Goedkoop NM, Mellwig KP, Carre F, Rasmusen H, Niebauer J, Behr ER, Thiene G, Sheppard MN, Basso C, Corrado D; Sport Cardiology Section of the EACPR of the ESC. Sudden Cardiac Arrest in Sports – Need for Uniform Registration: A Position Paper from the Sport Cardiology Section of the European Association for Cardiovascular Prevention and Rehabilitation. Eur J Prev Cardiol. 2015;23:657-67. 
  6. Roberts WO, Stovitz SD. Incidence of Sudden Cardiac Death in Minnesota High School Athletes 1993-2012 Screened with a Standardized Pre-Participation Evaluation. J Am Coll Cardiol. 2013;62:1298-1301. 
  7. 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;42:1959-63. 
  8. Drezner JA, O'Connor FG, Harmon KG, Fields KB, Asplund CA, Asif IM, Price DE, Dimeff RJ, Bernhardt DT, Roberts WO. Infographic: AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations and Future Directions. Br J Sports Med. 2017;51:168. 
  9. Pelliccia A, Fagard R, Bjørnstad HH, Anastassakis A, Arbustini E, Assanelli D, Biffi A, Borjesson M, Carrè F, Corrado D, Delise P, Dorwarth U, Hirth A, Heidbuchel H, Hoffmann E, Mellwig KP, Panhuyzen-Goedkoop N, Pisani A, Solberg EE, van-Buuren F, Vanhees L, Blomstrom-Lundqvist C, Deligiannis A, Dugmore D, Glikson M, Hoff PI, Hoffmann A, Hoffmann E, Horstkotte D, Nordrehaug JE, Oudhof J, McKenna WJ, Penco M, Priori S, Reybrouck T, Senden J, Spataro A, Thiene G; Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology; Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Recommendations for Competitive Sports Participation in Athletes with Cardiovascular Disease: A Consensus Document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005;26:1422-45. 
  10. Fudge J, Harmon KG, Owens DS, Prutkin JM, Salerno JC, Asif IM, Haruta A, Pelto H, Rao AL, Toresdahl BG, Drezner JA. Cardiovascular Screening in Adolescents and Young Adults: A Prospective Study Comparing the Pre-Participation Physical Evaluation Monograph 4th Edition and ECG. Br Sports Med. 2014;48:1172-8. 
  11. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U, Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Løchen ML, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB, van Dis I, Verschuren WMM, Binno S; ESC Scientific Document Group. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2315-81. 
  12. Finocchiaro G, Behr ER, Tanzarella G, Papadakis M, Malhotra A, Dhutia H, Miles C, Diemberger I, Sharma S, Sheppard MN. Anomalous Coronary Artery Origin and Sudden Cardiac Death. JACC Clin Electrophysiol. 2019;5:516-22. 
  13. Gati S, Malhotra A, Sharma S. Exercise recommendations in patients with valvular heart disease. Heart. 2019;105:106-110. 
  14. Pelliccia A, Solberg EE, Papadakis M, Adami PE, Biffi A, Caselli S, La Gerche A, Niebauer J, Pressler A, Schmied CM, Serratosa L, Halle M, Van Buuren F, Borjesson M, Carrè F, Panhuyzen-Goedkoop NM, Heidbuchel H, Olivotto I, Corrado D, Sinagra G, Sharma S. Recommendations for Participation in Competitive and Leisure Time Sport in Athletes with Cardiomyopathies, Myocarditis, and Pericarditis: Position Statement of the Sport Cardiology Section of the European Association of Preventive Cardiology (EAPC). Eur Heart J. 2019;40:19-33. 
  15. Authors/Task Force members, Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, Limongelli G, Mahrholdt H, McKenna WJ, Mogensen J, Nihoyannopoulos P, Nistri S, Pieper PG, Pieske B, Rapezzi C, Rutten FH, Tillmanns C, Watkins H. 2014 ESC Guidelines on Diagnosis and Management of Hypertrophic Cardiomyopathy: The Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J. 2014;35:2733-79. 
  16. Bhonsale A, James CA, Tichnell C, Murray B, Gagarin D, Philips B, Dalal D, Tedford R, Russell SD, Abraham T, Tandri H, Judge DP, Calkins H. Incidence and Predictors of Implantable Cardioverter-Defibrillator Therapy in Patients with Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy Undergoing Implantable Cardioverter-Defibrillator Implantation for Primary Prevention. J Am Coll Cardiol. 2011;58:1485-96. 
  17. Gupta R, Tichnell C, Murray B, Rizzo S, Te Riele A, Tandri H, Judge DP, Thiene G, Basso C, Calkins H, James CA. Comparison of Features of Fatal Versus Nonfatal Cardiac Arrest in Patients With Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy. Am J Cardiol. 2017;120:111-7. 
  18. Lynge TH, Jeppesen AG, Winkel BG, Glinge C, Schmidt MR, Søndergaard L, Risgaard B, Tfelt-Hansen J. Nationwide Study of Sudden Cardiac Death in People with Congenital Heart Defects Aged 0 to 35 Years. Circ Arrhythm Electrophysiol. 2018;11:e005757. 
  19. Corrado D, Pelliccia A, Bjørnstad HH, Vanhees L, Biffi A, Borjesson M, Panhuyzen-Goedkoop N, Deligiannis A, Solberg E, Dugmore D, Mellwig KP, Assanelli D, Delise P, van-Buuren F, Anastasakis A, Heidbuchel H, Hoffmann E, Fagard R, Priori SG, Basso C, Arbustini E, Blomstrom-Lundqvist C, McKenna WJ, Thiene G; Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Cardiovascular Pre-Participation Screening of Young Competitive Athletes for Prevention of Sudden Death: Proposal for a Common European Protocol - Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J. 2005;26:516-24. 
  20. Corrado D, Basso C, Pelliccia A, Thiene G. Sports and Heart Disease. In, The ESC Textbook of Cardiovascular Medicine. Oxford, UK: Oxford University Press; 2009. 
  21. Corrado D, Basso C, Pavei A, Michieli P, Schiavon M, Thiene G. Trends in Sudden Cardiovascular Death in Young Competitive Athletes. JAMA. 2006;296:1593-601.

Notes to editor


Assistant Professor Mohammad El-Tahlawi, MD
Cardiology Department, Zagazig University, Zagazig, Egypt

Address for correspondence:

Assistant Professor Mohammad El-Tahlawi,
Zagazig University Hospitals, Cardiology Department, Zagazig, Egypt.


Author disclosures:

The author has no conflict of interest to declare.


The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.