Sudden cardiac death in football players: Towards a new pre-participation algorithm

Athletic pre-participation screening is essential for minimizing the risk for sudden cardiac death (SCD) in athletes participating in either competitive or leisure sporting activities. The primary causes of SCD in young athletes (<35 years of age) include hypertrophic cardiomyopathy, congenital anomalies of the coronary artery and arrhythmogenic right ventricular cardiomyopathy. Other abnormalities, such as malignant arrhythmia due to blunt trauma to the chest (commotio cordis), myocarditis, valvular disease, aortic rupture (in Marfan syndrome) and ion channelopathies (catecholaminergic polymorphic ventricular tachycardia, Brugada syndrome, long or short QT syndrome), also contribute to a lesser degree to SCD. Currently, clinical assessment, electrocardiogram (ECG) and echocardiography are the cornerstones of the pre-participation athletic evaluation. However, their low sensitivity raises queries as regards the need for the application of more sophisticated modalities, such as cardiovascular magnetic resonance (CMR). CMR offers precise biventricular assessment and is greatly reproducible without the inherent limitations of echocardiography; i.e., low quality of images due to the lack of appropriate acoustic window or operator's experience. Furthermore, myocardium replacement fibrosis, indicative of patients' increased risk for future cardiac events, can be effectively detected by late gadolinium enhanced (LGE) images, acquired 15 min post-contrast injection. Finally, diffuse myocardial fibrosis not identified by LGE, can also be detected by pre-contrast (native) T1, post-contrast T1 mapping and extracellular volume images, which provide detailed information about the underlying pathophysiologic background. Therefore, CMR is recommended in all football players with a positive family or personal history of syncope or SCD, abnormal/doubtful ECG or echocardiogram.