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Sudden Unexpected Death Due to Myocarditis in Young People, Including Athletes
Kevin M Harris1, Shannon Mackey-Bojack2, Mosi Bennett1
1Minneapolis Heart Institute Foundation at Abbott-Northwestern Hospital, Minneapolis, Minnesota.
Insights
Myocarditis, an inflammation of the heart muscle, is an under-recognized cause of sudden cardiac death in young athletes. Early diagnosis is challenging due to nonspecific symptoms, necessitating a high index of suspicion.
Area of Science:
- Cardiology
- Pathology
- Sports Medicine
Background:
- Sudden cardiac death in young individuals is rare but often linked to known cardiovascular conditions.
- Myocarditis is a significant, yet frequently overlooked, cause of sudden death in young people, particularly athletes.
Purpose of the Study:
- To analyze clinical, demographic, and pathological findings of myocarditis in young individuals using data from two large registries.
- To highlight the under-recognized nature of myocarditis as a cause of sudden death and inform diagnostic and management strategies.
Main Methods:
- Reviewed two large registries to identify cases of myocarditis in young individuals.
- Assessed clinical, demographic, and pathological data, including inflammatory infiltrate and conduction system involvement.
Main Results:
- Identified 97 cases of myocarditis in individuals aged 19.3 ± 6.2 years, with 76% being male and 58% physically active near death.
- Nearly half (47%) experienced viral prodrome or symptoms; none were diagnosed with myocarditis before death, despite some cardiology evaluations.
- Predominantly lymphocytic (67%) and multifocal (59%) inflammation was observed, with 38% involving the conduction system.
Conclusions:
- Myocarditis is a critical, under-recognized cause of sudden death in young people and athletes, posing diagnostic challenges due to nonspecific symptoms.
- A high index of suspicion is crucial for clinical diagnosis. Current guidelines recommending removal from sports during recovery are supported.
- Conduction system involvement in myocarditis suggests a potential novel mechanism for sudden cardiac death.
Abstract:
Sudden deaths in young active people and athletes are distinctly uncommon and frequently related to highly visible cardiovascular conditions including hypertrophic cardiomyopathy and congenital coronary anomalies. Myocarditis is also a cause of sudden death in the young, but frequently under-recognized clinically, and therefore deserving of the present analysis. Two large registries were interrogated for cases of myocarditis, and clinical, demographic, and pathologic findings were assessed. Of 97 cases of myocarditis identified, ages were 19.3 ± 6.2 years, 76% male, and 58 were physically active at or near the time of death. Almost one-half of the 97 cases (47%) had a viral prodrome or symptoms (i.e., syncope, malaise, chest pain or palpitations). Nine were evaluated by cardiologists, but in none was a diagnosis of myocarditis established before death. The inflammatory cellular infiltrate was predominantly lymphocytic (67%), was most frequently multifocal (59%) and involved the conduction system (including atrioventricular node), 38%. In conclusion, myocarditis is an important but under-recognized cause of sudden death in young people including competitive athletes. Clinical diagnosis is difficult because symptoms are nonspecific and often ignored, requiring high index of suspicion for diagnosis. Our data support the ACC/AHA consensus guidelines recommending removal of individuals with myocarditis from competitive sports during recovery. Selective examination of conduction systems showed a number of cases with involvement of myocarditis, suggesting a novel mechanism for sudden death.
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