Atherosclerosis and sudden cardiac death in athletes

Asymptomatic atherosclerotic cardiovascular disease (ASCVD) is the leading cause of sudden cardiac death (SCD) in athletes over 35 years of age. Despite their high physical fitness, athletes in this age group remain vulnerable to undetected coronary atherosclerosis, which predisposes them to plaque rupture and acute coronary thrombosis. In contrast, congenital coronary anomalies are the predominant cause of SCD in younger athletes. While SCD accounts for over 90 % of sports-related cardiovascular mortality, identifying at-risk individuals remains challenging due to the silent progression of coronary artery disease (CAD). Current screening methods, such as electrocardiography and stress testing, have limited sensitivity for detecting asymptomatic ASCVD, underscoring the need for advanced imaging modalities like coronary computed tomography angiography (CCTA) in high-risk populations. Risk mitigation requires a multifaceted approach: Tailored pre-participation cardiovascular screening incorporating age-specific risk factors, lifestyle interventions targeting atherosclerosis progression, education for early recognition of cardiac symptoms, and widespread availability of automated external defibrillators (AEDs) during athletic events. Emerging evidence supports integrating biomarkers, for instance, coronary calcium scoring and genetic testing for congenital anomalies, to enhance risk stratification. A comprehensive strategy combining targeted screening, advanced diagnostics, and evidence-based interventions is critical to reducing SCD incidence and improving outcomes in athletes.