Possible mechanisms of sudden cardiac death in top athletes: a basic cardiac electrophysiological point of view

Abstract

Sudden death among athletes is very rare (1:50,000-1:100,000 annually) but it is still 2-4 times more frequent than in the age-matched control population and attracts significant media attention. We propose a mechanism underlying sudden cardiac death in athletes that does not relate to myocardial ischemia but is based on repolarization abnormalities due to potassium channel downregulation and can also be best explained by the concurrent presence of several factors such as cardiac hypertrophy (athlete's heart), and/or hypertrophic cardiomyopathy, increased sympathetic tone, genetic defects, drugs, doping agents, food, or dietary ingredients. These factors together can increase the repolarization inhomogeneity of the heart ("substrate") and an otherwise harmless extrasystole ("trigger") occurring with a very unfortunate timing may sometimes induce life-threatening arrhythmias. The effective and possible prevention of sudden cardiac death requires the development of novel cost effective cardiac electrophysiological screening methods. Athletes identified by these tests as individuals at higher proarrhythmic risk should then be subjected to more costly genetic tests in order to uncover possible underlying genetic causes for alterations in ionic channel structure and/or function.