Book Review

Arrhythmias and Sudden Death in Athletes

N Engl J Med 2001; 344:535February 15, 2001

Article

Arrhythmias and Sudden Death in Athletes
(Developments in Cardiovascular Medicine. Vol. 232.) Edited by A. Bayés de Luna, F. Furlanello, B.J. Maron, and D.P. Zipes. 163 pp., illustrated. Boston, Kluwer Academic, 2000. $77. ISBN: 0-7923-6337-X

This excellent short compilation speaks to the identification and management of potentially fatal cardiac problems that face athletes as well as practicing physicians, nurses, physician's assistants, and public health, school, university, and professional team administrators who are involved in sports medicine. The two central topics — whether or not and how to modify the athlete's life from a cardiologic viewpoint — are clearly outlined in a multiauthored book whose information is derived from substantial experience in American, Italian, and Spanish sports medicine. Pertinent literature is well summarized. The book comprises 10 very readable, well-referenced monographs, which nevertheless would have benefited considerably from more fully integrated or amplified commentary and more sophisticated coordination by the editors. However, pragmatic clinician-readers can make up their own minds in cases in which there are clear differences among American, Italian, and Spanish concepts or bases of classification of athletes' cardiovascular risks and their proper management.

The highlights of the book include a detailed presentation of the Italian classification of sports with keyed guidelines for athletes with cardiac arrhythmias. This classification forms part of the national medical rules for participation in sports that must be followed both by athletes (from school age upward) and by physicians who evaluate and care for athletes. An excellent compilation of American guidelines provides a practical approach, although there is no national athletic health policy in the United States. A clear result of Italy's national policy regarding the medical care of athletes is a far lower rate of death from hypertrophic cardiomyopathy among competitive athletes in Italy than in the United States. A consensus has emerged in the United States and Europe that athletes with supraventricular arrhythmias involving accessory pathways may be permitted to resume participation in competitive sports after successful electrophysiologic catheter ablation. Likewise, athletes who have fully recovered from a blunt blow to the chest (commotio cordis) or from myocarditis may take up competitive sports again. All of these athletes must continue to undergo regular medical observation. The recommendation to have automatic external defibrillators available at all athletic events, if not tough practice sessions, seems well justified.

The hesitancy of the American Heart Association to recommend 12-lead electrocardiography (ECG) in the screening of athletes seems unwarranted in the face of the successful European “safety first” policy, which achieved a reduction in deaths due to hypertrophic cardiomyopathy. Screening by ECG, a cheap, quickly applied technology, can reveal QRS, QT, ST-segment, and T-wave abnormalities in patients with hypertrophic cardiomyopathy or the Brugada, Wolff–Parkinson–White, or long-QT syndrome. Thus, ECG screening prompts further investigation in potential athletes who are at risk; such an investigation may include rapid echocardiographic evaluation for the high-risk hypertrophic cardiomyopathies and arrhythmogenic right ventricular dysplasia.

Quick-screen transthoracic echocardiography in children and adolescents who plan to participate in sports allows for the identification, in less than 10 minutes, of 95 percent of cases of hypertrophic cardiomyopathy and can be performed with relatively inexpensive ultrasonographic equipment. Arrhythmogenic right ventricular dysplasia, bicuspid aortic valves, and prolapses of the mitral and tricuspid valves are also rapidly detectable. Anomalous coronary arterial origin remains a difficult diagnostic challenge. Unfortunately, contemporary quick-screen transthoracic echocardiography cannot speedily visualize the origins of left and right coronary arteries and thus precludes the easy detection and surgical treatment of these high-risk congenital lesions.

The authors do not mention gene-specific arrhythmogenic disorders triggered by swimming in patients with the long-QT syndrome. Interested readers should peruse the recent, intriguing study in the Journal, involving male physicians in the United States, of death from cardiac causes triggered by vigorous exercise which found that this risk is diminished by habitual exercise (C.M. Albert, et al., 2000;343:1355–1361). The article will enrich readers' perspectives regarding the aging athlete.

Measures that can protect the precordium against commotio cordis, particularly in pediatric sports medicine, merit more detailed coverage than they are given in the book. Moreover, there is no discussion of protection against a blow to the neck's sensitive cardiovascular zone, the carotid sinus. I know of a case in which a lacrosse ball struck a player's neck, resulting in asystole. The lacrosse projectile thus joins the baseball, the softball, and the hockey puck as a potential cause of commotio cordis from the “R-on-T” phenomenon when it strikes the unprotected chest and as a potential cause of asystole when it strikes the unshielded carotid sinus.

Poor proofreading, sundry misspellings, four unlabeled panels in a figure, unnecessary duplication of tables, untranslated Italian or Spanish cardiologic terms, omissions of key words and reference numbers, and an inaccurate index detract from the otherwise enticing and interesting content. Furthermore, the index inconveniences the reader with its peculiarities. The important Brugada, long-QT, and Wolff–Parkinson–White syndromes, for instance, are listed only under the entry for “syndrome.” For such a high-priced book, the type is a bit too small — a false economy in an interesting and important book that is printed on acid-free paper. Despite flaws due to hasty assembly in the rush to print, however, this book, with its many common-sense views and precise recommendations, is a “must have” for all those seriously involved in sports medicine.

Richard Crampton, D.M.
University of Virginia School of Medicine, Charlottesville, VA 22908