Sudden cardiac death in athletes: what 30 years since Brugada teach us

On 26 June 2003, the Cameroonian midfielder Marc-Vivien Foé collapsed on the pitch of the Stade de Gerland in Lyon during a Confederations Cup match. Twenty-nine years old, an elite player at the peak of his physical performance. Thirty minutes later, Dr. Alain Choutet, the emergency cardiologist who fought for his life, confirmed his death from a sudden arrhythmic event. The cause: undiagnosed hypertrophic cardiomyopathy.

Cases like Foé's are, sadly, not rare. Each year, between 1 and 3 young athletes per 100,000 die suddenly from cardiac arrest. According to the most recent study by the European Society of Cardiology, this amounts to between 500 and 1,500 deaths annually in Europe alone. Most of these deaths are preventable. We have known this since 1982.

Thirty years after the Brugada brothers described the syndrome that bears their name, we have learned a great deal about the cardiac causes behind these events. But the implementation of cardiovascular screening programmes in sport remains inconsistent — and in some countries almost non-existent. In this article we review what these three decades have taught us about identifying at-risk athletes, and what still remains to be done.

A silent problem with an enormous impact

Sudden cardiac death in young athletes has a cruel peculiarity: it rarely gives warning signs. In 60% of cases, the fatal event is the first and only manifestation of the underlying disease. When symptoms do appear — exertional syncope, abnormal chest pain, sustained palpitations — the window to intervene is narrow.

Epidemiological data vary by country and screening method, but there is consensus on some facts:

• Demographic profile: The average age of the victim is 23. Ninety percent are men. The sports with the highest relative incidence are football, basketball, athletics, and rugby.
• Real incidence: 1-3 per 100,000 competitive athletes/year (Corrado et al., 2003). In North American collegiate athletes, incidence reaches 1 in 43,700 in male basketball players (Harmon et al., 2015).
• Aetiology: In athletes under 35, the leading causes are genetic: hypertrophic cardiomyopathy (36%), congenital coronary anomalies (17%), arrhythmogenic right ventricular cardiomyopathy (10%), and primary arrhythmic syndromes such as Brugada and long QT (8-10%).

There is one important exception to this pattern. In athletes over 35, the dominant cause is atherosclerotic coronary disease — far more diagnosable with conventional techniques. The real tragedy lies with the young, apparently healthy athletes.

The Italian experience: 30 years that changed European sport

In 1982, Italy became the first country in the world to make pre-participation cardiovascular screening with electrocardiogram mandatory for all competitive athletes. Italian law requires an annual examination with clinical history, physical examination and 12-lead ECG for anyone competing in a recognised sport.

The results of this natural experiment are the foundation of modern screening evidence:

• 1979-1981 (before the programme): incidence of sudden cardiac death in Italian competitive athletes of 3.6 per 100,000/year.
• 1993-2004 (10 years after): the incidence had fallen to 0.4 per 100,000/year, a reduction of 89%.

This was the first systematic evidence that ECG screening could save athletes' lives. The results directly influenced the guidelines of the European Society of Cardiology (2005) and the Fédération Internationale de Football Association (FIFA), which adopted ECG screening as standard.

The American Heart Association, in contrast, has maintained a more conservative position, arguing that the cost-benefit ratio of population ECG screening in the United States is not sufficiently demonstrated. This divergence between continents remains one of the most active discussions in sports cardiology.

What Brugada syndrome brought to sports screening

When the brothers Pedro and Josep Brugada described in 1992 in the Journal of the American College of Cardiology the syndrome that bears their name, they added an essential piece to the puzzle of sudden death in apparently healthy young people. For the first time, there was a well-defined clinical entity for individuals without structural heart disease but with a significant arrhythmic risk.

For sports cardiology, this discovery had three crucial implications:

• A new ECG-identifiable diagnosis: The type 1 pattern (concave ST-segment elevation ≥ 2 mm followed by a negative T wave in V1-V2) allows identification of the syndrome from a simple ECG reading. This makes it an ideal candidate for sports screening.
• A risk factor modifiable by exercise: Intense exercise produces changes in body temperature, hydration status and autonomic tone that can unmask ECG patterns in asymptomatic carriers. Fever — a common symptom after intense effort in hot climates — is an especially potent trigger.
• Specific clinical management: Symptomatic carriers or those at elevated risk benefit from specific sporting restrictions and, in some cases, from an implantable cardioverter-defibrillator (ICD). Not all carriers should avoid sport, but the decision requires specialist cardiological evaluation.

According to data from European and Asian cohorts, Brugada syndrome is responsible for 4-8% of sudden cardiac deaths in competitive athletes under 35. The proportion is higher in Southeast Asian populations, where the baseline prevalence of the syndrome is greater.

The Latin American perspective: Dr. Roberto Keegan

For athletes in countries with less developed screening systems, the equation is different. In Latin America, access to a pre-participation ECG is not universal, and where it exists, a standardised reading protocol is often not applied.

Dr. Roberto Keegan, Electrophysiology Consultant at Hospital Privado del Sur (Bahía Blanca, Argentina) and at Hospital Español de Bahía Blanca, and former President of the Latin American Heart Rhythm Society (LAHRS), has been a consistent voice highlighting the relevance of the electrocardiogram as a screening tool for cardiovascular disease. According to data presented at regional congresses, adopting screening protocols such as the one proposed by the ESC could prevent between 60% and 70% of sudden cardiac deaths in young athletes in the region.

The prevalence and clinical characteristics of sudden death in athletes in Latin America are similar to those in other regions. Although the demographic, socio-economic and healthcare particularities of our region may represent a greater challenge for implementing evaluation models, the majority of recommendations from Latin American scientific societies (e.g. Argentina, Uruguay, Chile, Panama and Mexico, among others) agree — as do the European ones — on the relevance of the electrocardiogram as a screening tool for detecting structural and electrical heart diseases before the start of sporting activity.

This geographical perspective is crucial. Sudden cardiac death in athletes is not only a medical problem but also one of global health equity.

What modern pre-participation screening should include

Building on 30 years of Italian evidence and three decades of refinement of knowledge about inherited arrhythmic syndromes, modern pre-participation screening should at minimum include the following elements.

Basic elements (recommended by ESC and FIFA):

• Detailed clinical history (personal and family)
• Comprehensive physical examination
• 12-lead electrocardiogram
• Annual repetition for competitive athletes

Second-line elements (indicated in specific cases):

• ECG stress test
• Echocardiogram
• Pharmacological test (e.g. ajmaline) to confirm Brugada pattern
• Cardiac magnetic resonance
• Genetic study

One of the least recognised aspects of sports screening is the need for ECG reading by a specialist experienced with athletes. Many ECG patterns considered abnormal in the general population are normal variants in well-trained athletes (sinus bradycardia, incomplete right bundle branch block, diffuse ST-segment elevation). Distinguishing these variants from real abnormalities requires specific criteria — the Seattle criteria (2013) and the international criteria (2017) are the most widely used tools.

Where digital technology can help

The main obstacle to implementing ECG screening in many countries is not technical but logistical and economic. Conventional equipment is expensive, requires dedicated personnel, and interpretation by a cardiologist is not available in many primary-care settings.

The evolution of portable ECG devices and diagnostic support systems based on artificial intelligence opens real possibilities for democratising access to cardiac screening. A wireless 12-lead ECG, integrated with mobile apps and with an AI-assisted automatic analysis system, can transform the workflow of a population screening programme.

This does not replace cardiologist review for cases with suspicion, but it can:

• Scale initial screening to amateur and grassroots sport.
• Standardise ECG capture quality, reducing technical errors.
• Filter cases requiring human review, allowing cardiologists to focus on those who truly need it.
• Longitudinally document an athlete's ECG throughout their career.

At MedicalCSE, we designed ECG-Expert with exactly this philosophy: a portable 12-lead electrocardiograph, MDR Class IIa certified, that can integrate into sports screening, primary-care and sports-medicine workflows. With the clinical supervision of Dr. Josep Brugada and Dr. Roberto Keegan, we design technology intended to change the statistics with which we opened this article.

What a club, a federation or a sports doctor can do today

At club or federation level:

• Adopt pre-participation ECG screening as standard.
• Establish standardised interpretation criteria (Seattle 2013 or International 2017).
• Train personnel in CPR and use of automated external defibrillators (AEDs).
• Install AEDs at all sporting venues and keep them operational.
• Establish emergency plans with target response times (less than 3 minutes to first shock).

At athlete and family level:

• Always communicate family history of sudden death, especially under age 45.
• Report exertional syncope, chest pain, sustained palpitations or disproportionate dyspnoea.
• Fever is an arrhythmic risk factor in Brugada syndrome carriers — avoid intense exercise with fever.
• Undergo periodic check-ups, especially in high-intensity sports.

Frequently asked questions

Do athletes have a higher risk of sudden cardiac death than the general population?

The absolute risk in a young athlete is low (1-3 per 100,000/year), but intense exercise acts as a trigger in people with undiagnosed underlying heart disease. The relative risk is 2-3 times higher than in sedentary peers.

Does a normal ECG rule out the risk of sudden death?

Not completely. Some athletes with inherited arrhythmic syndromes may have a normal resting ECG. Systematic screening with detailed family history and, in cases of suspicion, complementary tests (stress, echocardiogram, MRI, pharmacological tests) is essential.

At what age should screening begin?

Most international guidelines recommend beginning ECG screening from 12-14 years of age for competitive athletes, with annual frequency. In recreational adult athletes, screening is indicated before starting an intense training programme after age 35.

Can an athlete with Brugada syndrome compete?

It depends on the clinical profile. Asymptomatic carriers of a type 1 Brugada pattern with low arrhythmic risk can maintain sporting activity, avoiding high-intensity sports in hot environments and strictly controlling fever. Symptomatic or high-risk cases usually require competitive restriction and, often, an implantable defibrillator.

Want to know more about how ECG-Expert can integrate into sports screening?

If you are a sports doctor, cardiologist, representative of a federation or club, or simply interested in exploring how digital ECG solutions can integrate into sudden-cardiac-death prevention programmes, you can contact our team through the contact form.

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Article prepared by the MedicalCSE editorial team, with the clinical supervision of Dr. Josep Brugada Terradellas, co-discoverer of Brugada syndrome and Medical Advisor at MedicalCSE, and Dr. Roberto Keegan, former President of the Latin American Heart Rhythm Society and Medical Advisor at MedicalCSE.