ABC | Volume 111, Nº6, December 2018

Viewpoint Sudden Death in Young Brazilian Athletes: Isn’t It Time We Created a Genuinely National Register? Lucas Helal, 1,2 Filipe Ferrari, 1,3 Ricardo Stein 2,3,4 Programa de Pós-graduação em Cardiologia e Ciências Cardiovasculares da Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, 1 Porto Alegre, RS – Brasil Laboratório de Fisiopatologia do Exercício, Hospital de Clínicas de Porto Alegre, 2 Porto Alegre, RS – Brazil Grupo de Pesquisa em Cardiologia do Exercício, Hospital de Clínicas de Porto Alegre, 3 Porto Alegre, RS – Brazil Departamento de Medicina Interna da Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, 4 Porto Alegre, RS – Brazil Mailing Address: Ricardo Stein • João Caetano, 20/402. Postal Code 90470-260, Petrópolis, Porto Alegre, RS – Brazil E-mail: rstein@cardiol.br , kuqui.r@gmail.com Manuscript received April 16, 2018, revised manuscript June 12, 2018, accepted June 12, 2018 Keywords Cardiovascular Diseases; Athletes; Adolescent; Youth Sports; Death, Sudden, Cardiac; Genotype. DOI: 10.5935/abc.20180207 Abstract Young competitive athletes (≤ 35 years old) with or without a previous diagnosis of cardiovascular disease may suddenly die in competitive activities, potentially leading to an impact in society through the media. Although the relative risk for sudden death (SD) in athletes is twice as high as for their counterparts, the absolute incidence is low. While there is consensus among medical societies worldwide that early detection of causal factors is highly desirable, there is debate among different screening schemes to that end. In Brazil, the recommendations of the Brazilian Society of Cardiology mirror the guidelines of the European Society of Cardiology (ESC), which indicate a clinical examination combined with a 12‑lead resting electrocardiogram, regardless of the presence of risk factors. The possibility of genetic screening is also plausible, since most clinical entities that cause SD in young competitive athletes are related to genotype. Finally, considering the diversity of practiced sports, and the population miscegenation, we emphasize the need to a national registry of cases. Introduction Sudden death (SD) in young athletes (under 35 years old) is a peculiar event. Despite being rare, cases have been reported by far-reaching media, which may cause a major impact on both health agencies and the society. The counterintuitive feeling that young, presumably asymptomatic individuals with above-average physical fitness may die suddenly during sports practice seems particularly striking to many people, especially when it affects elite athletes. People involved in intense competitive activities have a relative SD risk that is nearly twice as high as that of their non‑athlete counterparts, though incidence in absolute numbers is very low – 0.5 to 2 events per 100,000 athletes per year. 1 Usually, clinical entities of cardiac or vascular nature, whether previously diagnosed or not, are the most prevalent causes of SD, and participation in sports events one of is the triggering factor for its occurrence. The most frequent are of genetic origin and hereditary, whether they structural (e.g., myocardiopathies) or not (e.g., channelopathies). On the other hand, the aortic (e.g., Marfan Syndrome) and coronary artery diseases are less prevalent but have also been described in this age group. 2 Based on evidence unrelated to exercise, external causal factors can also be considered. For example, the use of central nervous system stimulant drugs and anabolic steroids seems to increase the risk of SD in adults, 3,4 so it is plausible to hypothesize that athletes exposed to these risk factors may add to that statistic. In relation to its prevention, some success rate can be achieved if the disease is detected in time. There is treatment available for some illnesses and, on certain occasions, there may be a medical decision to suspend the athlete's participation in competitive sport (disqualification), thereby protecting them. Therefore, whenever possible, early detection of triggering diseases should be made. However, medical societies in various countries recommend different screening schemes. 5,6 Since the etiology of causative factors can differ regarding geography, ethnicity, sporting modality, genetic inheritance, and age, this point-of-view article aims to discuss the need for a national register of cases so the best prevention and early detection strategy may be laid out in Brazil – an idea already mentioned in this journal seven years ago. 7 Screening Schemes Suggested and the Absence of a Brazilian Register In 2011, Peidro, Froelicher and Stein published a point of view discussing particularities of Pre-Participation Physical Examination (PPE) for SD prevention in young athletes in Argentina and Brazil. 7 At the time, given the experiences that the American and Italian communities had about the effectiveness of the different decision algorithms, the need for national registers (in Argentina and Brazil) for SD cases was suggested. Since then, little has been done, and the national recommendation is not based on local data or robust evidence, such as: a) the prevalence of SD and its causes; b) ideally, subsequent evaluation of the effectiveness of potential screening strategies by means of randomized clinical trials; c) health technology assessment the algorithm to be proposed. The Brazilian Society of Cardiology (SBC) and the Brazilian Society of Exercise and Sports Medicine (SBMEE) jointly recommend the same screening scheme as the European Society of Cardiology (ESC) 6,8 – i.e., anamnesis, physical examination 856