Each start of the new school year, headlines bear the names of a handful of young, seemingly healthy athletes who die suddenly on the basketball court, the football field, or the track.

Already this school year, three Houston-area teen athletes, ranging from 12 to 19 years old have died suddenly during or following athletic workouts. Though one was attributed to an aggressive form of meningitis, the other two were determined to be either from enlarged hearts or fatal arrhythmias.

When an otherwise superbly-conditioned teenager dies suddenly, a condition called sudden cardiac death is often to blame, say experts.

Spotting these cases in pre-athletic medical screenings can be a challenge when there are no prior problems to report. And, though these incidences are tragic beyond measure, physicians urge parents to keep perspective: sudden cardiac death in teens is still rare.

Sudden cardiac death occurs when the heart stops abruptly. In teenagers and young adults, structural heart abnormalities or heart rhythm disturbances are a common cause of sudden death. The condition claims the lives of a few athletes each fall, usually in the beginning of the sports season. And, though physical exertion in Houston heat can create opportunity for other complications, it rarely is the underlying cause of sudden cardiac death.

Newspapers splash headlines and communities are devastated " because it is such an unexpected death in someone who was always thought to be healthy, an athlete," says Dr. Grant Fowler, professor and vice chair in the Department of Family Practice and Community Medicine at The University of Texas Medical School, and certified in primary care sports medicine. "Typically the athletes have had symptoms as a warning, but they may have ignored it or assumed that they had just overdone it, over-exerted themselves or become too dehydrated."

What causes a broken heart?

An inherited heart defect called hypertrophic cardiomyopathy is a common cause of sudden cardiac death. In persons with hypertrophic cardiomyopathy, the heart muscle, usually the left ventricle, is abnormally enlarged. The malformed ventricle can block the blood flow and cause abnormal heart rhythms, called arrhythmias. Some arrhythmias (not all) can lead to sudden death.

In athletic teens with normal hearts, the heart muscle, like any other muscle, naturally thickens and enlarges from strenuous exercise so that it can pump more efficiently. “Athlete’s heart” is not a cause of sudden death, says Dr. Syam P. Rao, director of the Division of Pediatric Cardiology at UT Medical School, “but should be distinguished from hypertrophic cardiomyopathy by a cardiologist.”

Marfan syndrome is another inherited disorder that increases risk for sudden death. This connective tissue disorder affects the skeleton, lungs, eyes, heart and blood vessels, and can cause aortic dilations, which can rupture suddenly when the heart is under stress.

People with the syndrome are tall and have unusually long limbs, traits that are often desirable in sports like basketball. However, Marfan teens should avoid all contact sports.

Coronary heart disease, congenital anomalies of the coronary arteries, some rare arrhythmias, aortic aneurysm dissection, myocarditis, long QT syndrome, Kawasaki's disease, and hard blows to the chest are also risk factors for sudden death, Rao explains.

Warning signs

Fainting, chest pain, difficulty breathing and dizziness with exercise can all be warning signs of heart problems and warrant attention. Parents and teenagers should take them seriously, and see a doctor. Better yet, tell your doctor about any problems you may be having, before the season starts, at your annual sports screening. He or she can help determine whether you at risk for heart problems.

After an initial, thorough physical exam, "I typically have three questions for patients: have they ever passed out when exercising, have they ever had palpitations or felt like they were going to faint while exercising, or is there a family member who has ever died suddenly," Fowler says.

If students answer yes to any of the questions, they may have an underlying heart problem that necessitates additional diagnostic testing. The tests that are selected are based on what is found on the history and physical examination.

Most of the time, the tests are only a precaution and the results reveal nothing wrong. And, not all tests are required for all patients who have cardiac symptoms. But in rare cases, tests uncover a heart abnormality that could be dangerous to a teenager who plays sports.

Taking precautionary measures can help ease the minds of both parents and students concerned about sudden death. When exercising in hot conditions, take frequent water breaks and rest breaks. If you are not feeling well, stop exercising immediately. And don't be afraid that you will look wimpy or weak.

Why wait for disaster?

Dr. Rao says that “every child should undergo pre-sports participation screening history and physical examination, performed by the primary care physician or team physician. Routine screening using ECG and echocardiogram are not recommended at this time. If an abnormality is detected by the primary care physician or sports physician during the exam, then referral to a pediatric cardiologist (for patients younger than 18 or 21) or to an adult cardiologist (for patients older than 21) is suggested.”

He says the pediatric cardiologists may then perform an ECG, echocardiogram, have a patient wear a 24-hour Holter monitor (see sidebar), and perform exercise tests or other tests, as necessary.

Rao explains that the statistically low risk of sudden cardiac death in teens “makes assessment of cost-effectiveness of screening methods difficult. The objective is to identify people at risk for sudden death during strenuous exercise in a cost-effective, non-invasive way. Unfortunately we have no universally accepted standards for screening,” Rao says.

Don't live in fear

Reports of sudden death are scary, but parents and students should keep in mind that, despite the media blitz these cases receive, this is an unusual event. It seems that with each tragic loss, the anxiety and fear of children dying of this is elevated exponentially above the actually risk.

“Cardiac conditions with a predisposition to sudden death during or following exercise occur in about 5 of 100,000 participants and sudden death occurs in 0.5 of 100,000 people,” Rao says.

UPDATED: 10-04-2006

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