ART-920: Cardiac Screening in Tennis — Sudden Cardiac Death Prevention
Executive Summary
Sudden cardiac death (SCD) in young athletes is a rare but devastating event, and tennis is not immune. Conditions such as hypertrophic cardiomyopathy, anomalous coronary arteries, and commotio cordis can cause fatal cardiac events during competition. Pre-participation cardiac screening, including ECG and echocardiography, can identify at-risk individuals and prevent tragedy. Awareness of warning symptoms and access to automated external defibrillators (AEDs) at tennis facilities are critical components of a comprehensive safety plan.
Sudden Cardiac Death in Athletes
Sudden cardiac death in athletes under 35 years of age is most commonly caused by structural heart abnormalities that are often asymptomatic until the fatal event. The incidence is approximately 1 in 50,000 to 1 in 80,000 athletes per year, though this may be underestimated due to underreporting. In tennis, several high-profile cases have highlighted the risk. The mechanism typically involves ventricular fibrillation, where the heart's electrical activity becomes chaotic, resulting in loss of consciousness and absence of effective cardiac output. Without immediate defibrillation, survival decreases by approximately 7-10% per minute. The survival rate with immediate CPR and defibrillation within 3-5 minutes exceeds 50%.
Hypertrophic Cardiomyopathy
Hypertrophic cardiomyopathy (HCM) is the most common cause of SCD in young athletes, accounting for approximately 36% of cases. HCM is characterized by abnormal thickening of the left ventricular wall, which can obstruct blood flow and create an arrhythmogenic substrate. The condition is genetic, caused by mutations in sarcomeric proteins. Many individuals with HCM are asymptomatic, and the condition may only be detected through cardiac screening. Symptoms that may suggest HCM include exertional chest pain, exertional syncope (fainting), palpitations, and a family history of sudden death. Diagnosis is made through echocardiography, which reveals the characteristic wall thickening. ECG abnormalities are present in approximately 90% of HCM patients and may show deep T-wave inversions, ST-segment depression, and large QRS voltages.
Anomalous Coronary Arteries
Anomalous aortic origin of the coronary arteries (AAOCA) is the second most common cause of SCD in young athletes, accounting for approximately 17% of cases. In this condition, one or both coronary arteries arise from the wrong sinus of Valsalva and course between the aorta and pulmonary artery, creating a "slit-like" opening that can become compressed during exercise. This compression reduces blood flow to the heart muscle, causing ischemia and potentially triggering ventricular fibrillation. Symptoms may include exertional chest pain, syncope, or palpitations, but many individuals are asymptomatic. Diagnosis is made through echocardiography, CT angiography, or MRI. Surgical repair is recommended for athletes with symptomatic AAOCA or certain high-risk anatomical features.
Commotio Cordis
Commotio cordis is a unique cause of SCD that occurs when a blunt impact to the chest triggers ventricular fibrillation at a specific vulnerable moment in the cardiac cycle, during the T-wave upslope. In tennis, commotio cordis can occur when a ball strikes a player's chest at the precise moment of vulnerability. The impact does not need to be severe; studies have shown that impacts from baseballs, hockey pucks, and tennis balls can all produce commotio cordis under the right circumstances. The event is instantaneous, with the player collapsing immediately after impact. Survival depends on immediate recognition, CPR, and defibrillation. The incidence is higher in sports with projectiles, but tennis players, particularly juniors, are at risk during serves and return of serves.
Pre-Participation Screening
Pre-participation cardiac screening aims to identify athletes with conditions that increase SCD risk. The standard screening includes a personal and family history questionnaire and a physical examination. Adding a 12-lead ECG to the screening process significantly improves detection rates, identifying approximately 90% of HCM cases that would be missed by history and physical alone. However, ECG screening has a false positive rate of approximately 2-5%, requiring further evaluation with echocardiography. The European Society of Cardiology and the International Olympic Committee recommend ECG-inclusive screening for all competitive athletes. In the United States, the American Heart Association has historically recommended against routine ECG screening, though this position is evolving.
Warning Symptoms
Athletes and coaches should be educated about warning symptoms that may indicate cardiac disease. These include exertional chest pain or pressure, exertional syncope or near-syncope (fainting or almost fainting during exercise), palpitations with exercise, and a family history of sudden death before age 50. Any athlete with these symptoms should be evaluated by a sports medicine physician before returning to play. The pre-participation questionnaire should include questions about these symptoms, and athletes should be educated that "playing through" chest pain or dizziness is never acceptable.
AED Access and Emergency Action Plans
Every tennis facility should have an automated external defibrillator (AED) readily accessible and staff trained in its use. The AED should be located within 3 minutes of any court, and staff should be trained in CPR and AED use. An emergency action plan should be in place that includes calling emergency services, initiating CPR, deploying the AED, and directing paramedics to the location. Regular drills ensure that staff can execute the plan effectively under pressure. The presence of an AED and trained personnel can mean the difference between life and death in the event of sudden cardiac arrest.
Practical Application: "Screen, Recognize, Respond"
If you are a competitive tennis player, ensure you have undergone pre-participation cardiac screening that includes at minimum a thorough personal and family history. If you are a coach or facility manager, advocate for ECG-inclusive screening for all your athletes and ensure your facility has an AED on-site with trained personnel. Learn to recognize the signs of cardiac distress: chest pain, dizziness, or loss of consciousness during play are always reasons to stop immediately. In the event of a collapse, call 911, start CPR, and retrieve the AED. Every minute counts — your response could save a life.
Diagnostic & Training Matrix
| Observation | Failure | Result | Corrective Strategy |
|---|---|---|---|
| Player reports exertional chest pain or syncope | Potential HCM, AAOCA, or other cardiac pathology | Risk of sudden cardiac death during play | Immediate referral to sports medicine; ECG; echocardiography; exercise testing |
| Family history of sudden death before age 50 | Genetic cardiac condition (HCM, long QT syndrome) | Elevated SCD risk | Comprehensive cardiac evaluation; genetic counseling; activity restriction pending evaluation |
| Player collapses after ball strike to chest | Commotio cordis; ventricular fibrillation | Cardiac arrest; death without immediate treatment | Immediate CPR; AED deployment; emergency medical services; cool first, transport second |
| Facility lacks AED or trained staff | Inadequate emergency preparedness | Reduced survival in cardiac arrest | AED acquisition; staff CPR/AED training; emergency action plan development; regular drills |
| Player experiences palpitations during exercise | Arrhythmia; potential cardiac pathology | Performance limitation; potential SCD risk | Holter monitor; event monitor; electrophysiology evaluation; activity modification |
Practical Application: "Screen, Recognize, Respond"
If you are a competitive tennis player, ensure you have undergone pre-participation cardiac screening that includes at minimum a thorough personal and family history. If you are a coach or facility manager, advocate for ECG-inclusive screening for all your athletes and ensure your facility has an AED on-site with trained personnel. Learn to recognize the signs of cardiac distress: chest pain, dizziness, or loss of consciousness during play are always reasons to stop immediately. In the event of a collapse, call 911, start CPR, and retrieve the AED. Every minute counts — your response could save a life.