When a young athlete collapses on a sports field, the impact is felt far beyond the immediate tragedy. The scenes from the football player Eriksen collapsing on the ground in 2020 and more recently this week during a match are still fresh in people's minds. These events shake families, communities, and the medical profession. Sudden cardiac death in children and young adults is rare but it is not random, and in many cases it is not unpreventable. The new consensus statement from the European Association of Preventive Cardiology and the Association for European Paediatric and Congenital Cardiology, published this year in the European Heart Journal, brings together the best available evidence on why this happens and what we can do about it.

Let us start with the epidemiology, because it matters for understanding the approach. Sudden cardiac arrest or death in athletes aged 8 to 15 years occurs at a rate of approximately 0.7 per 100,000 per year. That rises to around 1.2 per 100,000 per year in the 12 to 15 age group. These numbers are small. But the conditions behind them are identifiable, and in many cases treatable. An estimated one in 300 children in competitive sport carries a cardiac condition that could put them at risk.

What is striking about sudden death in children compared to adults is how often the heart appears structurally normal at post-mortem. In more than half of sudden cardiac deaths in individuals under 18, no structural abnormality is found on autopsy. This points firmly towards primary arrhythmia syndromes, conditions like Long QT syndrome, catecholaminergic polymorphic ventricular tachycardia, and Brugada syndrome as the dominant cause in younger children. These conditions live in the electrical system of the heart, not its walls or valves, and they are exactly what a resting 12-lead ECG is designed to detect.

As children move into adolescence, the picture shifts. Structural causes become more prominent. Hypertrophic cardiomyopathy, the commonest inherited heart muscle disease, often remains subclinical in childhood but begins to manifest structurally during the adolescent growth spurt. Arrhythmogenic cardiomyopathy, which predominantly affects the right ventricle, similarly tends to emerge in the second decade. Anomalous coronary artery origins are the second most common structural cause in young athletes; the affected child may have exercised for years without symptoms before the combination of high cardiac output and the anomalous vessel geometry produces a fatal arrhythmia.

What role does exercise itself play? The consensus statement is direct on this point. Among young people with an underlying cardiac predisposition, exercise can act as a trigger for arrhythmia. Competitive athletes face higher exposure than non-athletes to sustained high-intensity effort, and there is evidence that intense training and competition are more likely to provoke lethal events in susceptible individuals. Importantly, some evidence suggests that adolescents with cardiomyopathies, particularly in the 10 to 15 age range, may face higher relative risk during exercise than adults with the same conditions.

This is the foundation on which the screening argument rests. Screening will not find every case. Some conditions evolve, and a normal screen at 12 does not guarantee safety at 15. Some findings remain genuinely ambiguous. The document is admirably honest about all of this. But serial screening (with history taking, examination, and ECG at age 12 and every two years thereafter) does identify conditions. A large Italian study of over 22,000 children found that 0.3% had conditions associated with sudden cardiac arrest; nearly two-thirds of those diagnoses were made only on repeat examination, not the first screen.

For parents asking what to watch for between screens, the answer comes from the family history and symptom picture. Unexplained syncope during exercise (not the faint after a hot race, but the sudden collapse during effort) warrants urgent assessment. Palpitations that occur during sport rather than at rest, or exertional chest pain that is not clearly musculoskeletal, deserve investigation. A family history of sudden death under 40, or a relative known to carry an inherited cardiac condition, changes the picture entirely and should prompt specialist referral regardless of whether a routine screen is due.

The new guidance gives us better tools and clearer criteria. What it cannot replace is attentiveness from coaches, parents, schools, and sports organisations to the child in front of them. Most sudden deaths in young athletes are preceded by at least one warning sign that, in retrospect, was not recognised for what it was. Awareness is part of the safety net too.

Author: Dr. Alessandro Giardini, MD, PhD, Consultant Paediatric Cardiologist

Written 06/06/2026