Canadian Journal of Cardiology

Sports-Related Sudden Cardiac Death Attributable to Myocarditis: A Systematic Review and Meta-analysis



      The incidence of sports-related sudden cardiac death (SrSCD) attributable to myocarditis is unknown. With the known association between SARS-CoV-2 (COVID-19) and myocarditis, an understanding of pre-pandemic rates of SrSCD due to myocarditis will be important in assessing a change of risk in the future. The objective was to ascertain the incidence of SrSCD or aborted sudden cardiac death (SCD) attributable to myocarditis in the general population.


      A literature search through PubMed/Medline and Ovid/Embase was completed. Studies of SrSCD with autopsy data or clear-cause-aborted SrSCD were included. SrSCD was defined as SCD which occurred within 1 hour of exercise. Data were abstracted by 2 independent reviewers using the MOOSE guidelines. Risk assessment was performed with the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Random effects models were used to report the incidence and 95% CIs. The primary outcome was the incidence of SrSCD attributable to myocarditis, and the secondary outcome was SrSCD overall.


      Fifteen studies were included comprising 347,092,437 person-years (PY). There were 1955 SrSCD or aborted SrSCD overall with an incidence of 0.93 (95% CI 0.47-1.82) per 100,000 PY. Fifty-three SrSCD were attributed to myocarditis with an incidence of 0.047 (95% CI 0.018-0.123) per 100,000 PY, or 1 death attributable to myocarditis in 2.13 million PY.


      In this meta-analysis, the overall incidence of SrSCD was low. Furthermore, SrSCD attributed to myocarditis is exceedingly rare.



      L’incidence de l’arrêt cardiaque subit lié à la pratique sportive (ACSs) et attribuable à une myocardite reste inconnue. Au vu de l’association connue entre le SARS-CoV-2 (COVID-19) et la myocardite, il serait important de connaître le taux prépandémique d’ACSs attribuables à une myocardite pour évaluer l’évolution du risque. L’objectif était de vérifier l’incidence de l’ACSs ou de l’arrêt cardiaque subit (ACS) avorté attribuable à une myocardite dans la population générale.


      Une recherche documentaire dans PubMed/Medline et Ovid/Embase a été réalisée. Elle comprenait les études portant sur les ACSs et leurs rapports d’autopsie ou les ACS avortés et de cause évidente. L’ACSs y était défini comme un ACS survenant dans la première heure d’une activité physique. Deux examinateurs indépendants ont recueilli les données selon les lignes directrices MOOSE. Une évaluation du risque a été réalisée à partir de la liste de vérification du Joanna Briggs Institute pour l’évaluation critique des études sur la prévalence. Des modèles à effets aléatoires ont servi à calculer l’incidence et les intervalles de confiance (IC) à 95 %. L’incidence de l’ACSs attribuable à une myocardite constituait le critère principal et l’ACS en général, le critère secondaire.


      L’analyse portait sur quinze études regroupant 347 092 437 années-personnes (AP). Elle a permis de recenser un total de 1 955 ACSs ou ACS avortés, soit une incidence de 0,93 (IC à 95 %; 0,47-1,82) pour 100 000 AP. Cinquante-trois ACSs ont été attribués à une myocardite, soit une incidence de 0,047 (IC à 95 %; 0,018-0,123) pour 100 000 AP, ce qui représente une mort attribuable à la myocardite pour 2,13 millions d’AP.


      Il ressort de cette méta-analyse que l’incidence de l’ACSs est faible. De plus, les cas d’ACSs attribuables à une myocardite sont extrêmement rares.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Malholtra A.
        • Dhutia H.
        • Finocchiaro G.
        • et al.
        Outcomes of cardiac screening in adolescent soccer players.
        N Engl J Med. 2018; 379: 524-534
        • Marijon E.
        • Tafflet M.
        • Celermajer D.S.
        • Dumas F.
        Sports-related sudden death in the general population.
        Circulation. 2011; 124: 672-681
        • Mohananey D.
        • Masri A.
        • Desai R.
        • Dalal S.
        • Phelan D.
        Global incidence of sports-related sudden cardiac death.
        J Am Coll Cardiol. 2017; 69: 2672-2673
        • Siripanthong B.
        • Cantab B.A.
        • Nazarian S.
        • et al.
        Recognising COVID-19–related myocarditis: the possible pathophysiology and proposed guideline for diagnosis and management.
        Heart Rhythm. 2020; 17: 1463-1471
        • Harris K.M.
        • Mackey-Bojack S.
        • Bennett M.
        • et al.
        Sudden unexpected death due to myocarditis in young people, including athletes.
        Am J Cardiol. 2020; 143: 131-134
        • Daniels C.J.
        • Rajpal S.
        • Greenshields J.T.
        • et al.
        Prevalence of clinical and subclinical myocarditis in competitive athletes with recent SARS-CoV-2 infection results From the Big Ten COVID-19 Cardiac Registry.
        JAMA Cardiol. 2021; 6: 1078-1087
        • Moulson N.
        • Petek B.J.
        • Drezner J.A.
        • et al.
        SARS-CoV-2 cardiac involvement in young competitive athletes.
        Circulation. 2021; 144: 256-266
        • Martinez M.W.
        • Tucker A.M.
        • Bloom O.J.
        • et al.
        Prevalence of inflammatory heart disease among professional athletes with prior COVID-19 infection who received systematic return-to-play cardiac screening.
        JAMA Cardiol. 2021; 6: 745-752
        • Inciardi R.M.
        • Lupi L.
        • Zaccone G.
        • et al.
        Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19).
        JAMA Cardiol. 2020; 5: 819-824
        • Corrado D.
        • Basso C.
        • Pavai A.
        • Michieli P.
        Trends in sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program.
        J Am Med Assoc. 2006; 296: 1593-1601
        • Stroup D.F.
        • Berlin J.A.
        • Morton S.C.
        • et al.
        Meta-analysis of observational studies in epidemiology.
        JAMA. 2021; 285: 2008-2012
        • Harmon K.G.
        • Asif I.M.
        • Maleszewski J.J.
        • et al.
        Incidence and etiology of sudden cardiac arrest and death in high school athletes in the United States.
        Mayo Clin Proc. 2016; 91: 1493-1502
        • Landry C.
        • Allan K.
        • Connelly K.
        • et al.
        Sudden cardiac arrest during participation in competitive sports.
        N Engl J Med. 2017; 377: 1943-1953
        • Drezner J.A.
        • Rao A.L.
        • Heistand J.
        • Bloomingdale M.K.
        • Harmon K.G.
        Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators.
        Circulation. 2009; 120: 518-525
        • Joanna Briggs Institute
        The Joanna Briggs Institute critical appraisal tools for use in JBI systematic reviews: checklist for prevalence studies.
        (Available at:)
        • Borenstein M.
        • Hedges L.V.
        • Higgins J.P.T.
        • Rothstein H.R.
        A basic introduction to fixed-effect and random-effects models for meta-analysis.
        Res Synth Methods. 2010; : 97-111
        • Riley R.D.
        • Higgins J.P.T.
        • Deeks J.J.
        Interpretation of random effects meta-analyses.
        BMJ. 2011; 342: 964-967
        • Higgins J.P.T.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        Br Med J. 2003; 327: 557-560
        • Balduzzi S.
        • Rücker G.
        • Schwarzer G.
        How to perform a meta-analysis with R: a practical tutorial.
        Evid Based Ment Heal. 2019; 22: 153-160
        • Viechtbauer W.
        Conducting meta-analyses in R with the metafor package.
        J Stat Softw. 2010; 36: 1-47
        • Team R.C.
        R: a language and environment for statistical computing. 201. 2013
        • Harmon K.G.
        • Asif I.M.
        • Maleszewski J.J.
        • et al.
        Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association athletes. A decade in review.
        Circulation. 2015; 132: 10-19
        • Maron B.J.
        • Haas T.S.
        • Ahluwalia A.
        • Rutten-ramos S.C.
        Incidence of cardiovascular sudden deaths in Minnesota high school athletes.
        Heart Rhythm. 2013; 10: 374-377
        • Risgaard B.
        • Winkel B.G.
        • Jabbari R.
        • Thomsen J.L.
        • Ottesen G.L.
        Sports-related sudden cardiac death in a competitive and a noncompetitive athlete population aged 12 to 49 years: data from an unselected nationwide study in Denmark.
        Heart Rhythm. 2014; 11: 1673-1681
        • Waller B.
        • Hawley D.
        • Clark M.
        • Pless J.
        Incidence of sudden athletic deaths between 1985 and 1990 in Marion County, Indiana.
        Clin Cardiol. 1992; 15: 851-858
        • Phillips M.
        • Robinowitz M.
        • Higgins J.R.
        • et al.
        Sudden cardiac death in Air Force recruits: a 20-year review.
        JAMA. 2021; 256: 1-4
        • Holst A.G.
        • Winkel B.G.
        • Theilade J.
        • et al.
        Incidence and etiology of sports-related sudden cardiac death in Denmark—implications for preparticipation screening.
        Heart Rhythm. 2010; 7: 1365-1371
        • Finocchiaro G.
        • Papadakis M.
        • Robertus J.
        • et al.
        Etiology of sudden death in sports.
        insights from a United Kingdom regional registry. J Am Coll Cardiol. 2016; 67: 2108-2115
        • Pelliccia A.
        • Sharma S.
        • Gati S.
        • et al.
        2020 ESC guidelines on sports cardiology and exercise in patients with cardiovascular disease.
        Eur Heart J. 2021; 42: 17-96
      1. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.
        Lancet. 2015; 386: 743-800
        • Mckinney J.
        • Connelly K.A.
        • Dorian P.
        • et al.
        COVID-19–myocarditis and return to play: reflections and recommendations from a Canadian working group.
        Can J Cardiol. 2021; 37: 1165-1174
        • Kim J.
        • Levine B.
        • Phelan D.
        • Emery M.
        Coronavirus disease 2019 and the athletic heart: emerging perspectives on pathology, risks, and return to play.
        JAMA Cardiol. 2021; 6: 219-227
        • Udelson J.E.
        • Rowin E.J.
        • Maron B.J.
        Return to play for athletes after COVID-19 infection: the fog begins to clear.
        JAMA Cardiol. 2021; 6: 997-999
        • Pesce M.
        • Agostoni P.
        • Bøtker H.
        • et al.
        COVID-19–related cardiac complications from clinical evidences to basic mechanisms: opinion paper of the ESC Working Group on Cellular Biology of the Heart.
        Cardiovasc Res. 2021; 117: 2148-2160
        • Tschope C.
        • Ammirati E.
        • Bozkurt B.
        • et al.
        Myocarditis and inflammatory cardiomyopathy: current evidence and future directions.
        Nat Rev Cardiol. 2021; 18: 169-193
        • Eckart R.E.
        • Shry E.A.
        • Burke A.P.
        • et al.
        Sudden death in young adults: an autopsy-based series of a population undergoing active surveillance.
        J Am Coll Cardiol. 2011; 58: 1254-1261
        • Grani C.
        • Chappex N.
        • Fracasso T.
        • et al.
        Sports-related sudden cardiac death in Switzerland classified by static and dynamic components of exercise.
        Eur J Prev Cardiol. 2016; 23: 1228-1236
        • Morentin B.
        • Suarez-Mier P.
        • Monzo A.
        • et al.
        Sports-related sudden cardiac death in Spain. A multicentre, population-based, forensic study of 288 cases.
        Rev Esp Cadiologia. 2021; 74: 225-232
        • van Camp S.
        • Bloor C.
        • Mueller F.
        • Cantu R.
        • Olson H.
        Nontraumatic sports death in high school and college athletes.
        Med Sci Sports Exerc. 1995; : 641-647

      Linked Article