FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 339:364-369 August 6, 1998 Number 6 Next

Abstract PDF Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background For more than 20 years in Italy, young athletes have been screened before participating in competitive sports. We assessed whether this strategy results in the prevention of sudden death from hypertrophic cardiomyopathy, a common cardiovascular cause of death in young athletes.

Methods We prospectively studied sudden deaths among athletes and nonathletes (35 years of age or less) in the Veneto region of Italy from 1979 to 1996. The causes of sudden death in both populations were compared, and the pathological findings in the athletes were related to their clinical histories and electrocardiograms. Cardiovascular reasons for disqualification from participation in sports were investigated and follow-up was performed in a consecutive series of 33,735 young athletes who underwent preparticipation screening in Padua, Italy, during the same period.

Results Of 269 sudden deaths in young people, 49 occurred in competitive athletes (44 male and 5 female athletes; mean [±SD] age, 23±7 years). The most common causes of sudden death in athletes were arrhythmogenic right ventricular cardiomyopathy (22.4 percent), coronary atherosclerosis (18.4 percent), and anomalous origin of a coronary artery (12.2 percent). Hypertrophic cardiomyopathy caused only 1 sudden death among the athletes (2.0 percent) but caused 16 sudden deaths in the nonathletes (7.3 percent). Hypertrophic cardiomyopathy was detected in 22 athletes (0.07 percent) at preparticipation screening and accounted for 3.5 percent of the cardiovascular reasons for disqualification. None of the disqualified athletes with hypertrophic cardiomyopathy died during a mean follow-up period of 8.2±5 years.

Conclusions The results show that hypertrophic cardiomyopathy was an uncommon cause of death in these young competitive athletes and suggest that the identification and disqualification of affected athletes at screening before participation in competitive sports may have prevented sudden death.

Methods

Since 1971 Italian law has required that every athlete undergo an annual clinical evaluation to obtain approval to participate in competitive sports.^13,14,15 We evaluated the effects of this community-based screening strategy through a prospective investigation of the causes of sudden death in both competitive athletes and nonathletes 35 years of age or younger in the Veneto region of Italy from 1979 to 1996 and an assessment of the cardiovascular reasons for disqualification in a large series of young competitive athletes who underwent preparticipation screening during this time in the Padua area. A competitive athlete was defined as "a participant in an organized sports program requiring regular training and competition."⁹

Sudden Death in Young Athletes and Nonathletes

The Veneto region of Italy covers an area of 18,368 km². During the study period, the population was stable and averaged 4,379,900, according to census data. There were 2,009,600 persons 35 years of age or less, defined as "young" in this paper. Nearly all residents were white, and the population was ethnically homogeneous. According to the Sports Medicine Data Base of the Veneto region, the rate of participation in competitive athletics among young people was 9.6 percent.

A prospective clinicopathological study of sudden death in young people has been carried out in the Veneto region since 1979.¹⁶ The sudden infant death syndrome was excluded from this investigation. The medical centers participating in this project (see the Appendix) serve 94.4 percent of the population. In all cases of sudden death in young people that occurred from 1979 to 1996, an autopsy was carried out by the local pathologist or medical examiner at one of these medical centers. Sudden death was defined as unexpected death occurring as a result of natural causes in which loss of all functions occurred instantaneously or within six hours of the onset of symptoms or collapse. After noncardiac causes of death were ruled out, all the hearts were fixed in formalin and forwarded to the Institute of Pathological Anatomy of the University of Padua for detailed morphologic assessment, according to a previously described protocol.¹⁶ The subject's clinical history and athletic activity and the circumstances surrounding the cardiac arrest were investigated in each case. Causes of sudden death in competitive athletes and nonathletes were compared to assess which conditions were significantly associated with cardiac arrest during athletic activity. The pathological findings in athletes were related to their clinical history and electrocardiographic findings in order to establish why the underlying disease had not been suspected at the preparticipation screening.

Preparticipation Cardiovascular Screening of Young Competitive Athletes

From 1979 to 1996, a consecutive series of 33,735 young athletes (28,539 male and 5196 female athletes; mean [±SD] age, 19±5 years) underwent 73,718 preparticipation cardiovascular evaluations at the Center for Sports Medicine in Padua. Screening for cardiac disease was part of a more comprehensive medical evaluation that included a general clinical history taking, physical examination, orthopedic examination, spirometry, and urinalysis. The initial cardiovascular protocol included family and personal history taking, physical examination with determination of blood pressure, basal 12-lead electrocardiography, and limited exercise testing (with the Montoye step test). Additional tests, such as echocardiography, 24-hour ambulatory Holter monitoring, or submaximal exercise testing, were requested for subjects who had positive findings (discussed below) at the initial evaluation.

The family history was considered positive if one or more close relatives had had a premature heart attack (i.e., at 50 years of age or less) or sudden death or if there was a family history of coronary artery disease, cardiomyopathy, Marfan's syndrome, the long-QT syndrome, severe arrhythmias, or other disabling cardiovascular diseases.

The personal history was considered positive if the subject had had chest pain or discomfort, syncope or near-syncope, or irregular heartbeat or palpitations on exertion, or if the subject had had shortness of breath or fatigue on exertion that was out of proportion to the degree of physical effort.

Positive physical findings included musculoskeletal and ocular features suggestive of Marfan's syndrome, diminished and delayed femoral-artery pulses, mid- or end-systolic clicks, a second heart sound that was single or widely split and fixed with respiration, marked heart murmurs (any diastolic and systolic grade 2/6 or higher), irregular heart rhythm, and brachial blood pressure greater than 145/90 mm Hg on more than one reading. The electrocardiogram was considered positive according to accepted criteria^{11,17,18,19,20} if one or more of the findings listed in Table 1 were present.

View this table: [in this window] [in a new window]   Table 1. Criteria for a Positive 12-Lead Electrocardiogram.

 
Hypertrophic cardiomyopathy was suspected at the initial screening in young people with a suggestive personal or family history, positive physical findings, or positive electrocardiographic findings. The definitive diagnosis was subsequently based on the echocardiographic demonstration of a hypertrophic, nondilated left ventricle (wall thickness, 13 mm), in the absence of another cardiac or systemic disease that could cause hypertrophy of the magnitude present in that person.²¹

The distinction between hypertrophic cardiomyopathy and athlete's heart was based on echocardiographic and clinical features, such as the magnitude and distribution of thickening of the left ventricular wall, the dimension of the left ventricular cavity, the presence or absence of electrocardiographic abnormalities, the type of sport played, and the results of deconditioning.^{22,23,24,25,26,27} The criteria for hypertrophic cardiomyopathy included a high degree of left ventricular hypertrophy (wall thickness, >16 mm) with an unusual distribution (heterogeneous, asymmetric, or sparing the anterior septum); a left ventricular cavity of normal size (<45 mm); the presence of striking electrocardiographic abnormalities (a marked increase in voltages, prominent Q waves, and deep, negative T waves); training in athletic disciplines other than endurance sports, such as rowing, canoeing, cycling, and swimming; and the persistence of hypertrophy after six months of deconditioning.^{22,23,24,25,26,27}

Subjects were disqualified from competitive athletic activity when clinically relevant cardiovascular abnormalities were recognized. The Italian guidelines for assessing athletic risk are similar to those of the 16th and 26th Bethesda Conferences,^28,29 although the Italian criteria for sports eligibility are more restrictive.³⁰ Follow-up data were obtained from office visits, telephone interviews, or written questionnaires and were available for all subjects who were disqualified because of cardiovascular problems.

Causes of Death

At autopsy, hypertrophic cardiomyopathy was diagnosed when the subject had macroscopic cardiac hypertrophy, defined according to population-based criteria for normal cardiac weight; either asymmetric or symmetric thickening of the septum and free wall, in the absence of other cardiac causes of hypertrophy, such as hypertensive, valvular, or congenital heart disease; and microscopical evidence of myocardial disarray involving a substantial portion of the interventricular septum.^31,32,33,34 Arrhythmogenic right ventricular cardiomyopathy was diagnosed when there was gross or histologic evidence of regional or diffuse full-thickness replacement of the myocardium of the right ventricular free wall by fat and fibrous tissue, in the absence of other known cardiac or noncardiac causes of death.¹⁶ Obstructive atherosclerotic coronary artery disease was diagnosed when one or more major epicardial coronary arteries showed cross-sectional narrowing of 70 percent or more.³⁵ Myocarditis was diagnosed according to the Dallas criteria,³⁶ on the basis of the presence of an inflammatory infiltrate in the myocardium with degeneration or necrosis of adjacent myocytes. Mitral-valve prolapse was diagnosed when there was increased thickness, floppiness, and redundancy of the leaflets, intercordal hooding, and billowing of the leaflet toward the left atrium.³⁷ Sudden death was classified as unexplained if there was no macroscopically or microscopically apparent structural heart disease or other identifiable cause of death.

Statistical Analysis

Continuous variables were expressed as means ±SD. The chi-square or Fisher's exact test was used to assess the significance of differences between subgroups. The relative risk of sudden death (the ratio of the risk of sudden death among competitive athletes to the risk among nonathletes) and 95 percent confidence intervals were calculated with the Stata 5.0 statistical package (Stata, College Station, Tex.). A two-tailed P value of less than 0.05 was considered to indicate statistical significance.

Results

Sudden Death in Young Competitive Athletes

From 1979 to 1996, 269 sudden deaths occurred in people 35 years of age or less in the Veneto region (0.8 per 100,000 persons per year): 49 among competitive athletes (1.6 per 100,000 per year) and 220 among nonathletes (0.75 per 100,000 per year). The estimated relative risk of sudden death among athletes as compared with nonathletes was 2.1 (95 percent confidence interval, 1.5 to 2.9; P<0.001).

The 49 athletes (44 male and 5 female athletes) ranged in age from 11 to 35 years (mean, 23±7 years) and had participated in a variety of sports: soccer (22 subjects); basketball (5); swimming (4); cycling (3); rugby, running, gymnastics, tennis, skiing, judo, and volleyball (2 subjects each); and weight lifting (1). Fourteen athletes had previously had palpitations on exertion, syncopal episodes, or both; 16 had had recorded electrocardiographic abnormalities or rhythm and conduction disturbances. In 40 cases, sudden death occurred during sports activity (35 cases) or immediately afterward (5 cases).

The most common causes of sudden death in the athletes were arrhythmogenic right ventricular cardiomyopathy (11 subjects, 22.4 percent), atherosclerotic coronary artery disease (9 subjects, 18.4 percent), and anomalous origin of a coronary artery from the contralateral aortic sinus (6 subjects, 12.2 percent) (Table 2). Arrhythmogenic right ventricular cardiomyopathy (P=0.008) and anomalous origin of a coronary artery (P<0.001) were the only cardiovascular conditions that were associated with sudden death significantly more often in athletes than in nonathletes. Hypertrophic cardiomyopathy caused only 1 sudden death among the athletes (2.0 percent), whereas it was the cause of 16 sudden deaths in the nonathletic population (7.3 percent). Three of the 16 nonathletes with hypertrophic cardiomyopathy died suddenly during mild exertion unrelated to participation in sports. None of the nonathletes who died suddenly from hypertrophic cardiomyopathy had been screened before death and excluded.

View this table: [in this window] [in a new window]   Table 2. Causes of Sudden Death in Athletes and Nonathletes 35 Years of Age or Less in the Veneto Region of Italy, 1979 to 1996.

 
As summarized in Table 3, clinical findings indicative of cardiovascular disease had been detected at preparticipation screening in 82 percent of the athletes who died of arrhythmogenic right ventricular cardiomyopathy, as compared with 22 percent of those who died of atherosclerotic coronary artery disease (P=0.02) and 25 percent of those who died of congenital anomalies of the coronary arteries (P=0.02).

View this table: [in this window] [in a new window]   Table 3. Clinical Findings at Preparticipation Screening of Athletes Who Died Suddenly of One of the Leading Three Cardiovascular Causes.

 
Disqualifying Cardiovascular Conditions at Preparticipation Cardiovascular Screening

Of the 33,735 young athletes who were screened at the Center for Sports Medicine in Padua, 1058 were disqualified from participation in competitive sports for medical reasons because of the following types of conditions: cardiovascular in 621 (58.7 percent), orthopedic in 134 (12.7 percent), ophthalmic in 130 (12.3 percent), neurologic in 46 (4.3 percent), respiratory in 37 (3.5 percent), nephrologic or urinary in 34 (3.2 percent), otorhinolaryngologic in 22 (2.1 percent), endocrinologic in 22 (2.1 percent), and other in 12 (1.1 percent). The most frequent cardiovascular conditions causing disqualification were rhythm and conduction abnormalities (38.3 percent), systemic hypertension (27.1 percent), and valvular diseases, including mitral-valve prolapse complicated by clinically significant ventricular arrhythmias, mitral-valve regurgitation, or both (21.4 percent) (Table 4). Among the rhythm and conduction abnormalities, ventricular arrhythmias accounted for 19.5 percent of the total number of disqualifications, supraventricular tachycardia, atrial flutter, or fibrillation for 7.6 percent, the Wolff–Parkinson–White syndrome for 7.1 percent, complete left bundle-branch block or right bundle-branch block and left-axis deviation for 1.9 percent, second-degree atrioventricular block for 1.6 percent, and the long-QT syndrome for 0.6 percent. Hypertrophic cardiomyopathy was identified in 22 young athletes (0.07 percent of those screened) and accounted for 3.5 percent of the cardiovascular causes of disqualification. Less frequent cardiovascular reasons for disqualification included congenital, rheumatic, and ischemic heart disease, as well as pericarditis.

View this table: [in this window] [in a new window]   Table 4. Cardiovascular Conditions Causing Disqualification from Competitive Sports in 621 Athletes in Padua, 1979 to 1996.

 
Hypertrophic Cardiomyopathy

Of the 33,735 athletes initially screened, 3016 (8.9 percent) were referred for echocardiographic evaluation because of the family history, abnormal physical findings, or electrocardiographic abnormalities. Twenty-two (20 male and 2 female athletes; mean age, 20±4 years; range, 16 to 28) had definite evidence of hypertrophic cardiomyopathy on echocardiographic examination. These 22 athletes were referred for echocardiographic study because they had one or more of the following findings: a positive family history in 3; cardiac murmur in 2; one or more electrocardiographic changes in 16 (73 percent), consisting of repolarization abnormalities in 14, elevated voltages in 11, and abnormal Q waves in 5; and premature ventricular beats in 5. The maximal thickness of the left ventricular wall was 19±3 mm (range, 16 to 24), and the end-diastolic diameter of the left ventricular cavity was 43±2 mm (range, 39 to 46). No significant differences in the degree of left ventricular hypertrophy were seen before and after deconditioning.

Follow-Up

Four of the 621 athletes who were disqualified for cardiovascular causes died during a mean follow-up period of 8.2±5 years (range, 1.3 to 16.8). One athlete with mild mitral-valve prolapse complicated by complex ventricular arrhythmias died suddenly of natural causes; the other three athletes, who had atrial septal defect, ventricular septal defect, and a bicuspid aortic valve with regurgitation, died of nonnatural causes (drug abuse, a car accident, and suicide, respectively).

None of the 22 athletes who were disqualified because they had hypertrophic cardiomyopathy died during follow-up. Two patients with paroxysmal atrial fibrillation were treated, one with a beta-blocker and the other with amiodarone. In both cases, the treatment was effective in restoring and maintaining sinus rhythm. Another asymptomatic patient with a family history of sudden death was treated with amiodarone after 24-hour Holter monitoring documented the presence of nonsustained ventricular tachycardia.

Discussion

A structural cardiac abnormality was found at autopsy in most of the cases of sudden death in young competitive athletes that have been previously reported.^{1,2,3,4,5,6,7,8,9,10} Several cardiovascular disorders were implicated, including hypertrophic cardiomyopathy,^3,7,8,9 congenital anomaly of a coronary artery,^6,7,8,9 Marfan's syndrome,^3,8,9 atherosclerotic coronary artery disease,^6,7,8 and arrhythmogenic right ventricular cardiomyopathy.^6,16 In the present study, sudden death in young competitive athletes was related to the same underlying disorders, but the prevalence of each cause of death differed substantially from that previously reported. Studies from the United States have consistently found that hypertrophic cardiomyopathy was the most common cause of cardiac arrest in young competitive athletes (up to 30 percent).^3,7,8,9 In this Italian study, hypertrophic cardiomyopathy caused only one death among the athletes but caused sudden death in the nonathletic young population with a frequency similar to that found in the United States.⁷ Moreover, we found a high prevalence of arrhythmogenic right ventricular cardiomyopathy and premature atherosclerotic coronary artery disease among both groups.

The low prevalence of hypertrophic cardiomyopathy among young competitive athletes who died suddenly was most likely the result of the systematic preparticipation screening that has been in practice in Italy for more than 20 years.^13,14,15 Indeed, two of our main findings provide indirect evidence that screening reduces sudden death from hypertrophic cardiomyopathy. First, the prevalence of hypertrophic cardiomyopathy among young nonathletes who died suddenly was similar in our study (7.3 percent) and in the study of Burke et al.⁷ in the United States (3 percent). Among young athletes who died suddenly, however, the prevalence of hypertrophic cardiomyopathy was very different in the two studies (2 percent vs. 24 percent). This pattern suggests a selective reduction in sudden death from hypertrophic cardiomyopathy among the competitive athletes who underwent systematic preparticipation screening.

Second, screening of 33,735 young competitive athletes in the Padua area identified and disqualified 22 athletes with hypertrophic cardiomyopathy, thus protecting them from the risk entailed by athletic activity. In the United States, hypertrophic cardiomyopathy is present in approximately 0.2 percent of young adults who are screened by echocardiography. The prevalence is higher among blacks (0.24 percent) than among whites (0.10 percent).³⁸ The prevalence of 0.07 percent among the white athletes in the Veneto region is thus similar to that reported among young white persons in the United States, although the screening in Italy was done mainly by electrocardiography rather than by echocardiography. This shows that the screening program based largely on the electrocardiogram was an efficient means of detecting hypertrophic cardiomyopathy in the population of young athletes.

None of the athletes who were disqualified from participation in sports because of hypertrophic cardiomyopathy died during the follow-up. This finding further supports the conclusion that systematic preparticipation screening might reduce mortality through the detection of hypertrophic cardiomyopathy in athletes and their disqualification from competitive sports.

Although echocardiography is the main diagnostic tool for the clinical recognition of hypertrophic cardiomyopathy, it is very expensive and impractical for large-scale screening of athletes.^11,12 Twelve-lead electrocardiography has been proposed as a more cost-effective alternative. In the present study, a combination of electrocardiography, clinical history taking, and physical examination successfully selected athletes as candidates for echocardiography. Of the 33,735 athletes initially screened, 3016 (8.9 percent) were referred for echocardiographic evaluation, and 22 were eventually found to have evidence of hypertrophic cardiomyopathy and were disqualified from sports. Thus, more than 90 percent of the screened population did not undergo echocardiography, resulting in a considerable cost savings.

The present study confirms that the identification at preparticipation screening of young athletes with coronary artery disease is limited by the scarcity of warning signs and the low sensitivity of both base-line and exercise electrocardiography in detecting signs of myocardial ischemia.^39,40 In contrast, athletes who died of arrhythmogenic right ventricular cardiomyopathy often had a history of syncopal episodes, electrocardiographic abnormalities consisting of inverted T waves in the right precordial leads, and ventricular arrhythmias with a left bundle-branch block pattern. Nonetheless, these athletes were not identified at preparticipation screening, because this disease is not widely recognized as a cause of sudden death during sports activity. The results of the present study suggest that the finding of even isolated premature ventricular beats at cardiovascular screening, with morphologic features of left bundle-branch block associated with right precordial T-wave abnormalities on the electrocardiogram, with or without a history of syncopal attacks, should suggest the possibility of an underlying arrhythmogenic right ventricular cardiomyopathy and lead to further testing, such as echocardiography.

Supported by grants from the Veneto Region Research Project on Juvenile Sudden Death, Venice, Italy; the National Research Council; and the Ministry of University Research, Science, and Technology Research Project on Myocardial Infarction, Rome.

We are indebted to Dr. Marina Bittante, Dr. Pietro Maturi, Dr. Gabriella Morandi, Dr. Salvatore Morello, Dr. Lorenzo Spigolon, Dr. Daniela Toazza, and Dr. Daniela Tognin (of the Center for Sports Medicine, Padua) for carrying out the preparticipation screening and follow-up of the athletes; to Dr. Giulio Rizzoli (of the Department of Cardiovascular Surgery, University of Padua) for the statistical and epidemiologic analysis; and to Dr. Gianfranco Buja and Dr. Andrea Nava (of the Department of Cardiology, University of Padua) for their helpful advice throughout the investigation.

Source Information

From the Department of Cardiology (D.C.) and the Institute of Pathological Anatomy (C.B., G.T.), University of Padua, and the Center for Sports Medicine, National Health Service (M.S.) — both in Padua, Italy.

Address reprint requests to Dr. Thiene at the Istituto di Anatomia Patologica, Via A. Gabelli 61, 35121 Padua, Italy.

References

1. Buddington RS, Stahl CJI, McAllister HA, Schwartz RA. Sports, death, and unusual heart disease. Am J Cardiol 1974;33:129-129.abstract 
2. Thompson PD, Stern MP, Williams P, Duncan K, Haskell WL, Wood PD. Death during jogging or running: a study of 18 cases. JAMA 1979;242:1265-1267. [Abstract]
3. Maron BJ, Roberts WC, McAllister HA, Rosing DR, Epstein SE. Sudden death in young athletes. Circulation 1980;62:218-229. [Free Full Text]
4. Waller BF, Roberts WC. Sudden death while running in conditioned runners aged 40 years or over. Am J Cardiol 1980;45:1292-1300. [CrossRef][Medline]
5. Virmani R, Robinowitz M, McAllister HA Jr. Nontraumatic death in joggers: a series of 30 patients at autopsy. Am J Med 1982;72:874-882. [CrossRef][Medline]
6. Corrado D, Thiene G, Nava A, Rossi L, Pennelli N. Sudden death in young competitive athletes: clinicopathologic correlations in 22 cases. Am J Med 1990;89:588-596. [CrossRef][Medline]
7. Burke AP, Farb A, Virmani R, Goodin J, Smialek JE. Sports-related and non-sports-related sudden cardiac death in young adults. Am Heart J 1991;121:568-575. [CrossRef][Medline]
8. Van Camp SP, Bloor CM, Mueller FO, Cantu RC, Olson HG. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27:641-647. [Medline]
9. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes: clinical, demographic, and pathological profiles. JAMA 1996;276:199-204. [Abstract]
10. Thiene G, Pennelli N, Rossi L. Cardiac conduction system abnormalities as a possible cause of sudden death in young athletes. Hum Pathol 1983;14:704-709. [Medline]
11. Maron BJ, Bodison SA, Wesley YE, Tucker E, Green KJ. Results of screening a large group of intercollegiate competitive athletes for cardiovascular disease. J Am Coll Cardiol 1987;10:1214-1221. [Abstract]
12. Maron BJ, Thompson PD, Puffer JC, et al. Cardiovascular preparticipation screening of competitive athletes: a statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association. Circulation 1996;94:850-856. [Free Full Text]
13. Tutela sanitaria delle attività sportive. Gazzetta Ufficiale della Repubblica Italiana. December 23, 1971:8162-4.
14. Norme per la tutela sanitaria dell'attività sportiva agonistica. Gazzetta Ufficiale della Repubblica Italiana. March 5, 1982:1715-9.
15. Pelliccia A, Maron BJ. Preparticipation cardiovascular evaluation of the competitive athlete: perspectives from the 30-year Italian experience. Am J Cardiol 1995;75:827-829. [CrossRef][Medline]
16. Thiene G, Nava A, Corrado D, Rossi L, Pennelli N. Right ventricular cardiomyopathy and sudden death in young people. N Engl J Med 1988;318:129-133. [Abstract]
17. Friedman HH. Diagnostic electrocardiography and vectorcardiography. New York: McGraw-Hill, 1971.
18. Romhilt DW, Estes EH Jr. A point-score system for the ECG diagnosis of left ventricular hypertrophy. Am Heart J 1968;75:752-758. [CrossRef][Medline]
19. Morris JJ Jr, Estes EH Jr, Whalen RE, Thompson HK Jr, McIntosh HD. P-wave analysis in valvular heart disease. Circulation 1964;29:242-251. [Free Full Text]
20. Savage DD, Seides SF, Clark CE, et al. Electrocardiographic findings in patients with obstructive and nonobstructive hypertrophic cardiomyopathy. Circulation 1978;58:402-408. [Free Full Text]
21. Maron BJ, Epstein SE. Hypertrophic cardiomyopathy: a discussion of nomenclature. Am J Cardiol 1979;43:1242-1244. [CrossRef][Medline]
22. Pelliccia A, Maron BJ, Spataro A, Proschan MA, Spirito P. The upper limit of physiologic cardiac hypertrophy in highly trained elite athletes. N Engl J Med 1991;324:295-301. [Abstract]
23. Pelliccia A, Spataro A, Caselli G, Maron BJ. Absence of left ventricular wall thickening in athletes engaged in intense power training. Am J Cardiol 1993;72:1048-1054. [CrossRef][Medline]
24. Maron BJ, Gottdiener JS, Epstein SE. Patterns and significance of the distribution of left ventricular hypertrophy in hypertrophic cardiomyopathy: a wide angle, two dimensional echocardiographic study in 125 patients. Am J Cardiol 1981;48:418-428. [CrossRef][Medline]
25. Wigle ED, Sasson Z, Henderson MA, et al. Hypertrophic cardiomyopathy: the importance of the site and extent of hypertrophy: a review. Prog Cardiovasc Dis 1985;28:1-83. [CrossRef][Medline]
26. Shapiro LM, Smith RG. Effect of training on left ventricular structure and function: an echocardiographic study. Br Heart J 1983;50:534-539. [Free Full Text]
27. Maron BJ, Pelliccia A, Spirito P. Cardiac disease in young trained athletes: insights into methods for distinguishing athlete's heart from structural heart disease, with particular emphasis on hypertrophic cardiomyopathy. Circulation 1995;91:1596-1601. [Free Full Text]
28. Mitchell JH, Maron BJ, Epstein SE. 16th Bethesda Conference: cardiovascular abnormalities in the athlete: recommendations regarding eligibility for competition: October 3-5, 1984. J Am Coll Cardiol 1985;6:1186-1232. [Medline]
29. 26th Bethesda Conference: recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities: January 6-7, 1994. J Am Coll Cardiol 1994;24:845-899. [Medline]
30. Comitato Organizzativo Cardiologico per l'Idoneità allo Sport (COCIS). Protocolli cardiologici per il giudizio di idoneità allo sport agonistico. G Ital Cardiol 1989;19:250-272. [Medline]
31. Pomerance A, Davies MJ, eds. The pathology of the heart. Oxford, England: Blackwell Scientific, 1975:42-3.
32. Scholz DG, Kitzman DW, Hagen PT, Ilstrup DM, Edwards WD. Age-related changes in normal human hearts during the first 10 decades of life. I. (Growth): a quantitative anatomic study of 200 specimens from subjects from birth to 19 years old. Mayo Clin Proc 1988;63:126-136. [Medline]
33. Kitzman DW, Scholz DG, Hagen PT, Ilstrup DM, Edwards WD. Age-related changes in normal human hearts during the first 10 decades of life. II. (Maturity): a quantitative anatomic study of 765 specimens from subjects 20 to 99 years old. Mayo Clin Proc 1988;63:137-146. [Medline]
34. Davies MJ, McKenna WJ. Hypertrophic cardiomyopathy -- pathology and pathogenesis. Histopathology 1995;26:493-500. [Medline]
35. Corrado D, Basso C, Poletti A, Angelini A, Valente M, Thiene G. Sudden death in the young: is coronary thrombosis the major precipitating factor? Circulation 1994;90:2315-2323. [Free Full Text]
36. Aretz HT, Billingham ME, Edwards WD, et al. Myocarditis: a histopathologic definition and classification. Am J Cardiovasc Pathol 1987;1:3-14. [Medline]
37. Chesler E, King RA, Edwards JE. The myxomatous mitral valve and sudden death. Circulation 1983;67:632-639. [Free Full Text]
38. Maron BJ, Gardin JM, Flack JM, Gidding SS, Kurosaki TT, Bild DE. Prevalence of hypertrophic cardiomyopathy in a general population of young adults: echocardiographic analysis of 4111 subjects in the CARDIA study: Coronary Artery Risk Development in (Young) Adults. Circulation 1995;92:785-789. [Free Full Text]
39. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350-1358. [Abstract]
40. Schlant RC, Blomqvist CG, Brandenburg RO, et al. Guidelines for exercise testing: a report of the Joint American College of Cardiology/American Heart Association Task Force on Assessment of Cardiovascular Procedures (Subcommittee on Exercise Testing). Circulation 1986;74:653A-667A.

The following medical centers participated in the Research Project on Juvenile Sudden Death in the Veneto region of Italy: the Center for Sports Medicine, National Health Service, Padua; the Institutes of Pathological Anatomy and Forensic Medicine, University of Padua; and the departments of pathological anatomy of the following institutions: Civil Hospital, Vicenza; Civil Hospital, Treviso; Civil Hospital, Castelfranco Veneto; Civil Hospital, Dolo; University of Verona; Civil Hospital, Conegliano; Civil Hospital, Belluno; Civil Hospital, Camposampiero; Civil Hospital, Chioggia; Civil Hospital, Feltre; Civil Hospital, Piove di Sacco; Civil Hospital, Thiene; Civil Hospital, Cittadella; Civil Hospital, Este; Civil Hospital, Mestre; Civil Hospital, Montebelluna; Civil Hospital, Mirano; Civil Hospital, Arzignano; Civil Hospital, Battaglia Terme; Civil Hospital, Noale; Civil Hospital, Valdagno; Civil Hospital, Venice; Civil Hospital, Bassano; Civil Hospital, San Donà di Piave; and Civil Hospital, Asolo.

Abstract PDF Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

This article has been cited by other articles:

• Papadakis, M., Whyte, G., Sharma, S. (2008). Preparticipation screening for cardiovascular abnormalities in young competitive athletes. BMJ 337: a1596-a1596 [Full Text]  
• Shephard, R. J (2008). Mass ECG screening of young athletes. Br. J. Sports. Med. 42: 707-708 [Full Text]  
• Drezner, J. A, Khan, K. (2008). Sudden cardiac death in young athletes. BMJ 337: a309-a309 [Full Text]  
• Epstein, A. E., DiMarco, J. P., Ellenbogen, K. A., Estes, N.A. M. III, Freedman, R. A., Gettes, L. S., Gillinov, A. M., Gregoratos, G., Hammill, S. C., Hayes, D. L., Hlatky, M. A., Newby, L. K., Page, R. L., Schoenfeld, M. H., Silka, M. J., Stevenson, L. W., Sweeney, M. O. (2008). ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol 51: e1-e62 [Full Text]  
• Epstein, A. E., DiMarco, J. P., Ellenbogen, K. A., Estes, N.A. M. III, Freedman, R. A., Gettes, L. S., Gillinov, A. M., Gregoratos, G., Hammill, S. C., Hayes, D. L., Hlatky, M. A., Newby, L. K., Page, R. L., Schoenfeld, M. H., Silka, M. J., Stevenson, L. W., Sweeney, M. O. (2008). ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 117: e350-e408 [Full Text]  
• Vetter, V. L., Elia, J., Erickson, C., Berger, S., Blum, N., Uzark, K., Webb, C. L. (2008). Cardiovascular Monitoring of Children and Adolescents With Heart Disease Receiving Medications for Attention Deficit/Hyperactivity Disorder: A Scientific Statement From the American Heart Association Council on Cardiovascular Disease in the Young Congenital Cardiac Defects Committee and the Council on Cardiovascular Nursing. Circulation 117: 2407-2423 [Full Text]  
• Basavarajaiah, S., Wilson, M., Whyte, G., Shah, A., McKenna, W., Sharma, S. (2008). Prevalence of hypertrophic cardiomyopathy in highly trained athletes: relevance to pre-participation screening.. J Am Coll Cardiol 51: 1033-1039 [Abstract] [Full Text]  
• Faber, L., van Buuren, F. (2008). Athlete screening for occult cardiac disease: no risk, no fun?. J Am Coll Cardiol 51: 1040-1041 [Full Text]  
• Wilson, M G, Basavarajaiah, S, Whyte, G P, Cox, S, Loosemore, M, Sharma, S (2008). Efficacy of personal symptom and family history questionnaires when screening for inherited cardiac pathologies: the role of electrocardiography. Br. J. Sports. Med. 42: 207-211 [Abstract] [Full Text]  
• Basavarajaiah, S., Wilson, M., Whyte, G., Shah, A., Behr, E., Sharma, S. (2007). Prevalence and significance of an isolated long QT interval in elite athletes. Eur Heart J 28: 2944-2949 [Abstract] [Full Text]  
• Morrison, A. B., Schoffl, V. R. (2007). Physiological responses to rock climbing in young climbers. Br. J. Sports. Med. 41: 852-861 [Abstract] [Full Text]  
• Chaitman, B. R. (2007). An Electrocardiogram Should Not Be Included in Routine Preparticipation Screening of Young Athletes. Circulation 116: 2610-2615 [Full Text]  
• Myerburg, R. J., Vetter, V. L. (2007). Electrocardiograms Should Be Included in Preparticipation Screening of Athletes. Circulation 116: 2616-2626 [Full Text]  
• Pelliccia, A., Culasso, F., Di Paolo, F. M., Accettura, D., Cantore, R., Castagna, W., Ciacciarelli, A., Costini, G., Cuffari, B., Drago, E., Federici, V., Gribaudo, C. G., Iacovelli, G., Landolfi, L., Menichetti, G., Atzeni, U. O., Parisi, A., Pizzi, A. R., Rosa, M., Santelli, F., Santilio, F., Vagnini, A., Casasco, M., Di Luigi, L. (2007). Prevalence of abnormal electrocardiograms in a large, unselected population undergoing pre-participation cardiovascular screening. Eur Heart J 28: 2006-2010 [Abstract] [Full Text]  
• Corrado, D., McKenna, W. J. (2007). Appropriate interpretation of the athlete's electrocardiogram saves lives as well as money. Eur Heart J 28: 1920-1922 [Full Text]  
• Crawford, M. H (2007). Screening athletes for heart disease. Heart 93: 875-879 [Full Text]  
• Nistri, S., Olivotto, I., Cecchi, F., Basso, C., Thiene, G. (2007). ECG-based screening: not only for athletes. Eur Heart J 28: 1170-1170 [Full Text]  
• Maron, B. J., Thompson, P. D., Ackerman, M. J., Balady, G., Berger, S., Cohen, D., Dimeff, R., Douglas, P. S., Glover, D. W., Hutter, A. M. Jr, Krauss, M. D., Maron, M. S., Mitten, M. J., Roberts, W. O., Puffer, J. C. (2007). Recommendations and Considerations Related to Preparticipation Screening for Cardiovascular Abnormalities in Competitive Athletes: 2007 Update: A Scientific Statement From the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: Endorsed by the American College of Cardiology Foundation. Circulation 115: 1643-1655 [Full Text]  
• De Castro, S., Caselli, S., Maron, M., Pelliccia, A., Cavarretta, E., Maddukuri, P., Cartoni, D., Di Angelantonio, E., Kuvin, J. T, Patel, A. R, Pandian, N. G (2007). Left ventricular remodelling index (LVRI) in various pathophysiological conditions: a real-time three-dimensional echocardiographic study. Heart 93: 205-209 [Abstract] [Full Text]  
• Vitiello, R. (2006). Commentary: the value of the ECG in the preparticipation sports physical examination: the Italian experience.. Pediatr. Rev. 27: e75-e76 [Full Text]  
• Maron, B. J., Pelliccia, A. (2006). The Heart of Trained Athletes: Cardiac Remodeling and the Risks of Sports, Including Sudden Death. Circulation 114: 1633-1644 [Full Text]  
• Corrado, D., Basso, C., Pavei, A., Michieli, P., Schiavon, M., Thiene, G. (2006). Trends in Sudden Cardiovascular Death in Young Competitive Athletes After Implementation of a Preparticipation Screening Program. JAMA 296: 1593-1601 [Abstract] [Full Text]  
• Thompson, P. D., Levine, B. D. (2006). Protecting Athletes From Sudden Cardiac Death. JAMA 296: 1648-1650 [Full Text]  
• Harris, K. M., Sponsel, A., Hutter, A. M. Jr., Maron, B. J. (2006). Brief communication: Cardiovascular screening practices of major North American professional sports teams.. ANN INTERN MED 145: 507-511 [Abstract] [Full Text]  
• Pelliccia, A., Di Paolo, F. M., Corrado, D., Buccolieri, C., Quattrini, F. M., Pisicchio, C., Spataro, A., Biffi, A., Granata, M., Maron, B. J. (2006). Evidence for efficacy of the Italian national pre-participation screening programme for identification of hypertrophic cardiomyopathy in competitive athletes. Eur Heart J 27: 2196-2200 [Abstract] [Full Text]  
• Panhuyzen-Goedkoop, N. M., Verheugt, F. W.A. (2006). Sudden cardiac death due to hypertrophic cardiomyopathy can be reduced by pre-participation cardiovascular screening in young athletes. Eur Heart J 27: 2152-2153 [Full Text]  
• Wald, D. S, Law, M. (2006). Hypertrophic cardiomyopathy: Sudden death is rare in young people with hypertrophic cardiomyopathy. BMJ 333: 96-97 [Full Text]  
• Dalal, D., Molin, L. H., Piccini, J., Tichnell, C., James, C., Bomma, C., Prakasa, K., Towbin, J. A., Marcus, F. I., Spevak, P. J., Bluemke, D. A., Abraham, T., Russell, S. D., Calkins, H., Judge, D. P. (2006). Clinical Features of Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy Associated With Mutations in Plakophilin-2. Circulation 113: 1641-1649 [Abstract] [Full Text]  
• Dalal, D., Nasir, K., Bomma, C., Prakasa, K., Tandri, H., Piccini, J., Roguin, A., Tichnell, C., James, C., Russell, S. D., Judge, D. P., Abraham, T., Spevak, P. J., Bluemke, D. A., Calkins, H. (2005). Arrhythmogenic Right Ventricular Dysplasia: A United States Experience. Circulation 112: 3823-3832 [Abstract] [Full Text]  
• Maron, B J (2005). Distinguishing hypertrophic cardiomyopathy from athlete's heart: a clinical problem of increasing magnitude and significance. Heart 91: 1380-1382 [Abstract] [Full Text]  
• Lemola, K, Brunckhorst, C, Helfenstein, U, Oechslin, E, Jenni, R, Duru, F (2005). Predictors of adverse outcome in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy: long term experience of a tertiary care centre. Heart 91: 1167-1172 [Abstract] [Full Text]  
• Corrado, D., Pelliccia, A., Bjornstad, H. H., Thiene, G. (2005). Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol: reply. Eur Heart J 26: 1804-1805 [Full Text]  
• Olivotto, I., Maron, M. S., Adabag, A. S., Casey, S. A., Vargiu, D., Link, M. S., Udelson, J. E., Cecchi, F., Maron, B. J. (2005). Gender-Related Differences in the Clinical Presentation and Outcome of Hypertrophic Cardiomyopathy. J Am Coll Cardiol 46: 480-487 [Abstract] [Full Text]  
• Pelliccia, A., Fagard, R., Bjornstad, H. H., Anastassakis, A., Arbustini, E., Assanelli, D., Biffi, A., Borjesson, M., Carre, F., Corrado, D., Delise, P., Dorwarth, U., Hirth, A., Heidbuchel, H., Hoffmann, E., Mellwig, K. P., Panhuyzen-Goedkoop, N., Pisani, A., Solberg, E. E., van-Buuren, F., Vanhees, L., Experts who contributed to and revised parts of th, , Blomstrom-Lundqvist, C., Deligiannis, A., Dugmore, D., Glikson, M., Hoff, P. I., Hoffmann, A., Hoffmann, E., Horstkotte, D., Nordrehaug, J. E., Oudhof, J., McKenna, W. J., Penco, M., Priori, S., Reybrouck, T., Senden, J., Spataro, A., Thiene, G. (2005). Recommendations for competitive sports participation in athletes with cardiovascular disease: A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 26: 1422-1445 [Full Text]  
• Maron, B. J., Douglas, P. S., Graham, T. P., Nishimura, R. A., Thompson, P. D. (2005). Task Force 1: Preparticipation screening and diagnosis of cardiovascular disease in athletes. J Am Coll Cardiol 45: 1322-1326 [Full Text]  
• Myerburg, R. J., Estes, N.A. M. III, Fontaine, J. M., Link, M. S., Zipes, D. P. (2005). Task Force 10: Automated external defibrillators. J Am Coll Cardiol 45: 1369-1371 [Full Text]  
• Corrado, D., Pelliccia, A., Bjornstad, H. H., Vanhees, L., Biffi, A., Borjesson, M., Panhuyzen-Goedkoop, N., Deligiannis, A., Solberg, E., Dugmore, D., Mellwig, K. P., Assanelli, D., Delise, P., van-Buuren, F., Anastasakis, A., Heidbuchel, H., Hoffmann, E., Fagard, R., Priori, S. G., Basso, C., Arbustini, E., Blomstrom-Lundqvist, C., McKenna, W. J., Thiene, G. (2005). Cardiovascular pre-participation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol: Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J 26: 516-524 [Abstract] [Full Text]  
• Maron, B. J. (2005). How should we screen competitive athletes for cardiovascular disease?. Eur Heart J 26: 428-430 [Full Text]  
• Eckart, R. E., Scoville, S. L., Campbell, C. L., Shry, E. A., Stajduhar, K. C., Potter, R. N., Pearse, L. A., Virmani, R. (2004). Sudden Death in Young Adults: A 25-Year Review of Autopsies in Military Recruits. ANN INTERN MED 141: 829-834 [Abstract] [Full Text]  
• Colivicchi, F., Ammirati, F., Santini, M. (2004). Epidemiology and prognostic implications of syncope in young competing athletes. Eur Heart J 25: 1749-1753 [Abstract] [Full Text]  
• Biffi, A., Maron, B. J., Verdile, L., Fernando, F., Spataro, A., Marcello, G., Ciardo, R., Ammirati, F., Colivicchi, F., Pelliccia, A. (2004). Impact of physical deconditioning on ventricular tachyarrhythmias in trained athletes. J Am Coll Cardiol 44: 1053-1058 [Abstract] [Full Text]  
• Soejima, K., Stevenson, W. G. (2004). Athens, athletes, and arrhythmias: The cardiologist's dilemma. J Am Coll Cardiol 44: 1059-1061 [Full Text]  
• Maron, B. J., Chaitman, B. R., Ackerman, M. J., Bayes de Luna, A., Corrado, D., Crosson, J. E., Deal, B. J., Driscoll, D. J., Estes, N.A. M. III, Araujo, C. G. S., Liang, D. H., Mitten, M. J., Myerburg, R. J., Pelliccia, A., Thompson, P. D., Towbin, J. A., Van Camp, S. P., for the Working Groups of the American Heart Assoc, (2004). Recommendations for Physical Activity and Recreational Sports Participation for Young Patients With Genetic Cardiovascular Diseases. Circulation 109: 2807-2816 [Abstract] [Full Text]  
• Corrado, D., Basso, C., Rizzoli, G., Schiavon, M., Thiene, G. (2003). Does sports activity enhance the risk of sudden death in adolescents and young adults?. J Am Coll Cardiol 42: 1959-1963 [Abstract] [Full Text]  
• Maron, B. J., McKenna, W. J., Danielson, G. K., Kappenberger, L. J., Kuhn, H. J., Seidman, C. E., Shah, P. M., Spencer, W. H. III, Spirito, P., Ten Cate, F. J., Wigle, E. D., Vogel, R. A., Abrams, J., Bates, E. R., Brodie, B. R., Danias, P. G., Gregoratos, G., Hlatky, M. A., Hochman, J. S., Kaul, S., Lichtenberg, R. C., Lindner, J. R., O'rourke, R. A., Pohost, G. M., Schofield, R. S., Tracy, C. M., Winters, W. L. Jr, Klein, W. W., Priori, S. G., Alonso-Garcia, A., Blomstrom-Lundqvist, C., De Backer, G., Deckers, J., Flather, M., Hradec, J., Oto, A., Parkhomenko, A., Silber, S., Torbicki, A. (2003). American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines. J Am Coll Cardiol 42: 1687-1713 [Full Text]  
• Writing Committee Members, , Maron, B. J., McKenna, W. J., Danielson, G. K., Kappenberger, L. J., Kuhn, H. J., Seidman, C. E., Shah, P. M., Spencer, W. H. III, Spirito, P., Ten Cate, F. J., Wigle, E. D., ACCF Task Force on Clinical Expert Consensus Docum, , Vogel, R. A., Abrams, J., Bates, E. R., Brodie, B. R., Danias, P. G., Gregoratos, G., Hlatky, M. A., Hochman, J. S., Kaul, S., Lichtenberg, R. C., Lindner, J. R., O'Rourke, R. A., Pohost, G. M., Schofield, R. S., Tracy, C. M., Winters, W. L. Jr, ESC Committee for Practice Guidelines Members, , Klein, W. W., Priori, S. G., Alonso-Garcia, A., Blomstrom-Lundqvist, C., De Backer, G., Deckers, J., Flather, M., Hradec, J., Oto, A., Parkhomenko, A., Silber, S., Torbicki, A. (2003). American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy: A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines. Eur Heart J 24: 1965-1991 [Full Text]  
• Maron, B. J. (2003). Sudden Death in Young Athletes. NEJM 349: 1064-1075 [Full Text]  
• Batra, A. S., Hohn, A. R. (2003). Consultation with the Specialist: Palpitations, Syncope, and Sudden Cardiac Death in Children: Who's at Risk?. Pediatr. Rev. 24: 269-275 [Full Text]  
• Marian, A.J., Roberts, R. (2003). To Screen or Not Is Not the Question-- It Is When and How to Screen. Circulation 107: 2171-2174 [Full Text]  
• Maron, B. J., Carney, K. P., Lever, H. M., Lewis, J. F., Barac, I., Casey, S. A., Sherrid, M. V. (2003). Relationship of race to sudden cardiac death in competitive athletes with hypertrophic cardiomyopathy. J Am Coll Cardiol 41: 974-980 [Abstract] [Full Text]  
• Colivicchi, F., Ammirati, F., Santini, M. (2003). Syncope and Coronary Anomalies: Reply. Eur Heart J 24: 289-289 [Full Text]  
• Pigozzi, F, Spataro, A, Fagnani, F, Maffulli, N (2003). Preparticipation screening for the detection of cardiovascular abnormalities that may cause sudden death in competitive athletes. Br. J. Sports. Med. 37: 4-5 [Full Text]  
• Goldschlager, N., Epstein, A. E., Grubb, B. P., Olshansky, B., Prystowsky, E., Roberts, W. C., Scheinman, M. M., for the Practice Guidelines Subcommittee, North Am, (2003). Etiologic Considerations in the Patient With Syncope and an Apparently Normal Heart. Arch Intern Med 163: 151-162 [Full Text]  
• Krovetz, L. J. (2002). Preventing sudden death in athletes. AAP News 21: 292-292 [Full Text]  
• Biffi, A., Pelliccia, A., Verdile, L., Fernando, F., Spataro, A., Caselli, S., Santini, M., Maron, B. J. (2002). Long-term clinical significance of frequent and complex ventricular tachyarrhythmias in trained athletes. J Am Coll Cardiol 40: 446-452 [Abstract] [Full Text]  
• Maron, B. J. (2002). Hypertrophic Cardiomyopathy: A Systematic Review. JAMA 287: 1308-1320 [Abstract] [Full Text]  
• Oakley, D. (2001). GENERAL CARDIOLOGY: The athlete's heart. Heart 86: 722-726 [Full Text]  
• Priori, S.G., Aliot, E., Blomstrom-Lundqvist, C., Bossaert, L., Breithardt, G., Brugada, P., Camm, A.J., Cappato, R., Cobbe, S.M., Di Mario, C., Maron, B.J., McKenna, W.J., Pedersen, A.K., Ravens, U., Schwartz, P.J., Trusz-Gluza, M., Vardas, P., Wellens, H.J.J., Zipes, D.P. (2001). Task Force on Sudden Cardiac Death of the European Society of Cardiology. Eur Heart J 22: 1374-1450  
• Metzl, J. D. (2001). Preparticipation Examination of the Adolescent Athlete: Part 2. Pediatr. Rev. 22: 227-239 [Full Text]  
• Metzl, J. D. (2001). Preparticipation Examination of the Adolescent Athlete: Part 1. Pediatr. Rev. 22: 199-204 [Full Text]  
• Basso, C., Calabrese, F., Corrado, D., Thiene, G. (2001). Postmortem diagnosis in sudden cardiac death victims: macroscopic, microscopic and molecular findings. Cardiovasc Res 50: 290-300 [Full Text]  
• Corrado, D., Basso, C., Buja, G., Nava, A., Rossi, L., Thiene, G. (2001). Right Bundle Branch Block, Right Precordial ST-Segment Elevation, and Sudden Death in Young People. Circulation 103: 710-717 [Abstract] [Full Text]  
• Tiso, N., Stephan, D. A., Nava, A., Bagattin, A., Devaney, J. M., Stanchi, F., Larderet, G., Brahmbhatt, B., Brown, K., Bauce, B., Muriago, M., Basso, C., Thiene, G., Danieli, G. A., Rampazzo, A. (2001). Identification of mutations in the cardiac ryanodine receptor gene in families affected with arrhythmogenic right ventricular cardiomyopathy type 2 (ARVD2). Hum Mol Genet 10: 189-194 [Abstract] [Full Text]  
• Pelliccia, A. (2001). Congenital coronary artery anomalies in young patients: New perspectives for timely identification. J Am Coll Cardiol 37: 598-600 [Full Text]  
• Basso, C., Corrado, D., Rossi, L., Thiene, G. (2001). Ventricular Preexcitation in Children and Young Adults : Atrial Myocarditis as a Possible Trigger of Sudden Death. Circulation 103: 269-275 [Abstract] [Full Text]  
• Maron, B. J., Araujo, C. G. S., Thompson, P. D., Fletcher, G. F., de Luna, A. B., Fleg, J. L., Pelliccia, A., Balady, G. J., Furlanello, F., Van Camp, S. P., Elosua, R., Chaitman, B. R., Bazzarre, T. L. (2001). Recommendations for Preparticipation Screening and the Assessment of Cardiovascular Disease in Masters Athletes : An Advisory for Healthcare Professionals From the Working Groups of the World Heart Federation, the International Federation of Sports Medicine, and the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation 103: 327-334 [Full Text]  
• Maron, B. J., Olivotto, I., Spirito, P., Casey, S. A., Bellone, P., Gohman, T. E., Graham, K. J., Burton, D. A., Cecchi, F. (2000). Epidemiology of Hypertrophic Cardiomyopathy-Related Death : Revisited in a Large Non-Referral-Based Patient Population. Circulation 102: 858-864 [Abstract] [Full Text]  
• Pelliccia, A., Maron, B. J., Culasso, F., Di Paolo, F. M., Spataro, A., Biffi, A., Caselli, G., Piovano, P. (2000). Clinical Significance of Abnormal Electrocardiographic Patterns in Trained Athletes. Circulation 102: 278-284 [Abstract] [Full Text]  
• Spirito, P., Bellone, P., Harris, K. M., Bernabo, P., Bruzzi, P., Maron, B. J. (2000). Magnitude of Left Ventricular Hypertrophy and Risk of Sudden Death in Hypertrophic Cardiomyopathy. NEJM 342: 1778-1785 [Abstract] [Full Text]  
• Basso, C., Maron, B. J., Corrado, D., Thiene, G. (2000). Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes. J Am Coll Cardiol 35: 1493-1501 [Abstract] [Full Text]  
• Pedoe, D. T. (2000). Sudden cardiac death in sport--spectre or preventable risk?. Br. J. Sports. Med. 34: 137-140 [Full Text]  
• Wren, C, O'Sullivan, J J, Wright, C (2000). Sudden death in children and adolescents. Heart 83: 410-413 [Abstract] [Full Text]  
• Pfister, G. C., Puffer, J. C., Maron, B. J. (2000). Preparticipation Cardiovascular Screening for US Collegiate Student-Athletes. JAMA 283: 1597-1599 [Abstract] [Full Text]  
• Corrado, D., Fontaine, G., Marcus, F. I., McKenna, W. J., Nava, A., Thiene, G., Wichter, T. (2000). Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy : Need for an International Registry. Circulation 101 : e101-e106 [Abstract] [Full Text]  
• McCann, G.P., Muir, D.F., Hillis, W.S. (2000). Athletic left ventricular hypertrophy: long-term studies are required. Eur Heart J 21: 351-353  
• WREN, C. (1999). Cardiac causes for syncope or sudden death in childhood. Arch. Dis. Child. 81: 289-291 [Full Text]  
• Zipes, D. P., Wellens, H. J. J. (1998). Sudden Cardiac Death. Circulation 98: 2334-2351 [Full Text]  
• (1998). Preparticipation Sports Screening Can Prevent Sudden Deaths. JWatch Emergency Med. 1998: 14-14 [Full Text]  
• (1998). Preparticipation Screening Prevents Deaths Among Young Athletes. Journal Watch Cardiology 1998: 4-4 [Full Text]