Sudden cardiac death (SCD) represents a clinically significant event in the sports setting, as it may occur in individuals who appear healthy and are physically active. Sudden cardiac death is commonly defined as death occurring unexpectedly within the first hour after the onset of symptoms (25). Although its incidence is relatively low, its unpredictable and often fatal nature generates increasing concern. This phenomenon has attracted considerable interest from the medical and scientific community, particularly because it affects both professional and amateur athletes in a context where physical activity is widely promoted as a strategy to prevent chronic diseases, including cardiovascular conditions (1).

Several studies have shown that the incidence and causes of SCD vary according to the type of sport, the athlete’s age, and the level of competition (2). In young athletes, the primary causes are mainly related to inherited structural heart diseases and channelopathies, whereas in individuals older than 35 years, atherosclerotic coronary artery disease is more prevalent. In countries such as the United States and several European nations, sports such as soccer and basketball present the highest incidence rates, highlighting the need to develop sport- and population-specific preventive strategies (3).

The situation of amateur athletes is particularly concerning, as unlike professional athletes, they are less likely to undergo comprehensive medical evaluations. The absence of pre-participation cardiovascular screening, such as electrocardiography and echocardiography, limits the early detection of conditions such as hypertrophic cardiomyopathy, hypertension, or coronary artery disease, all of which are closely associated with SCD. In addition, modifiable risk factors such as the use of stimulant substances, smoking, and obesity are common among physically active individuals, revealing a contradiction between sports participation and true cardiovascular protection. This underscores the importance of incorporating cardiovascular health as a central component of training programs, regardless of the competitive level (4).

Although regular physical activity is widely recognized as essential for controlling cardiovascular risk factors, the continued occurrence of SCD among apparently healthy amateur athletes highlights an important gap in current knowledge (5). Many of these individuals lack evident clinical histories or abnormalities in conventional risk factors, raising the question of whether other, less investigated or undiagnosed factors may increase the likelihood of fatal events even in physically active populations.

In this context, it is relevant to systematically analyze which cardiovascular diseases and risk factors are associated with SCD in amateur athletes, as well as to explore their relationship with different sporting practices. Such an approach may help guide more effective strategies for early detection, clinical monitoring, and individualized prevention in this population (6, 7). Therefore, the following research question arises:

What are the most prevalent cardiovascular diseases and risk factors associated with sudden cardiac death in amateur athletes? A scoping review.

This scoping review was conducted following the guidelines of the PRISMA-ScR checklist for reporting scoping reviews (8), ensuring methodological transparency and rigor. In addition, the methodological framework proposed by the Joanna Briggs Institute (JBI) (9) was adopted, which included the following phases: formulation of the research question, identification of relevant studies, study selection, data extraction, and the synthesis and reporting of results and conclusions. The objective was to map the available evidence on the most prevalent cardiovascular diseases and the risk factors associated with sudden death in amateur athletes.

The research question was structured using the PCC framework: the population included amateur athletes aged 18 years and older (P), the concept encompassed cardiovascular diseases and associated risk factors (C), and the context focused on sudden cardiac death (C). Systematic searches were conducted in the PubMed, SciELO, Scopus, and Springer databases. Study selection was carried out in three phases (title screening, abstract screening, and full-text review with final inclusion) by two independent investigators, who also manually removed duplicate records. Studies were included without restrictions on publication date and in three languages: Spanish, English, and Portuguese. Data were extracted using a standardized table that included author, year, country, study design, population characteristics, identified diseases, risk factors, and relevant events.

A total of 1,807 studies were initially identified. After preliminary screening, titles and abstracts were evaluated, and the inclusion and exclusion criteria were applied. A total of 1,802 studies were excluded, and finally, five articles were included in the review (Figure 1).

All included studies had a descriptive design and were observational cohort studies, both prospective and retrospective (10–14), in which the causes of sudden cardiac death, type of sport or physical activity, and associated risk factors were evaluated. Regarding the origin of the identified studies, two were conducted in the United States (10, 14), one in Germany (11), one in Switzerland (12), and one consisted of an evaluation of autopsy reports from 67 different countries (13).

The most frequently reported cause of death across the studies was hypertrophic cardiomyopathy, accounting for approximately 80% of cases in most studies (10, 11, 13, 14). Other reported causes included arrhythmogenic right ventricular cardiomyopathy, congenital coronary artery anomalies, channelopathies (long QT syndrome and Brugada syndrome), mitral valve prolapse, aortic stenosis, aortic dissection, atherosclerotic coronary artery disease, myocarditis, acute myocardial infarction (10–14), and blunt trauma (commotio cordis) (10).

Regarding sports disciplines, sudden cardiac death was most frequently reported in soccer (10, 13), followed by athletics, basketball, baseball, and American football (10, 13, 14). One study did not specify the sport practiced by the deceased individuals (12). Across all included studies, a marked predominance of male sex was consistently observed, indicating that men represent the group at highest risk for sudden cardiac death in amateur sports settings (10–14).

The mean age at death in study (10) was 18 years, while in studies (11–14) it was 35 years, with variations observed depending on the population and competitive level. One study reported a higher number of deaths in recreational sports (10, 11), whereas another study indicated that the highest incidence of sudden death occurred in individuals who did not practice any type of sport, either recreational or elite (12).

The most frequently reported risk factors for sudden death included a previous diagnosis of cardiovascular disease, smoking, arterial hypertension, dyslipidemia, family history of premature coronary artery disease, coronary artery stenosis, and previous myocardial infarction (10, 12). Additionally, recent respiratory infections associated with myocarditis in young individuals and the absence of early cardiopulmonary resuscitation or defibrillation during events were also identified as relevant risk factors (11–14).

Methodological quality assessment showed that most studies had high methodological quality (11–14), while one study was rated as having moderate methodological quality (10), mainly due to the lack of representative group recruitment and heterogeneous measurement of exposures for the assignment between exposed and non-exposed groups (Table 3).

The main objective of this study was to map the available evidence on the most prevalent cardiovascular diseases and the risk factors associated with sudden cardiac death (SCD) in amateur athletes. Hypertrophic cardiomyopathy was identified as the most frequently reported cause, which can be explained by the fact that this condition compromises both the electrical and mechanical function of the heart, favoring the occurrence of fatal ventricular arrhythmias during intense exercise. Similar findings were reported in studies (10, 14), in which hypertrophic cardiomyopathy was identified as the most frequent etiological factor in young athletes.

These findings are consistent with studies conducted in the United States, such as study (10), where the analysis of a large cohort of sudden deaths in young adult athletes confirmed hypertrophic cardiomyopathy as the predominant etiology.

The most frequently reported cause of sudden death in amateur athletes was hypertrophic cardiomyopathy (HCM). This condition is characterized by marked hypertrophy of the interventricular septum and disorganization of myocardial tissue, which alters the normal architecture of muscle fibers. These structural modifications lead to prolonged electrical conduction pathways and increased electrical instability, facilitating the development of malignant ventricular tachyarrhythmias capable of triggering sudden death, particularly during intense physical exertion when myocardial metabolic demand is significantly increased (15).

The pathophysiology of HCM involves multiple mechanisms. On the one hand, myocardial hypertrophy and interstitial fibrosis impair diastolic relaxation and predispose to ischemia; on the other hand, myocyte disarray disrupts electrical conduction, promoting re-entry circuits and fatal ventricular arrhythmias. This scenario is exacerbated during exercise, when catecholamine release and increased myocardial contractility act as critical triggers (16).

Hypertrophic cardiomyopathy is considered predominantly congenital with a genetic basis, associated with mutations in sarcomeric genes such as MYH7 and MYBPC3, which lead to disproportionate hypertrophy of the interventricular septum and myocardial disorganization (17, 18). These structural alterations generate an electrically unstable substrate. Nevertheless, acquired or secondary conditions that may mimic a hypertrophic phenotype have been reported, including hypertrophy induced by chronic arterial hypertension due to sustained ventricular pressure overload, metabolic and storage diseases, or, in specific cases, the physiological hypertrophy observed in the “athlete’s heart.” Overall, HCM combines mechanical alterations (outflow tract obstruction and diastolic dysfunction) and electrical disturbances (re-entry circuits and arrhythmias) that increase the risk of sudden death (2, 19).

Hypertrophic cardiomyopathy represents a particular risk because it may remain asymptomatic for years, without evident clinical signs, until intense exertion triggers the first event, which is often sudden cardiac death. The danger lies in the fact that individuals considered “healthy” may begin sports practice without knowing they have this condition, thereby being exposed to malignant ventricular arrhythmias or circulatory collapse during exercise. For this reason, several scientific societies recommend the implementation of preventive cardiovascular screening, including tests such as electrocardiography and echocardiography, before engaging in high-intensity physical activities (20). These screening strategies allow the detection of structural or electrical cardiac abnormalities that, if diagnosed early, could significantly reduce sudden cardiac deaths in both competitive and recreational sports settings.

Other relevant causes of sudden death identified in the studies were atherosclerotic coronary artery disease, more frequent in athletes older than 35 years, and myocarditis, particularly observed in younger individuals with recent respiratory infections. Both conditions create a substrate for fatal events, either through myocardial ischemia, acute myocardial infarction, or secondary ventricular arrhythmias. These findings are consistent with international reports, such as the prospective German study, which described coronary artery disease as the leading cause in middle-aged adult athletes, whereas myocarditis predominated in those younger than 35 years (11). Similarly, studies conducted in Switzerland confirmed premature coronary artery disease as the most frequent etiology of sudden death in young populations, reinforcing the importance of integrating screening for classical cardiovascular risk factors and early detection of viral infections before returning to competitive sports (12).

The sports discipline with the highest number of reported deaths was soccer. This sport imposes very high cardiovascular demands, as players often perform at intensities close to 90% of their maximum heart rate while sustaining prolonged periods of exertion. This increases the risk of triggering events such as ventricular arrhythmias, myocardial ischemia, or infarction, especially in the presence of underlying cardiac conditions. These findings are consistent with those reported by Işın et al. (2021) in Turkey, where 82% of soccer-related sudden deaths occurred during recreational practice, with considerably higher attributable mortality in men aged 30 to 49 years (21).

The mean age at death was 29 years, indicating that SCD does not only affect older adults but also young individuals in their peak athletic years. This may be explained by the interaction between genetic predisposition and exposure to high-intensity physical exertion. Age was also reported as a determining factor, with differences in etiology between individuals younger and older than 35 years (11, 14).

Across the analyzed studies, the most frequently reported risk factors for sudden death were previous diagnoses of cardiovascular disease, such as coronary artery stenosis or prior myocardial infarction, as well as classical predisposing conditions including smoking, arterial hypertension, dyslipidemia, and family history of premature coronary artery disease. These findings reinforce that, even in physically active individuals, traditional cardiovascular risk factors continue to play a central role in the development of fatal events. In younger individuals, recent respiratory infections were consistently associated with myocarditis, demonstrating how seemingly benign inflammatory processes can become critical triggers during intense physical exertion (22). Furthermore, the absence of cardiopulmonary resuscitation or early defibrillation at the event site was associated with increased mortality, highlighting the importance of secondary prevention strategies. In addition, non-modifiable factors such as male sex, African American ethnicity, and participation in high-risk sports such as basketball or American football at high competitive levels were more frequently associated with sudden death. These findings align with international literature and suggest that the interaction between genetic predisposition, cardiovascular comorbidities, and sport-specific demands creates a high-risk scenario requiring targeted preventive measures in the amateur population (23).

This study provides relevant evidence by highlighting the need for cardiovascular screening in amateur athletes, including electrocardiography, echocardiography, and family history assessment, as well as educational programs in cardiopulmonary resuscitation and the availability of automated external defibrillators (AEDs) in sports settings (10, 12, 13, 23).

Overall methodological quality of the included studies ranged from high to moderate, indicating that the results are consistent and reliable, although heterogeneity in data collection methods and differences between countries should be acknowledged (10–14).

The strengths of this study lie in the integration of evidence from different regions, including Germany, the United States, and 67 countries, as well as multiple sports such as soccer, athletics, basketball, and baseball, providing a global perspective on the problem and highlighting common factors that may guide preventive strategies. In addition, structured information search protocols and methodological quality assessment of the included studies were applied (10–14).

The limitations of this study include the small number of selected studies, potential underreporting of cases in official registries, and lack of uniformity in diagnostic and autopsy criteria across countries, limitations that have also been reported in previous reviews of sports-related sudden cardiac death (24).

Future research should expand scientific production in non-professional sports contexts, where the risk of sudden death may be underestimated and preventive measures are less stringent than in elite sports. In addition, it is necessary to explore the influence of factors such as training level, absence of systematic cardiovascular screening, and the coexistence of comorbidities common in the general population, in order to develop prevention strategies tailored to this group of athletes.

Hypertrophic cardiomyopathy was identified as the main cause of sudden cardiac death in amateur athletes, followed by atherosclerotic coronary artery disease and myocarditis.

The main risk factors attributed to sudden death were arterial hypertension, dyslipidemia, previous myocardial infarction, coronary artery stenosis, and recent respiratory infections, as well as non-modifiable factors such as family history and participation in high-intensity sports, including the absence of automated external defibrillators (AEDs) in sports practice settings in the event of a sudden cardiac event.