Journal of Human Sport and Exercise

Sudden cardiac death and coronary artery anomalies in the athletes: A narrative review

Roberto Bianco, Giada Annarumma, Amos Cosimo Cocola, Felice Sirico, Veronica Romano



Sudden cardiac death (SCD) in the athletes is an unexpected dramatic event. The mechanism underneath SCD is often represented by a ventricular tachyarrhythmia arising as complication of a broad spectrum of cardiovascular diseases, with a silent clinical course. Therefore, SCD often represents the onset manifestation of an underlying heart disease. To prevent SCD in the athletes, several international guidelines proposed pre-participation screening protocols to identify high-risk subjects. Behind atherosclerotic diseases, other structural or functional conditions have been related to SCD, such as hypertrophic cardiomyopathy, QT-long syndrome, arrhythmogenic right ventricular dysplasia, and others. Among these, the coronary artery anomalies represent almost the 20% of all cases. The coronary artery anomalies can be classified into anomalies of origin, course and termination and can be isolated or associated with other congenital cardiac defects. Some of them are rarely symptomatic. Others could impair heart function and determine SCD. Some others determine secondary cardiovascular diseases such as increased risk of endocarditis, secondary aortic valve diseases, myocardial ischemia, and others. Innovative diagnostic and therapeutic options allowed to recognize the different coronary artery anomalies, preventing SCD in athletes. The aim of this review was to analyse coronary artery anomalies to understand their implications in SCD in athletes.


Coronary artery; Sudden cardiac death; Athletes


Adriana DM Villa, Eva Sammut, Arjun Nair, Ronak Rajani, Rodolfo Bonamini, A. C. (2016). Coronary artery anomalies overview: The normal and the abnormal. In World journal of radiology: Vol. June 28; 8.

Alsalehi, M., Jeewa, A., Wan, A., Contreras, J., Yoo, S. J., & Laks, J. A. (2019). A case series of left main coronary artery ostial atresia and a review of the literature. Congenital Heart Disease, 14(6), 901-923.

Angelini, P. (2007). Coronary artery anomalies: An entity in search of an identity. Circulation, 115(10), 1296-1305.

Angelini, P., Cheong, B. Y., Lenge De Rosen, V. V., Lopez, J. A., Uribe, C., Masso, A. H., Ali, S. W., Davis, B. R., Muthupillai, R., & Willerson, J. T. (2018). Magnetic Resonance Imaging-Based Screening Study in a General Population of Adolescents. Journal of the American College of Cardiology, 71(5), 579-580.

Angelini, P., Velasco, J. A., & Flamm, S. (2002). Coronary anomalies: Incidence, pathophysiology, and clinical relevance. Circulation, 105(20), 2449-2454.

Angelini, P., Villason, S., Albert Chan, J., & Diez, J. (1999). Chapter 4: Normal and Anomalous Coronary Arteries in Humans. Part 1: Historical Background. Coronary Artery Anomalies. Retrieved from:

Angelini, P., Villason, S., Chan, A. V, & Diez, G. (1999). Humans.

Baroldi, G., Mantero, O., & Scomazzoni, G. (1956). The collaterals of the coronary arteries in normal and pathologic hearts. Circulation Research, 4(2), 223-229.

Barry J. Maron, MD; Jamshid Shirani, MD; Liviu C. Poliac, M. et al. (1996). Sudden Death in Young Competitive Athletes Clinical, Demographic, and Pathological Profiles. JAMA, 276(3).

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. Journal of the American College of Cardiology, 35(6), 1493-1501.

Basso, Cristina, Thiene, G., Mackey-Bojack, S., Frigo, A. C., Corrado, D., & Maron, B. J. (2009). Myocardial bridging, a frequent component of the hypertrophic cardiomyopathy phenotype, lacks systematic association with sudden cardiac death. European Heart Journal, 30(13), 1627-1634.

Belviso, I., Angelini, F., Di Meglio, F., Picchio, V., Sacco, A. M., Nocella, C., Romano, V., Nurzynska, D., Frati, G., Maiello, C., Messina, E., Montagnani, S., Pagano, F., Castaldo, C., & Chimenti, I. (2020). The Microenvironment of Decellularized Extracellular Matrix from Heart Failure Myocardium Alters the Balance between Angiogenic and Fibrotic Signals from Stromal Primitive Cells. International Journal of Molecular Sciences, 21(21).

Belviso, I., Romano, V., Sacco, A. M., Ricci, G., Massai, D., Cammarota, M., Catizone, A., Schiraldi, C., Nurzynska, D., Terzini, M., Aldieri, A., Serino, G., Schonauer, F., Sirico, F., D'Andrea, F., Montagnani, S., Di Meglio, F., & Castaldo, C. (2020). Decellularized Human Dermal Matrix as a Biological Scaffold for Cardiac Repair and Regeneration. Frontiers in Bioengineering and Biotechnology, 8.

Bland, E. F., White, P. D., & Garland, J. (1933). Congenital anomalies of the coronary arteries: Report of an unusual case associated with cardiac hypertrophy. American Heart Journal, 8(6), 787-801.

Brown, K. N., & Borger, J. (2019). Anatomy, Thorax, Heart Anomalous Left Anterior Descending (LAD) Artery. StatPearls, 1-6.

Castaldo, C., Di Meglio, F., Miraglia, R., Sacco, A. M., Romano, V., Bancone, C., Della Corte, A., Montagnani, S., & Nurzynska, D. (2013). Cardiac fibroblast-derived extracellular matrix (biomatrix) as a model for the studies of cardiac primitive cell biological properties in normal and pathological adult human heart. BioMed Research International, 2013, 352370.

Castelletti, S., & Crotti, L. (2020). To be, or not to be engaged in sport activities, that is the amletic question for patients with coronary artery disease. European Journal of Preventive Cardiology, 27(7), 767-769.

Challoumas, D., Pericleous, A., Dimitrakaki, I. A., Danelatos, C., & Dimitrakakis, G. (2014). Coronary Arteriovenous Fistulae: A Review. The International Journal of Angiology : Official Publication of the International College of Angiology, Inc, 23(1), 1-10.

Corban, M. T., Hung, O. Y., Eshtehardi, P., Rasoul-Arzrumly, E., McDaniel, M., Mekonnen, G., Timmins, L. H., Lutz, J., Guyton, R. A., & Samady, H. (2014). Myocardial bridging: Contemporary understanding of pathophysiology with implications for diagnostic and therapeutic strategies. Journal of the American College of Cardiology, 63(22), 2346-2355.

Corrado, D., Thiene, G., Nava, A., Rossi, L., & Pennelli, N. (1990). Sudden death in young competitive athletes: Clinicopathologic correlations in 22 cases. The American Journal of Medicine, 89(5), 588-596.

Corrado, Domenico, Basso, C., Rizzoli, G., Schiavon, M., & Thiene, G. (2003). Does Sports Activity Enhance the Risk of Sudden Death in Adolescents and Young Adults? Journal of the American College of Cardiology, 42(11), 1959-1963.

Corrado, Domenico, Migliore, F., Basso, C., & Thiene, G. (2006). Exercise and the risk of sudden cardiac death. Herz, 31(6), 553-558.

D'Andrea, A., Mele, D., Palermi, S., Rizzo, M., Campana, M., Giannuario, G. D., Gimelli, A., Khoury, G., Moreo, A., & Ospedalieri (ANMCO), a nome dell'Area C. dell'Associazione N. M. C. (2020). Le "zone grigie" degli adattamenti cardiovascolari all'esercizio fisico: Come orientarsi nella valutazione ecocardiografica del cuore d'atleta. Giornale Italiano di Cardiologia, 21(6), 457-468.

Danias, P. G., Stuber, M., McConnell, M. V., & Manning, W. J. (2001). The diagnosis of congenital coronary anomalies with magnetic resonance imaging. Coronary Artery Disease, 12(8), 621-626.

De-Giorgio, F., & Arena, V. (2010). Ostial plication: A rarely reported cause of sudden death. Diagnostic Pathology, 5(1), 1-2.

Desmet, W., Vanhaecke, J., Vrolix, M., Van De Werf, F., Piessens, J., Willems, J., & De Geest, H. (1992). Isolated single coronary artery: A review of 50 000 consecutive coronary angiographies. European Heart Journal, 13(12), 1637-1640.

Dodge-Khatami, A., Mavroudis, C., & Backer, C. L. (2002). Anomalous origin of the left coronary artery from the pulmonary artery: Collective review of surgical therapy. Annals of Thoracic Surgery, 74(3), 946-955.

Dotan, M., Roguin, A., Sinyor, D., Yalonetsky, S., Asaad, K., Schwartz, Y., Khatib, I., & Lorber, A. (2013). Increased incidence of coronary artery origin anomalies associated with isolated patent ductus arteriosus. Pediatric Cardiology, 34(4), 907-911.

Edwards, C. P., Yavari, A., Sheppard, M. N., & Sharma, S. (2010). Anomalous coronary origin: The challenge in preventing exercise-related sudden cardiac death. British Journal of Sports Medicine, 44(12), 895-897.

Edwards, J. E., & Vlodaver, Z. (1971). Pathology of Coronary Atherosclerosis. Progress in Cardiovascular Diseases, XIV(3).

Ferreira, A. G., Trotter, S. E., Konig, B., Decourt, L. V., Fox, K., & Olsen, E. G. J. (1991). Myocardial bridges: Morphological and functional aspects. British Heart Journal, 66(5), 364-367.

Frescura, C., Basso, C., Thiene, G., Corrado, D., Pennelli, T., Angelini, A., & Daliento, L. (1998). Anomalous origin of coronary arteries and risk of sudden death: A study based on an autopsy population of congenital heart disease. Human Pathology, 29(7), 689-695.

Geuns, R. J. M., & Cademartiri, F. (2005). Anatomy of the Coronary Arteries and Veins in CT Imaging. CT of the Heart, 3, 219-227.

Ghosh PK, Agarwal SK, Kumar R, Chandra N, P. VK. (1994). Anomalous origin of right coronary artery from left aortic sinus. J Cardiovasc Surg (Torino), feb(32), 65-70.

Gowda, R. M., Vasavada, B. C., & Khan, I. A. (2006). Coronary artery fistulas: Clinical and therapeutic considerations. International Journal of Cardiology, 107(1), 7-10.

Gräni, C., Benz, D. C., Steffen, D. A., Giannopoulos, A. A., Messerli, M., Pazhenkottil, A. P., Gaemperli, O., Gebhard, C., Schmied, C., Kaufmann, P. A., & Buechel, R. R. (2018). Sports Behavior in Middle-Aged Individuals with Anomalous Coronary Artery from the Opposite Sinus of Valsalva. Cardiology (Switzerland), 139(4), 222-230.

Harmon, K. G., Asif, I. M., Maleszewski, J. J., Owens, D. S., Prutkin, J. M., Salerno, J. C., Zigman, M. L., Ellenbogen, R., Rao, A. L., Ackerman, M. J., & Drezner, J. A. (2015). Incidence, cause, and comparative frequency of sudden cardiac death in national collegiate athletic association athletes a decade in review. Circulation, 132(1), 10-19.

Heart, A., Liberthson, R. R., Sagar, K., Berkoben, J. P., Weintraub, R. M., & Levine, F. H. (2010). Cir cAln Official Journal of the Congenital Coronary Arteriovenous Fistula. Circulation, 59(5), 849-854.

Kim, M. S., Jung, J. I., & Chun, H. J. (2010). Coronary to pulmonary artery fistula: Morphologic features at multidetector CT. International Journal of Cardiovascular Imaging, 26(SUPPL. 2), 273-280.

Kim, S. Y., Seo, J. B., Do, K. H., Heo, J. N., Lee, J. S., Song, J. W., Choe, Y. H., Kim, T. H., Yong, H. S., Choi, S. Il, Song, K. S., & Lim, T. H. (2006). Coronary artery anomalies: Classification and ECG-gated multi-detector row CT findings with angiographic correlation. Radiographics, 26(2), 317-333.

Kugelmass, A. D., Manning, W. J., Piana, R. N., Weintraub, R. M., Baim, D. S., & Grossman, W. (1992). Coronary arteriovenous fistula presenting as congestive heart failure. Catheterization and Cardiovascular Diagnosis, 26(1), 19-25.

Kumari, M., Rha, S.-W., Poddar, K. L., Park, J. Y., Choi, B. G., Kim, Y. K., Na, J. O., Choi, C. U., Lim, H. E., Kim, J. W., Kim, E. J., Park, C. G., Seo, H. S., & Oh, D. J. (2011). Clinical and Angiographic Characteristics of Coronary Endothelial Dysfunction Severity in Patients With Myocardial Bridge As Assessed By Acetylcholine Provocation Test. Journal of the American College of Cardiology, 57(14), E1513.

Lange, R., Vogt, M., Hörer, J., Cleuziou, J., Menzel, A., Holper, K., Hess, J., & Schreiber, C. (2007). Long-Term Results of Repair of Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery. Annals of Thoracic Surgery, 83(4), 1463-1471.

Latson, L. A. (2007). Coronary artery fistulas: How to manage them. Catheterization and Cardiovascular Interventions, 70(1), 111-118.

Lipton, M. J., Barry, W. H., Obrez, I., Silverman, J. F., & Wexler, L. (1979). Isolated single coronary artery: Diagnosis, angiographic classification, and clinical significance. Radiology, 130(1), 39-47.

Luo, L., Kebede, S., Wu, S., & Stouffer, G. A. (2006). Coronary artery fistulae. American Journal of the Medical Sciences, 332(2), 79-84.

Macdonald, H. M., Nishiyama, K. K., Kang, J., Hanley, D. A., & Boyd, S. K. (2011). Age-related patterns of trabecular and cortical bone loss differ between sexes and skeletal sites: A population-based HR-pQCT study. Journal of Bone and Mineral Research: The Official Journal of the American Society for Bone and Mineral Research, 26(1), 50-62.

Mangukia, C. V. (2012). Coronary artery fistula. Annals of Thoracic Surgery, 93(6), 2084-2092.

Maron, B. J., Doerer, J. J., Haas, T. S., Tierney, D. M., & Mueller, F. O. (2009). Sudden deaths in young competitive athletes analysis of 1866 deaths in the united states, 1980-2006. Circulation, 119(8), 1085-1092.

McNamara JJ, G. R. (1969). Congenital coronary artery fistula. Surgery.

Moore, A. G., & Agarwal, P. P. (2014). Hammock sign. Journal of Thoracic Imaging, 29(5), W89.

Morales, A. R., Romanelli, R., Tate, L. G., Boucek, R. J., & de Marchena, E. (1993). Intramural left anterior descending coronary artery: Significance of the depth of the muscular tunnel. Human Pathology, 24(7), 693-701.

Morgan, J. R., Forker, A. D., O'Sullivan, M. J., & fosburg, R. G. (1972). Coronary arterial fistulas. Seven cases with unusual features. The American Journal of Cardiology, 30(4), 432-436.

Nieman, K., Oudkerk, M., Rensing, B. J., van Ooijen, P., Munne, A., van Geuns, R. J., & de Feyter, P. J. (2001). Coronary angiography with multi-slice computed tomography. Lancet (London, England), 357(9256), 599-603.

Olivotto, I., Cecchi, F., & Yacoub, M. H. (2009). Myocardial bridging and sudden death in hypertrophic cardiomyopathy: Salome drops another veil. European Heart Journal, 30(13), 1549-1550.

Palermi, S., Sacco, A. M., Belviso, I., Romano, V., Montesano, P., Corrado, B., & Sirico, F. (2020). Guidelines for Physical Activity-A Cross-Sectional Study to Assess Their Application in the General Population. Have We Achieved Our Goal? International Journal of Environmental Research and Public Health, 17(11).

Qureshi, S. A. (2006). Coronary arterial fistulas. Orphanet Journal of Rare Diseases, 1(1), 2-7.

Ricci, F., Aung, N., Gallina, S., Zemrak, F., Fung, K., Bisaccia, G., Paiva, J. M., Khanji, M. Y., Mantini, C., Palermi, S., Lee, A. M., Piechnik, S. K., Neubauer, S., & Petersen, S. E. (2020). Cardiovascular magnetic resonance reference values of mitral and tricuspid annular dimensions: The UK Biobank cohort. Journal of Cardiovascular Magnetic Resonance, 23(1), 5.

Ricci, F., Sutton, R., Palermi, S., Tana, C., Renda, G., Gallina, S., Melander, O., De Caterina, R., & Fedorowski, A. (2018). Prognostic significance of noncardiac syncope in the general population: A systematic review and meta-analysis. Journal of Cardiovascular Electrophysiology, 29(12), 1641-1647.

Rittenhouse, E. A., Doty, D. B., & Ehrenhaft, J. L. (1975). Congenital Coronary Artery-Cardiac Chamber Fistula: Review of Operative Management. Annals of Thoracic Surgery, 20(4), 468-485.

Roberts, W. C. (1986). Major anomalies of coronary arterial origin seen in adulthood. American Heart Journal, 111(5), 941-963.

Shiga, Y., Tsuchiya, Y., Yahiro, E., Kodama, S., Kotaki, Y., Shimoji, E., Fukuda, N., Morito, N., Urata, M., Saito, N., Niimura, H., Mihara, H., Yamanouchi, Y., & Urata, H. (2008). Left main coronary trunk connecting into right atrium with an aneurysmal coronary artery fistula. International Journal of Cardiology, 123(2), 28-30.

Sorajja, P., Ommen, S. R., Nishimura, R. A., Gersh, B. J., Tajik, A. J., & Holmes, D. R. (2003). Myocardial bridging in adult patients with hypertrophic cardiomyopathy. Journal of the American College of Cardiology, 42(5), 889-894.

Swensonn R.E., Murillo-Olivas A., Elias W., et al. (1988). Non invasive Doppler Color flow mapping for detection of anomalous origin of the fet coronary artery from the pulmonary artery and for evaluation of surgical repair. J Am Coll Cardiol.

Tio, R. A., Van Gelder, I. C., Boonstra, P. W., & Crijns, H. J. G. M. (1997). Myocardial bridging in a survivor of sudden cardiac near-death: Role of intracoronary Doppler flow measurements and angiography during dobutamine stress in the clinical evaluation. Heart, 77(3), 280-282.

Van Hare, G. F., Ackerman, M. J., Evangelista, J.-A. K., Kovacs, R. J., Myerburg, R. J., Shafer, K. M., Warnes, C. A., Washington, R. L., & American Heart Association Electrocardiography and Arrhythmias Committee of Council on Clinical Cardiology, Council on Cardiovascular Disease in Young, Council on Cardiovascular and Stroke Nursing, Council on Functional Genomics and Translational Biology, and American College of Cardiology. (2015). Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 4: Congenital Heart Disease: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation, 132(22), e281-291.

Vavuranakis, M., Bush, C. A., & Boudoulas, H. (1995). Coronary artery fistulas in adults: Incidence, angiographic characteristics, natural history. Catheterization and Cardiovascular Diagnosis, 35(2), 116-120.

Villa, A. D., Sammut, E., Nair, A., Rajani, R., Bonamini, R., & Chiribiri, A. (2016). Coronary artery anomalies overview: The normal and the abnormal. World Journal of Radiology, 8(6), 537.

Virmani, R., Chun, P. K. C., Goldstein, R. E., Robinowitz, M., & Mcallister, H. A. (1984). Acute takeoffs of the coronary arteries along the aortic wall and congenital coronary ostial valve-like ridges: Association with sudden death. Journal of the American College of Cardiology, 3(3), 766-771.

Vitarelli, A., De Curtis, G., Conde, Y., Colantonio, M., Di Benedetto, G., Pecce, P., De Nardo, L., & Squillaci, E. (2002). Assessment of congenital coronary artery fistulas by transesophageal color Doppler echocardiography. American Journal of Medicine, 113(2), 127-133.

Wesselhoeft H, Fawcett JS, J. AL. (1968). Anomalous origin of the left coronary artery from the pulmonary trunk: Its clinical spectrum, pathology and pathophysiology, based on review of 140 cases with seven further cases.

Yamanaka, O., & Hobbs, R. E. (1990). Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Catheterization and Cardiovascular Diagnosis, 21(1), 28-40.

Yu, R., Sharma, B., & Franciosa, J. A. (1986). Acquired coronary artery fistula to the left ventricle after acute myocardial infarction. The American Journal of Cardiology, 58(6), 557-558.

Yurtdas Mustafa, & Gülen Oktay. (2012). Anomalous origin of the right coronary artery from the left anterior descending artery: Review of the literature. Cardiology Journal, 19(2), 122-129.

Zeppilli, P. (1983). Med Sport-Miti e pregiudizi sulla morte improvvisa da sport.


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