The FIFA 2006 Big Count suggested more than 265 million football players are registered worldwide,1 making football one of the most popular and highly participated sports in the world. It is therefore not surprising that tragic cardiac events afflicting footballers are broadcast to the world through intense and emotive media coverage. Media reporting influences perceptions, however, even when these media reports are meticulously searched in high-profile athletes, only about half of sudden cardiac death (SCD) cases are revealed.2 Experts in sports cardiology, sport and exercise medicine and the wider medical community learn from these awful events, which have led to improvements in pitch side and sporting acute medical care, the development of numerous practical and educational ‘sport-specific prehospital emergency care guidelines’ and the development of cardiac screening programmes to try and identify a range of structural and electrical cardiac conditions that can lead to SCD in sport.3

However, each young athletic life lost to SCD or blighted by a sudden cardiac arrest (SCA), is a powerful reminder that despite our growing knowledge, we still lack many answers to basic questions about these afflictions. We do not know the exact numbers and trends in prevalence or incidence, and do not understand the multivariable causality that triggers SCD in previously healthy athletes. We have a limited understanding of the risks of SCD in individual sports and the variable risks by gender and ethnicity. We do not fully understand why a significant proportion of SCD remains unexplained, whether screening programmes have actually reduced the number of deaths and if they are cost effective. Variable ranges of false-positive rates continue to affect even thorough cardiac screening and we have not clarified whether risks vary by geographic region and genetics. SCD in sport has been difficult to track, and this has slowed our ability to learn and adapt best practices. Despite our best efforts, screenings will not be perfect, resuscitation not always successful and the potential for SCD to occur during sport will not be fully extinguished.

There are additional questions about how to manage screening findings and the possibility of highly variable genetic and racial trends, with Sub-Saharan Africa being cited as a cardiac hotspot.4,–,7 Recent studies have suggested a link of SCD on exertion with sickle-cell trait, which could explain some of this connection to Sub-Saharan Africa.8 ,9 One of the largest studies in the USA analysing SCD in National Collegiate Athletic Association athletes from 2004 to 2008, reported SCD being more than three times more common in African–Americans than Caucasians, but this varied greatly across sports. In Amercian Football, SCD was actually four times higher in Caucasians than African–Americans and no cardiac events were recorded during the 5-year period in football (soccer).2 Electrocardiographic patterns in African and African Caribbean athletes have also been found to differ from Caucasians, but the physiological implications on a developing athletic heart and whether these findings increase risk of SCD or are ‘normal’ for these ethnic groups is unknown.4 ,10

With improved medical facilities and expertise on site at sporting events, the probability of survival can be improved with quick emergency life support and defibrillation, if indicated.11,–,13 Access to a defibrillator on the pitch is a standard that should be uniform throughout all sport.

However, despite gains in our knowledge of SCD, sports cardiology and our response to a collapsed athlete in SCA, it is not surprising that emotions run high and assumptions are common when cardiac sporting incidents are reported in the media. This is perhaps compounded by expert debate that appears polarised on screening, a continuing issue fuelled by gaps in research and current study limitations.14 ,15

It is vital that we start to answer these questions based on reliable science and evidence. To achieve this, we propose the collection and recording of reliable data across sport of every SCD/SCA event.16 This will require collaboration and cooperation of sporting organisations, federations, clubs and the establishment of sport-specific and national registries for SCD/SCA.

FIFA made the precompetition medical assessment for all FIFA competitions mandatory17 ,18 and recently initiated the establishment of a database for SCA/SCD for all 208 Member Associations to obtain more information. This is one of many efforts needed to fill knowledge gaps and enable us to mitigate the risks of SCA/SCD in sport. We would encourage national registers for SCA/SCD, and minimum standards of emergency pitch-side medical care across sports.