A new urgency: addressing sudden cardiac death in young First Nations Australians through comprehensive screening

For over 25 years, we have known that First Nations people in the Northern Territory of Australia have disproportionately high rates of premature ischaemic heart disease. While data are scant, in 1999 Young et al. published their review of cases of sudden cardiac death (SCD) in Aboriginal sportsmen in the Northern Territory from 1982 to 1996 [1]. They reported a rate of 19–24 per 100,000 player-years which was up to 12 times higher than rates of SCD in sport and 40 times the incidence of ischaemic heart disease-related SCD in young Australian footballers in Victoria, Australia. Heat may have been a factor in many cases, with all deaths occurring in the hotter (wet season) months and at or after half-time in the game. Based on these findings, the authors called for prevention strategies including screening, heat-stress reduction strategies and education.

1. Disproportionate rates of SCD in the Northern Territory of Australia

In this issue of the Journal of Science and Medicine in Sport Plus, Pande and colleagues present critical findings of their study reviewing coronial records of SCD cases in young First Nations Australians aged 40 years and under in the Northern Territory [2]. They identified 59 SCD cases between 2019 and 2023. The population of the Northern Territory is estimated at about 250,000, of which 31 ​% identified as First Nations people (June 2021) [3]. This population has a younger age distribution than the non-Indigenous population. Thus, the study estimates the annual rate of SCD in young First Nations Australians in the Northern Territory as 19.8 per 100,000 persons. This is around 15 times higher than the estimates of the annual incidence in the Australian general population aged 1–35 years [4].

In this study, the mean age of death was 32 years and 61 ​% of cases were male. Just over 60 ​% of cases were caused by coronary artery disease, followed by rheumatic heart disease (RHD) (8.5 ​%) and sudden arrhythmic death syndrome (SADS) (7 ​%). Almost 39 ​% had cardiac risk factors and 20 ​% had RHD [2].

This study covered the period of the COVID-19 pandemic – a time where access to healthcare, diagnostic and post-mortem investigations may have been disrupted. It is possible that at some times during the period, the number of cases presenting for autopsy may have decreased. These findings should be interpreted in the context of broader structural health inequities and challenges. In addition, COVID-19 may have had a direct impact on the study population, as has been reported in the state of New South Wales, where cardiovascular deaths increased with COVID-19 cases [5].

2. A call to action

This paper provides vital and concerning data. The authors conclude that existing approaches are inadequate for young First Nations Australians, and advocate for tailored screening to begin at the age of 18 years. This aligns with the Heart Foundation and the 2020 consensus recommendations of the Royal Australian College of General Practitioners, the National Aboriginal Community Controlled Health Organisation, which recommend risk factor assessment from the age of 18 years and absolute risk assessment from the age of 30 years for First Nations Australians [6,7]. The consensus statement recommends that “assessment should occur as part of an annual health check or opportunistically” and that “subsequent review should be conducted according to level of risk”. The 2024 Australasian College of Sport and Exercise Physicians position statement on cardiac evaluation in young athletes, which notes the lack of data on SCD incidence in Indigenous populations, also points out the importance of including evaluation of risk factors for ischaemic heart disease as part of cardiac screening in this population [8].

Addressing this issue demands more than clinical alignment. We need a culturally safe, well-resourced and co-ordinated strategy for assessing risk factors and diagnosing cardiac disease. This should include accessible point of care testing for lipids and blood sugar levels, as well as mobile echocardiogram and electrocardiogram (ECG) services.

Most importantly, there is a critical need to develop and implement novel screening strategies that are culturally safe, co-designed and community-led. Programs must prioritise cultural authority and local knowledges including a clear pathway to care, and actively support trust and participation. Health screening in First Nations communities must be more than accessible – it must be ethically and culturally sound and responsive to the communities it aims to serve. This could be linked to exercise promotion as an essential part of modifying cardiac risk factors, which should be encouraged, acknowledging the cultural requirements and geographic barriers that exist in northern Australia.

Sport may offer a novel setting and approach. For example, cardiac screening of players in the AFL (Australian Football League), where around 10 ​% of the players are First Nations [9], typically includes ECG, history and examination, and is widely accepted. Similar screening in other elite sporting settings has demonstrated high uptake and acceptability [10,11]. Screening in sport often occurs at the training ground in a convenient, familiar and inclusive setting. This approach could be translated and tailored for First Nations Australians. Australian Rules Football has the highest participation rate in the Northern Territory, engaging over a quarter of the population – including many First Nations players and fans [12]. In addition, notable First Nations athletes who have undergone cardiac screening as part of their playing career could serve as powerful role models to the community to increase trust and visibility for screening programs.

Ideally, comprehensive cardiac programs should also include recognition and response to sudden cardiac arrest, including education for the community on basic life support/cardiopulmonary resuscitation and use of an automated external defibrillators. A new approach is needed.

Any effort to reduce SCD in First Nations Australians must be grounded in principles of cultural security, equity and respect for sovereignty, community consultation and incorporation of Aboriginal knowledge systems are essential for success. Screening programs must not be imposed, but requested, welcomed and shaped by the community.