Etiologies of Sudden Cardiac Death in National Collegiate Athletic Association Athletes.
Harmon KG, Drezner JA, Maleszewski JJ, Lopez-Anderson M, Owens D, Prutkin JM, Asif IM, Klossner D, Ackerman MJ. Circ Arrhythm Electrophysiol. 2014. doi:10.1161/CIRCEP.113.001376. http://circep.ahajournals.org/content/early/2014/02/28/CIRCEP.113.001376
Incidence and Causes of Sudden Death in U.S. College Athletes.
Maron BJ, Haas TS, Murphy CJ, Ahluwalia A, Rutten-Ramos S. J Am Coll Cardiol. 2014. doi:10.1016/j.jacc.2014.01.041.
Take Home Message: Two recent studies found different causes of SCD, which makes it difficult to develop cost-effective screening strategies when it remains uncertain what problems we should be screening for in preparticipation physicals.
There is an active debate regarding how best to prevent sudden cardiac death (SCD) in athletes with one camp recommending history and physical exam alone (per the 2007 AHA guidelines) versus another camp recommending history, physical exam, and electrocardiograms (per the 2005 EuropeanSports Study Group and 2004 IOC guidelines). The first step toward the development of an effective screening program is to determine the incidence and causes of SCD in athletic populations. In the United States, an accurate incidence rate remains elusive and estimates range from 1 in 200,000 in US athletes to 1 in 3,100 among male Division 1 basketball players. These two manuscripts sought to define the etiology of SCD. Maron et al looked at databases and autopsy reports from the US National Sudden Death in Athletes Registry and the NCAA from 2002-2011. During the 10-year period, 182 sudden deaths occurred. Of the 182, 118 (65%) were the result of non-cardiovascular issues with drug abuse and suicide leading the way – an incidence of 1.3 per 100,000 athlete-participation-years. Sixty-four athletes (35%) had a confirmed cardiovascular death – an incidence of 1.2 per 100,000 athlete-participation-years. Of note, the sudden cardiac death rate in African-American athletes was higher than white athletes (3.8 versus. 0.7/100,000 athlete-participation-years), but their rate of SCD was not different from the SCD rate in the general student body of African-Americans (3.8 versus 4.3/100,000 person-years). In the second study, Harmon et al examined the NCAA Database and the Parent Heart Watch (PHW) Database from 2004 through 2008. Harmon et al found 45 cases of SCD for an incidence of 1 in 43,770 (or 2.3 per 100,000). The most common cause in Maron’s 10-year study was hypertrophic cardiomyopathy (HCM) while the most common cause in Harmon’s 5-year study was autopsy-negative, sudden unexplained death (AN-SUD).
These studies will most certainly provoke discussion regarding SCD and SCD prevention strategies +/- ECG. Sudden cardiac death in college athletes is an exceedingly rare event. Much of our time as sports medicine clinicians is relegated to developing universal screening practices to prevent SCD. The data presented by Maron et al suggests that perhaps we should be spending at least as much time in the mental health arena developing strategies to prevent suicide and drug-related deaths. It is curious that these studies found different etiologies for SCD among athletes. Both of these studies examined forensic data. However, there is no standard autopsy protocol for these cases and there is room for interpretation for those charged with reviewing autopsy data. Maron alone interpreted this data in his study, while a committee reviewed the data and reached consensus opinion in the Harmon study. This potentially explains the difference in the reported etiologies between the two studies.
Perhaps of greatest concern, there exists significant disparity between the sudden death rate of African American college students when compared to white college students. This fivefold increased risk clearly warrants additional study. As more people take heed of the recommendations for increased physical activity in the population as a whole, perhaps SCD is more of a public health problem than a sports medicine problem, per se.
Questions for Discussion: Given the incidence data from these studies, do you think the sports medicine community spends too much, too little, or the right amount of time on the topic of SCD in athletes? What is the screening strategy at your program? Do you include ECG as part of the pre-participation process?
Written by: Marc Harwood
Reviewed by: Jeffrey Driban
Related Posts:What is the Cost of Electrocardiographic Screening in Athletes?Incidence of Sudden Cardiac Death among NCAA Athletes
Maron, B., Haas, T., Murphy, C., Ahluwalia, A., & Rutten-Ramos, S. (2014). Incidence and Causes of Sudden Death in U.S. College Athletes Journal of the American College of Cardiology DOI: 10.1016/j.jacc.2014.01.041