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
. 2014. doi:10.1161/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


What is the Cost of Electrocardiographic Screening in Athletes?

Incidence of Sudden Cardiac Death among NCAA Athletes

Harmon, K., Drezner, J., Maleszewski, J., Lopez-Anderson, M., Owens, D., Prutkin, J., Asif, I., Klossner, D., & Ackerman, M. (2014). Etiologies of Sudden Cardiac Death in National Collegiate Athletic Association Athletes Circulation: Arrhythmia and Electrophysiology DOI: 10.1161/CIRCEP.113.001376 

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