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Rates of Sudden Cardiac Death in College Athletes
Abstract & Commentary
By John P. DiMarco, MD, PhD, Professor of Medicine, Division of Cardiology, University of Virginia, Charlottesville. Dr. DiMarco does research for Medtronic, is a consultant for Medtronic, Novartis, and St. Jude, and is a speaker for Boston Scientific.
Source: Harmon KG, et al. Incidence of sudden cardiac death in National Collegiate Athletic Association Athletes. Circulation 2011;123:1594-1600.
This paper provides up-to-date information on the incidence of sudden cardiac death in athletes at National Collegiate Athletic Association (NCAA) institutions. The frequency of sudden death in college athletes has been incompletely estimated in the past. The NCAA maintains a voluntary database of all deaths among current NCAA student athletes. Historically, it has been unusual for student athlete deaths not to be reported in this way. They also searched for additional deaths in a database compiled by a group called Parent Heart Watch that is dedicated to the prevention and awareness of sudden cardiac arrest in young individuals. Parent Heart Watch searches the Internet on a regular basis to identify sudden cardiac deaths or sudden cardiac arrests in the young. In this study, the authors examine the causes of death in this combined database. Deaths were characterized as accidental, homicide, suicide, drug overdose, or medical. Medical deaths were further classified as to cause. Deaths were then analyzed by gender, ethnicity, and sport.
The study covered data from the 5-year period from 2004 to 2008. During this time, there were almost 2 million athlete participation years in the NCAA. Males accounted for 56% of the athlete participation years and females for 44%. Black athletes accounted for 16% compared to 84% for whites and others.
During this period, there were 273 deaths among NCAA student athletes. Of these, 87 (68%) occurred off the playing field and were due to non-medical causes including accidents (51%), suicide (9%), homicides (5%), and drug overdoses (2%). In 2% of deaths, the cause was unknown. The remaining 80 deaths (29%) were due to medical causes. Of these, 45 (56% of medical deaths) were cardiac deaths. Smaller numbers of deaths were due to cancer, sickle cell disease, heat stroke, meningitis, and other medical conditions. Overall, the incidence of sudden cardiac death in NCAA student athletes was 1 in 43,770 per year. However, the incidence of sudden death was higher among men (1:33,134) compared to women (1:76,646). The annual risk for sudden death was also higher among Division I athletes than among Division II and III athletes. Blacks had a higher risk for sudden death with an overall rate of 1 in 17,696 per year compared to 1 in 58,653 among whites. Among black males, the rate was 1 in 12,990. Athletes playing different sports had different risks. The highest mortality rate was in basketball where the rate for males was 1 in 11,394 with a 3-fold higher risk among blacks. Thirty-six of the 80 medical deaths occurred with exertion. Among these, 27 of 36 (75%) were related to cardiac causes with 9 exertional deaths related to heat stroke. Five of the latter were associated with sickle cell trait.
The authors conclude that systematic examination of NCAA records provides accurate data about the incidence of sudden cardiac death in college-age student athletes. The incidence rate is several-fold higher than previously reported in earlier papers for both male and female athletes. The mechanism for the higher race specific incidence is uncertain. The authors believe that more effective screening techniques might be targeted for the highest risk groups.
The death of an athlete, particularly one in a high-profile sport, is particularly shocking. We associate athletes with health and vitality and the death of an elite athlete often attracts media attention. In the past, the estimate for the frequency of sudden cardiac death among athletes has been estimated to be between 1 in 100,000 and 1 in 200,000 per participation year. The data here show that the overall sudden cardiac death rate is substantially higher and in certain categories, notably black male basketball athletes, the rate may be as high as 1 in 3,000. Currently, the American Heart Association recommends only a directed history and physical exam for screening athletes. Other countries recommend that at least an ECG be added to this evaluation. The data here suggest that in several high-risk groups more comprehensive screening may be beneficial since the event rate is higher than previously suspected. Implementing this on the collegiate level would probably not be prohibitively difficult. However, if this recommendation were to be extended to the high school level where there are many more participants, costs, and logistical considerations, the psychosocial costs of false-positive findings would be very problematic.