Sudden Cardiac Death in College Athletes

Preparticipation screening for cardiovascular disease with history and physical examination has been customary practice in the US for high-school and college-aged competitive athletes probably for at least 50 years, and this responsibility has fallen largely to the primary care (family practice) community. Although the process is not perfect, it has improved measurably, with increasing numbers of athletes identified as having cardiac disease. A careful family history is potentially very powerful, given that most of the deaths occur due to genetic heart diseases such as hypertrophic cardiomyopathy.

In recent years, public health issues surrounding sudden deaths in young athletes and strategies for identification of at-risk individuals have emerged and triggered a highly visible and sometimes contentious debate. There have been proponents for nationwide routine ECGs for all athletes in the US, although no conclusive evidence exists that adding a 12-lead ECG to the screening process would necessarily improve its overall efficacy, not to mention practicality. An occasional athlete with heart disease will be detected via ECG, but there will also be thousands of false positives, sometimes leading to over-diagnosis and unnecessary disqualification, as well as numerous false negatives, which can result in an unintended consequence of screening—sudden death.

Unfortunately, over-estimating the incidence of cardiovascular sudden death in athletes, media-based hyperbole, personal investigator bias, and misunderstanding of the complications incurred by applying the 12-lead ECG to general healthy populations has left the primary care community feeling unnecessarily vulnerable to attack and liability if not engaging in the practice of routine ECG screening. This should be resisted.

Fortunately, however, a large measure of clarification regarding the screening discussion comes from three recent and timely publications in the cardiovascular literature. In one study, by Maron and colleagues in the Journal of the American College of Cardiology (JACC),¹ an expansive study of more than 4 million college (NCAA) athletes over 10 years shows that risk for sudden death due to forensically proven cardiovascular diseases such as hypertrophic cardiomyopathy is relatively low—about 1/100,000 athlete-participation years, with 4 deaths occurring annually. These data are consistent with a vast and accumulating literature from cardiology investigators, which accurately characterize these tragic occurrences in young people as a low–event rate phenomenon.

The new NCAA data are important for three additional reasons:

• First, the low incidence is in sharp contrast with data previously reported in such athletes from the family practice community, which did not provide the causes of death documented by autopsy (or clinically), thereby appearing to overestimate the number of cardiovascular deaths and exaggerating the true risk by about twofold.
• Second, it is apparent that most cardiac deaths in college athletes are not likely to be preventable, nor can the responsible diseases be identified by preparticipation screening, even with ECGs.
• Finally, the mortality rate from cardiovascular disease does not differ from that due to suicide and drug abuse, suggesting that greater focus and energy devoted to prevention in these areas, as well as wider dissemination of automated external defibrillators, will best serve the public health of college-student athletes.

Particularly relevant to the issue of cardiovascular screening in general populations of young people is the robust paper from the UK by Chandra and colleagues, also published in JACC,² reporting on ECG screening in almost 12,000 young athletes and non-athletes. The authors found that fully 20% of non-athletes in a general population (and only one-third of athletes) had, in fact, ECG patterns judged to be pathologic by established European Society of Cardiology criteria. As the authors underscore, their data offer a paradigm shift in our perceptions of the practicality and effectiveness of ECG screening in general populations of healthy young people. There are significant limitations to the feasibility and cost-effectiveness of any nationwide screening program to detect cardiovascular disease in athletes and non-athletes alike.

The third paper by Harmon and colleagues in Circulation Arrhythmia and Electrophysiology³ appears to be an addendum (with forensic data) to a prior survey of sudden deaths in college athletes from a family practice group involved in preparticipation screening, arguing that standardized protocols for cardiovascular autopsies would be advantageous. This is a proposal about which we can certainly all agree.

References

1. Maron BJ, Hass TS, Murphy CJ, et al. Incidence and Causes of Sudden Death in US College Athletes [published online ahead of print February 26, 2014]. J Am Coll Cardiol. doi:10.1016/j.jacc.2014.01.041.
2. Chandra N, Bastiaenen R, Papadakis M, et al. The Prevalence of ECG Anomalies in Young Individuals; Relevance to a Nationwide Cardiac Screening Program [published online ahead of print February 26, 2014]. J Am Coll Cardiol. doi:10.1016/j.jacc.2014.01.046.
3. Harmon KG, Drezner JA, Maleszewski JJ, et al. Etiologies of Sudden Cardiac Death in National Collegiate Athletic Association Athletes [published online ahead of print March 1, 2014]. Circ Arrhythm Electrophysiol. doi: 10.1161/​CIRCEP.113.001376.