Incidence and Etiology of Sudden Cardiac Arrest and Death in High School Athletes in the United States

doi:10.1016/j.mayocp.2016.07.021

Mayo Clinic Proceedings

Volume 91, Issue 11, November 2016, Pages 1493-1502

https://doi.org/10.1016/j.mayocp.2016.07.021 Get rights and content

Abstract

Objective

To determine the incidence and etiology of sudden cardiac arrest and death (SCA/D) in US high school athletes.

Patients and Methods

A prospective media database of SCA/D was queried for cases aged 14 to 18 years from 7 states over 6 school years (September 1, 2007, to August 30, 2013). Event details were investigated to determine participation on a high school athletic team, sex, sport, and occurrence during school-sponsored activity or exertion. National sports participation numbers were used and a conversion factor was applied to account for multisport athletes. Autopsy reports were reviewed and cause of death was adjudicated by an expert panel.

Results

A total of 16,390,409 million athlete-seasons representing 6,974,640 athlete-years (AY) were examined, encompassing 36% of the total US high school athlete population. A total of 104 cases of SCA/D were identified (35 SCA with survival and 69 sudden cardiac deaths [SCDs]). The rate of SCD was 1:101,082 AY and of SCA/D 1:67,064 AY. Eighty-eight percent (92) of events occurred in male athletes. The rate of SCA/D in male athletes was 1:44,832 AY and in female athletes 1:237,510 AY (incidence rate ratio, 5.3; 95% CI, 2.9-10.6; P<.001). Men's basketball was the highest risk sport with an SCA/D incidence of 1:37,087 AY followed by men's football at 1:86,494 AY. Men's basketball and football athletes accounted for 57% (39) of deaths. Eighty percent of SCDs (55 of 69) were exertional and 55% (38 of 69) occurred while playing for a school-sponsored team. Autopsy reports were obtained in 73% (50) of cases. The most common findings of autopsy were idiopathic left ventricular hypertrophy or possible cardiomyopathy (13 of 50 [26%]), autopsy-negative sudden unexplained death (9 of 50 [18%]), hypertrophic cardiomyopathy (7 of 50 [14%]), and myocarditis (7 of 50 [14%]).

Conclusion

The rate of SCA/D in male high school athletes was 1:44,832 AY, with almost half due to possible or confirmed cardiomyopathy disease. It is likely that many cases were not identified because of reliance on media reports, and these numbers represent a minimum estimate.

Section snippets

Patients and Methods

Parent Heart Watch is a national nonprofit organization dedicated to the prevention and awareness of SCA/D in young athletes that maintains an ongoing database of SCA/D from prospective systematic searches of media reports. This database was queried for cases aged 14 to 18 years from 7 states (California, Florida, Minnesota, New Jersey, Ohio, Tennessee, and Texas) over 6 school years (September 1, 2007, to August 30, 2013) selected to provide broad geographical representation, large number of

Incidence

A total of 16,390,409 athlete-seasons representing 6,974,640 unduplicated AY were examined, encompassing 36% of the total US high school athlete population during the study period. The initial query included 127 cases of possible SCD. After investigation, it was determined 69 cases met the inclusion criteria. Of the cases excluded, there were 35 cases in nonathletes or athletes who did not participate on a high school team, 5 cases who were outside the specified dates, 11 cases without enough

Discussion

This study, encompassing more than one-third of all high school athletes over 6 years, found that the rate of SCD was 1:101,082 AY in all athletes and 1:68,742 AY in male athletes. These cases were identified using only media reports; therefore, this represents a minimum estimate. Previous studies have shown that media reports will detect only a proportion of SCD cases. In a Danish study¹⁶ using death certificates as the primary means of identifying cases, media reports recognized only 20% of

Conclusion

This autopsy-based study was inclusive of more than one-third of the US high school athlete population from 2007 to 2013 and confirms that a high school athletes' risk of SCA/D is higher than that of some previous reports. Consistent with other studies, male athletes accounted for most SCA/Ds and male basketball athletes were at the highest risk. Although these estimates are sound, they represent minimum estimates, given cases were identified using only media reports. When contemplating

Acknowledgments

We acknowledge the assistance of Parent Heart Watch in data collection.

References (26)

B.J. Maron et al.
Incidence and causes of sudden death in U.S. College athletes
J Am Coll Cardiol
(2014)
W.O. Roberts et al.
Incidence of sudden cardiac death in Minnesota high school athletes 1993-2012 screened with a standardized pre-participation evaluation
J Am Coll Cardiol
(2013)
B.J. Maron et al.
Incidence of cardiovascular sudden deaths in Minnesota high school athletes
Heart Rhythm
(2013)
B.G. Toresdahl et al.
Incidence of sudden cardiac arrest in high school student athletes on school campus
Heart Rhythm
(2014)
J.A. Drezner et al.
Incidence of sudden cardiac arrest in Minnesota high school student athletes: the limitations of catastrophic insurance claims
J Am Coll Cardiol
(2014)
B.J. Maron et al.
Prevalence of sudden cardiac death during competitive sports activities in Minnesota high school athletes
J Am Coll Cardiol
(1998)
D. Corrado et al.
Does sports activity enhance the risk of sudden death in adolescents and young adults?
J Am Coll Cardiol
(2003)
R. Puranik et al.
Sudden death in the young
Heart Rhythm
(2005)
A.G. Holst et al.
Incidence and etiology of sports-related sudden cardiac death in Denmark—implications for preparticipation screening
Heart Rhythm
(2010)
R.E. Eckart et al.
Department of Defense Cardiovascular Death Registry Group. Sudden death in young adults: an autopsy-based series of a population undergoing active surveillance
J Am Coll Cardiol
(2011)

M.P. Suárez-Mier et al.

Pathology of sudden death during recreational sports in Spain

Forensic Sci Int

(2013)

K. Harmon et al.

Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association Athletes: a decade in review

Circulation

(2015)

B.J. Maron et al.

Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology

Circulation

(2014)

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Early studies evaluating SCD in athletes implicated hypertrophic cardiomyopathy as the most common cause of SCD in the United States.1 However, more recent studies involving international data and the military have found normal autopsies in the majority of cases raising the possibility of yet undefined channelopathies and arrhythmia as a significant cause of SCD.2–11 To date, approximately 6% to 14% of SCD events in athletes are attributed to myocarditis.6,12
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2023, Athlete's Heart: A Multimodal Approach - From Physiological to Pathological Cardiac Adaptations
Strenuous exercise training can determine cardiac remodeling, often referred to as the athlete’s heart, characterized by increased left ventricular mass, cavity dimensions, and wall thickness with normal systolic and diastolic function. The physiological mechanisms of athlete’s heart are various and are not fully known. Sometimes, there may be some overlap between physiological and pathological conditions, some of which might be related to sudden cardiac death (SCD) (hypertrophic cardiomyopathy, arrhythmogenic cardiomyopathy, dilated cardiomyopathy, etc.). The differentiation between physiological and pathological cardiac anomalies in athletes is mandatory because an incorrect diagnosis has important consequences, such as exclusion from competitive sport, false reassurance, and missed opportunity for effective therapeutic intervention. For this reason, preparticipation cardiovascular screening aimed at the identification of pathological conditions in athletes, to prevent morbidity and SCD. However, the best strategies remain controversial. The inclusion of the 12‑lead electrocardiogram (ECG) in the initial screening is a source of debate. Familiar and personal medical history and physical examination are the first steps of preparticipation screening. Italian and European guidelines recommend performing an ECG, as the initial screening of athletes, whereas the United States and American Heart Association positions are against national mandatory screening with ECGs in athletes. The purpose of this chapter is to define athlete’s heart, summarize the most important causes of sudden cardiac death in athletes, and establish the diagnostic pathways to achieve eligibility in competitive sports.
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2023, The Youth Athlete: A Practitioner's Guide to Providing Comprehensive Sports Medicine Care
Sudden cardiac death is the leading cause of sports-related fatalities in young competitive athletes. The cardiac care of young athletes encompasses both cardiovascular screenings for the prevention of sudden cardiac death and the management of athletes with cardiac disease. The goals of this chapter are to help clinicians (1) understand the epidemiology and risk factors of sudden cardiac arrest or death (SCA/D) as it pertains to sport and exercise in young athletes, (2) evaluate common cardiovascular symptoms, and (3) emphasize the importance of emergency planning and rapid access to an automated external defibrillator as a core tenet of athlete cardiac care.
Sports-Related Sudden Cardiac Death Attributable to Myocarditis: A Systematic Review and Meta-analysis
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Citation Excerpt :
The determination of death varied by each study and included autopsy reports, death certificates, medical records, and database searches. Four studies included aborted SCD in their primary outcome.2,12-14 Two of those did not investigate the causes of the aborted SCD.2,12
The incidence of sports-related sudden cardiac death (SrSCD) attributable to myocarditis is unknown. With the known association between SARS-CoV-2 (COVID-19) and myocarditis, an understanding of pre-pandemic rates of SrSCD due to myocarditis will be important in assessing a change of risk in the future. The objective was to ascertain the incidence of SrSCD or aborted sudden cardiac death (SCD) attributable to myocarditis in the general population.
A literature search through PubMed/Medline and Ovid/Embase was completed. Studies of SrSCD with autopsy data or clear-cause aborted SrSCD were included. SrSCD was defined as SCD which occurred within 1 hour of exercise. Data were abstracted by 2 independent reviewers using the MOOSE guidelines. Risk assessment was performed with the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Random-effects models were used to report the incidence and 95% CIs. The primary outcome was the incidence of SrSCD attributable to myocarditis, and the secondary outcome was SrSCD overall.
Fifteen studies were included comprising 347,092,437 person-years (PY). There were 1955 SrSCD or aborted SrSCD overall with an incidence of 0.93 (95% CI 0.47-1.82) per 100,000 PY. Fifty-three SrSCD were attributed to myocarditis with an incidence of 0.047 (95% CI 0.018-0.123) per 100,000 PY, or 1 death attributable to myocarditis in 2.13 million PY.
In this meta-analysis, the overall incidence of SrSCD was low. Furthermore, SrSCD attributed to myocarditis is exceedingly rare.
L’incidence de l’arrêt cardiaque subit lié à la pratique sportive (ACSs) et attribuable à une myocardite reste inconnue. Avec l’association connue entre le SRAS-CoV-2 (COVID-19) et la myocardite, il serait important de connaître le taux prépandémique d’ACSs attribuables à une myocardite pour évaluer l’évolution du risque. L’objectif était de vérifier l’incidence de l’ACSs ou de l’arrêt cardiaque subit (ACS) avorté attribuable à une myocardite dans la population générale.
Une recherche documentaire dans PubMed/Medline et Ovid/Embase a été réalisée. Elle comprenait les études portant sur les ACSs et leurs rapports d’autopsie ou les ACSs avortés et de cause évidente. L’ACSs y était défini comme un ACS survenant dans la première heure d’une activité physique. Deux examinateurs indépendants ont recueilli les données selon les lignes directrices MOOSE. Une évaluation du risque a été réalisée à partir de la liste de vérification du Joanna Briggs Institute pour l’évaluation critique des études sur la prévalence. Des modèles à effets aléatoires ont servi à calculer l’incidence et les intervalles de confiance (IC) à 95 %. L’incidence de l’ACSs attribuable à une myocardite constituait le critère principal et l’ACSs en général, le critère secondaire.
L’analyse portait sur quinze études regroupant 347 092 437 années-personnes (AP). Elle a permis de recenser un total de 1 955 ACSs ou ACSs avortés, soit une incidence de 0,93 (IC à 95 %; 0,47-1,82) pour 100 000 AP. Cinquante-trois ACSs ont été attribués à une myocardite, soit une incidence de 0,047 (IC à 95 %; 0,018-0,123) pour 100 000 AP, ce qui représente une mort attribuable à la myocardite pour 2,13 millions d’AP.
Il ressort de cette méta-analyse que l’incidence de l’ACSs est faible. De plus, les cas d’ACSs attribuables à une myocardite sont extrêmement rares.

View all citing articles on Scopus

: For editorial comment, see page 1489; for related articles, see pages 1503, 1606, and 1617

: Grant Support: This work was supported by award KL2TR000421 (D.S.O.) from the National Center for Advancing Translational Sciences of the National Institutes of Health.

: Potential Competing Interests: Dr Prutkin has received grants from Boston Scientific and St. Jude Medical. Dr Ackerman is a consultant to Boston Scientific, Gilead Sciences, Medtronic, and St. Jude Medical and receives royalties from Transgenomic.

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Original articleIncidence and Etiology of Sudden Cardiac Arrest and Death in High School Athletes in the United States

Abstract

Objective

Patients and Methods

Results

Conclusion

Section snippets

Patients and Methods

Incidence

Discussion

Conclusion

Acknowledgments

J Am Coll Cardiol

J Am Coll Cardiol

Heart Rhythm

Heart Rhythm

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Heart Rhythm

Heart Rhythm

J Am Coll Cardiol

Forensic Sci Int

Incidence, cause, and comparative frequency of sudden cardiac death in National Collegiate Athletic Association Athletes: a decade in review

Circulation

Assessment of the 12-lead ECG as a screening test for detection of cardiovascular disease in healthy general populations of young people (12-25 years of age): a scientific statement from the American Heart Association and the American College of Cardiology

Circulation

Original article
Incidence and Etiology of Sudden Cardiac Arrest and Death in High School Athletes in the United States