CV Deaths in College Sport on Par With Drug Deaths, Suicides

February 27, 2014

MINNEAPOLIS, MN — The risk of sudden death from cardiovascular causes in US college student-athletes is similar to the risk of death from suicide and drug abuse, suggesting there might be unbalanced attention on these often–high-profile cardiac deaths compared with deaths from other preventable causes, say researchers[1]

Using data from the US National Registry of Sudden Death in Athletes and the National Collegiate Athletic Association (NCAA), investigators report there were 182 deaths over a 10-year study period that involved more than four million athletes participating in sports. Of these, a cardiovascular abnormality was determined to be the likely cause of death in 64 athletes and was the confirmed cause of death in 47 athletes.

This translated into an incidence rate of sudden death from confirmed cardiovascular causes of 1.2 per 100 000 athletes. The incidence rate of sudden death from confirmed/presumed cardiovascular causes was 1.6 per 100 000 athletes. Comparatively, the incidence of death from suicide or drugs was 1.3 per 100 000 athletes.

In their report, published online February 26, 2014 in the Journal of the American College of Cardiology, Dr Barry Maron (Minneapolis Heart Institute Foundation, MN) and colleagues say that student athletes "do not appear to be at unique or particularly high risk" for sudden cardiovascular death and that, given the number of deaths from suicide and drug use, "there may be a disproportionate focus on cardiovascular disease in this population."

Differing Opinions: AHA vs ESC

In the US, the American Heart Association (AHA) recommends screening young athletes before participating in sports, but the preparticipation screening protocol involves just a personal history, family history, and physical examination . Routine use of ECGs is not recommended. In contrast, the European Society of Cardiology (ESC), on the strength of the Italian model that pioneered the use of 12-lead ECG screening prior to sports participation, recommends the use of ECGs for young athletes planning on sports competition. This has led to some controversy and debate about whether or not an ECG should be part of the screening process for US athletes.

For Maron and colleagues, their study does not directly tackle the contentious issue about what would be the most effective method to screen athletes for potential cardiovascular problems, but "certain inferences are unavoidable." For example, they note that not all abnormalities would even be detectable by screening.

"Based on autopsy confirmation of cause of death, about 60% of the athletes in our study cohort would probably have been identified by a screening 12-lead ECG," write the authors. "However, we also estimate that at least 40% would likely have been 'false negatives,' not reliably suspected by 12-lead ECGs, as part of broad-based screening initiatives in athletes."

The common causes of death were hypertrophic cardiomyopathy (HCM), myocyte disarray, anomalous coronary artery, atherosclerotic coronary artery disease, arrhythmogenic right ventricular cardiomyopathy, and aortic dissection and rupture, among others. According to Maron et al, the ECG most likely would have detected or least suspected underlying HCM, aortic rupture, dilated cardiomyopathy, long-QT syndrome, and mitral-valve prolapse.

For Dr Anne Curtis (University of Buffalo, New York) and Dr Mohamad Bourji (VA Western New York Healthcare System at Buffalo, NY), who wrote an editorial accompanying the paper[2], "ECG screening programs prior to sports participation, especially in recreational athletes, are neither cost-effective nor sustainable." While it is tragic to lose even one young individual to sudden cardiac death, the most common finding of ECG screening "by far turns out to be a false positive, leading to additional testing before most individuals are found to be normal and cleared to exercise.

"The best way to avoid that scenario is not to screen with ECGs in the first place," state Curtis and Bourji.

Prevalence of Abnormal ECGs in Nonathletes

The editorial conclusions are also supported by a second study published in JAMA[3]. With senior investigator Dr Sanjay Sharma (University of London, UK), the medical director of the London Marathon and head cardiologist for the 2012 Olympic Games, Dr Navin Chandra (St George's University, London, UK) and colleagues investigated the prevalence of potentially abnormal ECG patterns in 7764 nonathletes aged 14 to 35 years old.

In comparing the ECG patterns with 4081 competitive athletes, the researchers found that normal training-related ECG patterns occurred in 49% of the nonathletes and 87% of the competitive athletes. ECG patterns that represented a possible underlying pathological abnormality, defined as a group-2 ECG pattern by the ESC, were present in 22% of the nonathletes and 33% of the athletes. Abnormal QT intervals were equally prevalent in both cohorts, accounting for 52% of the group-2 ECG patterns in the nonathletes.

ECG changes suggestive of an underlying cardiomyopathy or a structural cardiac abnormality were evident in 21% and 10% of the athletes and nonathletes, respectively. For the 784 nonathletes with group-2 ECG patterns, echocardiography showed a normal heart in 84% of patients. Just 2% of the nonathletes had an echocardiographic feature "consistent with a morphologically mild cardiomyopathy," report investigators.

"In keeping with concerns raised by the AHA, this study reveals that 20% of young individuals would fail the initial assessment following an ECG based on current ESC criteria," write Chandra et al. "The implications of the ensuing costs of further investigations on a financially constrained health budget in times of austerity would be insurmountable."

This problem would be compounded in cities or countries with large populations of black individuals, add the investigators. Male sex and black ethnicity doubled the likelihood of showing a group-2 ECG pattern, and this suggests that ECG screening in black individuals, regardless of their athletic status, "would have major ramifications."

In their analysis, Maron et al noted that deaths from cardiovascular causes were five times more likely to occur in African American athletes than white athletes. Although the rate was higher in African American athletes, the risk was similar when compared with a population of the same age and ethnicity. Males were also six times more likely than females to die from sudden cardiovascular death and more likely to die suddenly from suicide and drugs.

Chandra and Sharma report research grant support from the charitable organization Cardiac Risk in the Young. Maron et al have no disclosures reported. Curtis reports being on advisory boards for Biosense Webster, Bristol-Myers Squibb, Pfizer, Janssen Pharmaceuticals, Daiichi Sankyo, and Sanofi and receiving honoraria from St Jude Medical. Bourji had no conflicts of interest.

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