Background
An accurate estimate of the incidence of sudden cardiac arrest (SCA) in high school student athletes is needed to guide prevention strategies.
Objective
To prospectively investigate SCA rates in high school student athletes vs student nonathletes.
Methods
A prospective observational study of 2149 US high schools participating in the National Registry for AED Use in Sports was conducted from August 2009 to July 2011. Schools were contacted quarterly to collect and review SCA cases occurring on school campus. Ninety-five percent (2045) of the schools confirmed participation for the entire 2-year period.
Results
The average numbers of total students and student athletes per school were 963 and 367, respectively, providing more than 4.1 million total student-years and more than 1.5 million student athlete-years of surveillance. Twenty-six cases of SCA occurred in students, including 18 cases in student athletes—all during exercise. The incidence of SCA in all students was 0.63 per 100,000; in student athletes, 1.14 per 100,000; and in student nonathletes, 0.31 per 100,000. The relative risk of SCA in student athletes vs nonathletes was 3.65 (95% confidence interval 1.6–8.4; P < .01). Sixteen of 18 (89%) student athletes with SCA were boys, resulting in an incidence of 1.73 per 100,000 in boys and 0.31 per 100,000 in girls and a relative risk in male compared with female student athletes of 5.65 (95% confidence interval 1.3–24.6; P < .01).
Conclusion
The incidence of SCA in high school student athletes is higher than previous estimates and may justify more advanced cardiac screening and improved emergency planning in schools.
Abbreviations:
AED (automated external defibrillator), CI (confidence interval), NCAA (National Collegiate Athletic Association), PPE (preparticipation physical evaluation), SCA (sudden cardiac arrest), SCD (sudden cardiac death)Keywords
Introduction
Sudden cardiac death (SCD) in high school students and student athletes is a tragic event with devastating impact on the family, school, and community. The incidence of sudden cardiac arrest (SCA) in this population is the subject of current debate, and estimates vary widely depending on the study population and methodology. Young athletes have received particular attention, as SCA can be triggered by exertion in individuals with underlying cardiac disorders.
1
, 2
, 3
, 4
An accurate understanding of SCA incidence in students and student athletes is needed to guide appropriate screening programs and emergency planning in schools.The reported incidence of SCA in young athletes ranges from 0.24 to 9.80 per 100,000 per year.
4
, 5
, 6
, 7
, 8
, 9
, 10
, 11
Initial estimates in the United States were reliant on searches of newspaper clippings, media reports, and catastrophic insurance claims, and those estimates likely underestimated the true incidence because of incomplete case identification.5
, 6
Other studies are limited by their survey or cross-sectional design.7
, 8
A recent study performed with an internal reporting system from the National Collegiate Athletic Association (NCAA) found an overall annual incidence of SCD of 2.28 per 100,000.10
No US study has prospectively performed active surveillance of a predefined population, and no study has compared SCA rates in US athletes with those in age-matched nonathletes.The purpose of this study was to prospectively monitor a large cohort of US high schools to more accurately determine the incidence of SCA in high school students and student athletes.
Methods
Study design
The National Registry for AED Use in Sports was created to investigate emergency planning and to monitor SCA and use of automated external defibrillators (AEDs) in the high school and university athletic settings. A total of 2149 high schools enrolled in the registry agreed to participate in a 2-year prospective observational study.
School representatives provided information regarding student and student athlete enrollment and emergency preparedness for SCA at the school. From August 1, 2009, through July 31, 2011, any potential cases of SCA that occurred on school campuses were reported. School representatives, including school administrators, athletic directors, nurses, and certified athletic trainers, were contacted quarterly by e-mail as a reminder to report all potential cases. At the end of the study period, the school representatives were contacted by e-mail and phone to confirm the number of cases (if any) that occurred during the study period.
When a potential case of SCA was reported, the details of the case were reviewed over the phone with the school representative or another staff member who had witnessed the event or was involved in the emergency response. In some cases, media reports were used to clarify case demographics or supplement the information provided. A case was classified as SCA if (1) the person was determined unconscious with the absence of pulse and respirations, (2) cardiopulmonary resuscitation was provided or an AED deployed a shock, (3) a primary cardiac etiology was found, or (4) a traumatic blow to the chest occurred and was consistent with commotio cordis. Only those cases occurring on school campus during the study period were included. The study design did not allow for active surveillance of SCA cases occurring off school campus, at home, or outside the school setting.
For gender-specific incidence calculations in student athletes, gender demographics were obtained from the National Federation of State High School Associations 2010-11 High School Athletics Participation Survey results.
12
This nationwide survey reported that 59% of high school sport participations were in boys and 41% were in girls.2010-11 high school athletics participation survey results. National Federation of State High School Associations. Web site. http://www.Nfhs.Org/workarea/ linkit.Aspx?Linkidentifier=id&itemid=5751&libid=5773.2012. Accessed July 14, 2013.
The study was approved by the Human Subjects Division at the University of Washington.
Study outcomes
The primary outcome measure was the occurrence of SCA in a student or student athlete on a high school campus. Additional data collected included the victim’s age, sex, circumstances of the event, if the student was a student athlete, and the sport or activity at the time of arrest. A student athlete was defined as a student participating in any official school sponsored interscholastic team or individual sport requiring regular practice and competition. Data on emergency preparedness, the emergency response, and survival outcomes have been reported previously.
13
Statistical analysis
Descriptive statistics such as proportions and means were used to describe the data, as appropriate. Incidence confidence intervals (CIs) were calculated using the Byar approximation of a Poisson distribution. χ2 analysis was used to calculate the relative risk of SCA between populations. The number of SCA cases in year 1 vs year 2 of the study was compared to examine the consistency of reported cases between the 2 study years.
Results
Participants
A total of 2149 US high schools distributed throughout all 50 states participated in the study. The mean number of students and student athletes per school as reported by the school representative were 963 and 367, respectively. For the 2-year study period, this provided more than 4.1 million total student-years and more than 1.5 million student athlete-years of surveillance. Eighty-six percent of the participating schools were public and 14% private; 48% of schools were rural, 33% suburban, 15% urban, and 4% inner city. At the end of the study, 2045 of 2149 (95%) schools confirmed participation for the entire 2-year study period and the presence or absence of SCA cases on school campus. The remaining school representatives could not be contacted by phone and e-mail despite multiple attempts.
Cases of SCA
One hundred twenty-nine potential cases of SCA were reported by school representatives. Fifty-nine cases met the inclusion criteria. Of the 70 cases that were excluded, 20 were determined not to be SCA, 4 were secondary to trauma, 13 did not occur on school campus, and 32 occurred outside the study period. One potential case was reported, but the school representative and other witnesses could not be contacted to verify the details and therefore the case was excluded. Twenty-six cases of SCA occurred in students. The number of cases was similar during each year of the study: 15 cases in year 1 and 11 cases in year 2 (P = .4).
Eighteen (69%) cases occurred in student athletes, and all of them were associated with physical activity. The number of cases in student athletes was also similar during each year of the study: 10 cases in year 1 and 8 cases in year 2 (P = .64). Sixteen (89%) cases of SCA in student athletes occurred in males and 2 (11%) cases in females. There were 4 cases each in males and females among the student nonathletes with SCA. Of the student athlete SCA cases, 12 (67%) were White, 5 (28%) African American/black, and 1 (5%) Hispanic. Commotio cordis occurred in 3 (17%) cases in male student athletes, with 1 case each in football, ice hockey, and lacrosse.
Incidence of SCA
The overall annual incidence of SCA in all high school students occurring on school campus was 0.63 per 100,000 (95% CI] 0.41–0.92; Table 1). The incidence of SCA in student athletes was 1.14 per 100,000 (95% CI 0.68–1.80) and was higher in male student athletes (1.78 per 100,000; 95% CI 0.99–2.81) than in female student athletes (0.31 per 100,000; 95% CI 0.04–1.11). The relative risk of SCA in male vs female student athletes was 5.65 (95% CI 1.3–24.6; P < .01). Of the 18 cases of SCA in student athletes, 6 occurred in football, 3 basketball, 2 baseball, 2 track, and 1 each in cheer leading, cross country, hockey, lacrosse, and swimming. The incidence of SCA in student athletes by omitting cases of commotio cordis was 0.95 per 100,000 (95% CI 0.53–1.57), and in male student athletes it was 1.41 (95% CI 0.75–2.40).
Table 1Incidence of SCA in high school students
| Population | Cases of SCA over 2 y | Population (per year) | Annual incidence (per 100,000) | 95% confidence interval |
|---|---|---|---|---|
| Male student athletes | 16 | 462,269 | 1.73 | 0.99–2.81 |
| Student athletes | 18 | 788,683 | 1.14 | 0.68–1.80 |
| Students | 26 | 2,069,487 | 0.63 | 0.41–0.92 |
| Male student nonathletes | 4 | 572,474 | 0.35 | 0.10–0.89 |
| Students nonathletes | 8 | 1,280,804 | 0.31 | 0.13–0.62 |
| Female student athletes | 2 | 326,414 | 0.31 | 0.04–1.11 |
| Female student nonathletes | 4 | 708,330 | 0.28 | 0.08–0.72 |
SCA = sudden cardiac arrest.
The incidence of SCA in student nonathletes was 0.31 per 100,000 (95% CI 0.13–0.62). The relative risk of SCA in student athletes vs student nonathletes was 3.65 (95% CI 1.6–8.4; P < .01). The relative risk of SCA in male student athletes vs male student nonathletes was 4.95 (95% CI 1.6–14.8; P < .01) and in female student athletes vs female student nonathletes was 1.09 (95% CI 0.20–5.92; P = .92).
There were 2 deaths in the student athletes who suffered SCA (both males) and 2 deaths in the student nonathletes (both females). The incidence of SCD occurring on school campus in student athletes was 0.13 per 100,000 (95% CI 0.02–0.46) and 0.43 per 100,000 (95% CI 0.12–1.11) for male student athletes. The incidence of SCD in student nonathletes was 0.08 per 100,000 (95% CI 0.01–0.28).
Discussion
This is the first study to prospectively measure the incidence of SCA in US high school students and student athletes. Past estimates vary widely on the basis of study methodology, the reliability of case identification, use of unconfirmed athlete population statistics, differences in age range and athlete levels, and inclusion of all SCA cases vs only SCD cases (Table 2). This study focused on high school students and student athletes by closely monitoring a large predefined population for 2 years. With more than 4 million total student-years of active surveillance, this study found the incidence of SCA in high school student athletes to be higher than other US estimates based on searches of public media reports and catastrophic insurance claims,
5
, 6
, 9
, 11
even though this study captured only SCA cases occurring on school campus.Table 2Comparison of incidence studies of SCA in young athletes
| Study | Location | Population | Age (y) | Event type | Reporting system and methodology | Incidence (per 100,000) |
|---|---|---|---|---|---|---|
| Marijon et al 4 | France | Competitive athletes during sport | 10–35 | SCA | Prospective study using an EMS database and media reports | 9.8 |
| Corrado et al 15 | Italy (Veneto) | Competitive athletes (1979–1982) | 12–35 | SCD | Prospective study using a mandatory forensic database | 3.8 |
| Steinvil et al 33 | Israel | Athletes | 10–44 | SCA | Retrospective study using reports from 2 newspapers | 2.6 |
| Harmon et al 10 | United States | College student athletes | 17–23 | SCD | Retrospective study using NCAA database, media reports, and insurance claims | 2.3 |
| Corrado et al 2 | Italy (Veneto) | Athletes | 12–35 | SCD | Prospective study using a mandatory forensic database | 2.2 |
| Holst et al 14 | Denmark | Athletes | 12–35 | SCD | Retrospective study using media reports, hospital and autopsy databases | 1.2 |
| Maron et al 9 | United States | Competitive athletes | <40 | SCA | Retrospective study using media reports and other electronic databases | 0.6 |
| Maron et al 6 | United States (Minnesota) | High school student athletes | 13–19 | SCD | Retrospective study using catastrophic insurance claims | 0.5 |
| Van Camp et al 5 | United States | High school and college athletes | 13–24 | SCD | Retrospective study of media reports | 0.3 |
| Roberts et al 11 | United States (Minnesota) | High school student athletes | 12–19 | SCD | Retrospective study using catastrophic insurance claims | 0.2 |
EMS = Emergency medical service; NCAA = National Collegiate Athletic Association; SCA = sudden cardiac arrest.
The limitations of using media reports or catastrophic insurance claims as the primary method for case identification is highlighted by a study using an internal reporting structure for the NCAA, demonstrating that intensive search of public media reports missed 44% and analysis of catastrophic insurance claims missed 80% of SCD cases, despite the high profile nature of collegiate athletics.
10
Holst et al14
also found that search of media reports identified only 20% of sports-related SCD in Denmark. The higher incidence of SCA observed in this study is consistent with other studies2
, 10
, 15
using more reliable methods for case identification.Few studies have compared the incidence of SCA in a general population of young people vs young athletes. The cardiovascular health benefits of regular exercise and physical activity are unequivocal; however, exercise can also be a trigger for SCA in individuals with underlying pathological cardiac conditions.
16
In a prospective cohort study by Corrado et al,2
a higher risk of SCD (relative risk 2.5) was found in competitive athletes in the Veneto region of Italy than in age-matched sedentary controls (age 12–35 years). Marijon et al4
performed a 5-year prospective observational study in France and reported that the relative risk of sudden death was 4.5 times higher in competitive young athletes (age 10–35 years) than in recreational sports participants of the same age. In contrast, in a retrospective review14
of death certificates in Denmark, investigators reported a rate of SCD in athletes aged 12–35 years that was 3.3 times lower than in the general population.This is the first US study directly comparing the rate of SCA in athletes with that in nonathletes. The risk of SCA in high school student athletes was nearly 4 times higher than that in student nonathletes, and male student athletes were more than 5 times more likely to suffer SCA than did female student athletes.
The results of this study may have important implications on recommendations for cardiovascular screening in athletes. High school athletes in the United States are required to undergo a preparticipation physical evaluation (PPE) every 1–3 years (depending on state requirements). While there is universal support from national medical organizations for preparticipation cardiovascular screening in athletes, the optimal screening techniques are still unclear and agreement on the best protocol remains an area of continued debate within the primary care, sports medicine, and cardiology communities.
17
, - Maron B.J.
- Thompson P.D.
- Ackerman M.J.
- et al.
Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
Circulation. 2007; 115 (1643–1655)
18
, 19
, 20
The traditional model of screening as recommended by the American Heart Association includes a comprehensive personal history, family history, and physical examination.
17
Although a PPE requirement of any type creates a separate screening procedure for athletes that is not required in nonathletes, the ethics of employing a more intensive screening program only for athletes has been questioned, especially if there is no evidence that athletes are at higher risk than their nonathlete counterparts.- Maron B.J.
- Thompson P.D.
- Ackerman M.J.
- et al.
Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
Circulation. 2007; 115 (1643–1655)
17
, - Maron B.J.
- Thompson P.D.
- Ackerman M.J.
- et al.
Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
Circulation. 2007; 115 (1643–1655)
19
Proponents of more intensive screening contend that the current model is ineffective owing its poor sensitivity to detect athletes with underlying conditions associated with SCA.20
, 21
, 22
, 23
The limitations of screening by history and physical examination were recognized in a 1996 review of 134 cases of SCD in US athletes in which only 1 athlete was diagnosed correctly through preparticipation screening.24
Routine screening with a 12-lead electrocardiogram is required and standard practice in all major US professional sports and many NCAA Division I athletic programs.
25
The high incidence of SCD documented in collegiate athletes has prompted calls for more intensive screening, specifically in the highest-risk groups including male athletes (3.02 per 100,000), African American/black athletes (5.65 per 100,000), and male basketball players (14.3 per 100,000).10
Similar to the findings in collegiate athletes, the high event rate in this study was found despite each of the athletes receiving a PPE consisting, at a minimum, of a history and physical examination. The high rate of SCA in male high school student athletes may justify more intensive, targeted screening programs. In addition, 50% of the SCA cases in high school athletes occurred in only 2 sports—boys basketball and football—a finding consistent with past reports.9
More intensive screening programs may not be indicated in female student athletes with a lower risk of SCA equal to their nonathlete counterparts.Some authorities argue that the current screening model is sufficient because the incidence of SCD in young athletes in the United States is already low and approximates incidence rates in countries with electrocardiogram-inclusive screening programs.
9
, 15
, 17
, - Maron B.J.
- Thompson P.D.
- Ackerman M.J.
- et al.
Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
Circulation. 2007; 115 (1643–1655)
26
, 27
Recent cost-effectiveness studies have acknowledged the lack of prospective incidence data to guide recommendations.28
, 29
, 30
As this study demonstrates, reports examining only death rates may greatly underestimate the incidence of SCA and falsely assume that current screening strategies are effective.11
, 31
The incidence of SCA on school campuses is also used to guide recommendations for emergency planning and the implementation of school-based AED programs. AED programs provide a means of early defibrillation not just for student athletes but for all students and adults on a school campus. While the prevalence of AEDs in schools is increasing, this public safety measure is not yet a universal standard. The high survival rate and the resulting low incidence of SCD in this cohort are influenced by a selection bias of schools that elected to participate in this study. AED programs were present in 87% of the participating schools and in all but one of the schools reporting a case of SCA.
13
These schools are more prepared to respond to SCA, and the high survival rate may not be reproducible in a broader sample of schools across the United States.13
While emergency planning and school-based AED programs are strongly encouraged, the potential for successful resuscitation in student athletes does not eliminate the need or requirement for primary prevention. Student athletes must receive medical clearance before participating in high school sports, and the objective of this evaluation is the early detection of conditions at risk for catastrophic injury or sudden death.
17
, - Maron B.J.
- Thompson P.D.
- Ackerman M.J.
- et al.
Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.
Circulation. 2007; 115 (1643–1655)
32
The current model of screening does not prevent SCA in a high number of student athletes, and refinement of screening protocols should be considered. Ultimately, the combination of effective primary prevention (screening) and secondary prevention (SCA management) provides the highest likelihood to prevent sudden death in athletes.Study limitations
Although this study provides the first prospective surveillance of SCA in US athletes, study limitations must be recognized, especially if comparing incidence rates with those presented in prior reports. This study underestimates the true incidence of SCA in high school students and student athletes because it accounts for only those cases that occurred on high school campuses. This study does not account for cases that occurred outside the school campus, at home, on weekends, or when school was not in session. In prior studies, up to 20% of the cases of SCD in young athletes included in the incidence calculations occurred while away from school, at rest, or during sleep.
9
Because of the study design and lack of a mechanism for surveillance outside the school campus, this study does not include cases in student athletes while participating in “away” competitions, during recreational sports or with select/club teams not playing at a school facility, and individual training sessions outside the school. Thus, incidence rates in this study should be considered a minimum estimate of the annual risk of SCA in a student athlete. There also remains a possibility that additional cases of SCA were not reported, though this possibility is minimized by the frequent contact with school representatives, 2-year follow-up rate of 95%, and consistency of reported cases between the 2 study years.Conclusion
The incidence of SCA in high school athletes is higher than previous estimates, particularly among male student athletes. The results justify consideration for more advanced cardiovascular screening in high-risk groups as well as universal standards for emergency planning for SCA in schools including access to AEDs at school sporting facilities. More research is needed to better detail sex, race, etiology, and sport-specific differences in risk that could influence prevention strategies and improved safety in schools.
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Article info
Publication history
Published online: April 14, 2014
Footnotes
This work was supported by the National Operating Committee on Standards for Athletic Equipment.
Identification
Copyright
© 2014 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.
