For the past three decades, five to 10 student athletes competing for National Collegiate Athletic Association (NCAA) schools have died each year due to sudden cardiac death. Many more college athletes suffer from cardiovascular-related issues, as well.
With that in mind, the NCAA convened a multidisciplinary task force that met in September 2014 to discuss cardiovascular concerns and how to better care for student athletes. After that two-day meeting, the group continued to develop ideas and focus on important areas, including sudden cardiac death and screening with or without electrocardiograms.
Earlier this year, the NCAA, American College of Cardiology (ACC) and other leading cardiac and sports medicine organizations released an interassociation consensus statement on cardiovascular care for college student athletes.
Lead researcher Brian Hainline, MD, the NCAA’s chief medical officer, and colleagues published their findings in the Journal of the American College of Cardiology. Hainline also sent a memorandum to all of the head athletic trainers and team physicians for NCAA member schools outlining the best practices for cardiovascular care of student athletes.
“What this document does, although it’s not legislation, because it’s endorsed by so many organizations, it really creates a new cultural norm for the schools,” Hainline told Cardiovascular Business in a telephone interview. “Our plan with this is to provide this as a pretty strong recommendation. It’s not legislated. It’s not mandated. But because it is an interassociation document, what we’ve been finding is that the schools will follow it. To legislate something like this would take two or three years. It’s just an onerous and bureaucratic process that doesn’t work as smoothly.”
Hainline and his colleagues defined sudden cardiac death as “an unexpected death due to cardiac causes that occurs in a short time period in a person with or without previously known cardiovascular disease.” They found that the overall risk of sudden cardiac death in an NCAA student athlete was 1 in 54,000 athletes per year, including 1 in 38,000 for male athletes and 1 in 122,000 for female athletes. Further, the risk of sudden cardiac death is more than three times higher in African-Americans (1 in 22,000) than in Caucasians (1 in 68,000).
Some sports have higher risks of sudden cardiac death. For instance, men’s basketball and football players represent 23 percent of all male NCAA athletes, but they account for half of all sudden cardiac death cases. Still, Hainline said that it is difficult to accurately determine the rate of sudden cardiac death in subgroups because there are so few deaths each year.
The NCAA requires each student athlete to undergo an evaluation from a licensed medical doctor or doctor of osteopathic medicine within six months of participating in the sport. They also must complete a health history questionnaire and have their blood pressure measured each year. However, the NCAA has no established criteria for the pre-participation evaluations and does not require that the team’s physician conduct the medical examination.
In this document, Hainline and his colleagues suggest that schools follow the American Heart Association (AHA) recommendations to ask student athletes about their personal and family cardiovascular history and conduct a physical examination, including testing for a heart murmur, femoral pulses, physical stigmata of Marfan syndrome and brachial artery blood pressure.
Still, although pre-participation screening has been conducted for more than 50 years, the researchers mentioned that there is not much evidence showing that screening prevents sports-related deaths in athletes. They added that the broad nature of the questions lead to a high number of positive responses that may not indicate risk for athletes.
“The AHA recommends review of positive questionnaire responses by physicians to determine if further evaluation is warranted,” the researchers wrote. “However, the ability of practitioners to discern true positive from false positive responses has also never been studied prospectively in a large-scale clinical trial.”
Hainline added that no adequately designed study has shown that using a resting 12-lead electrocardiogram as a screening tool helps prevent sudden cardiac death in athletes. In fact, 60 percent to 80 percent of athletes who have sudden cardiac death do not have warning signs or symptoms before the event. Further, an electrocardiogram cannot detect anomalous aortic origin of a coronary artery and aortic root dilation, which are two causes of sudden cardiac death in young athletes.
However, Hainline said an electrocardiogram could detect hypertrophic cardiomyopathy and rhythm disturbances, which are major causes of sudden cardiac death. If schools decide to include an electrocardiogram as part of their cardiovascular screening for athletes, Hainline recommended that they disclose electrocardiograms have limits for accurately predicting the risk of sudden cardiac death. They also suggested that people conducting the electrocardiograms should be trained according to ACC/AHA/Heart Rhythm Society recommendations and that the equipment used should meet certain standards.
“I think the document demonstrated that there’s enough agreement that we can’t recommend electrocardiogram screening across all NCAA member schools because there’s not the infrastructure or knowledge base to support that,” Hainline said. “On the other hand, for those that are sort of naysayers for screening, for those centers that really do it exceptionally well, they really can provide guidance for how screening can be done. There’s sort of a meeting of the minds that’s evolving. That really was, to me, one of the most important things that this paper could provide to the medical community.”
The NCAA’s 1,100 member schools come from across the U.S., so the access to high-quality cardiovascular care varies significantly based on location, budgets and other factors. As such, Hainline has suggested setting up regional referral centers that will provide colleges with help on evaluating student athletes, clarifying their cardiovascular status and performing other tasks.
Hainline also acknowledged that athletic venues are not all the same. For instance, it is different treating athletes at a football stadium than at a tennis court, in terms of the crowd sizes, number of athletes involved, resources allocated to the sports and other factors. The NCAA’s document recommends schools have a well-rehearsed cardiac arrest emergency action plan, have automatic external defibrillators available at all fields and have protocols in place on how to respond if an athlete suffers cardiac arrest.
“The debate about the effectiveness of various screening examinations and tools to prevent [sudden cardiac death] in student-athletes will undoubtedly continue,” the researchers wrote. “However, there is no debate that a well-rehearsed and effectively implemented [emergency action plan] for treatment of cardiac arrest is effective at reducing the risk of death.”
Colleges are taking steps to better understand and track sudden cardiac death and other cardiovascular-related issues. In 2014, the NCAA implemented a rule requiring all member schools to report any catastrophic injuries that student athletes suffer, including sudden cardiac death and near fatalities from cardiac arrest. The NCAA has also pledged to fund a study of athletes who have sudden cardiac death. The trial will examine heart tissue and blood and attempt to determine what cardiac and genetic conditions are associated with sudden cardiac death.
“Right now, some of [the reasons for athletes dying] is a guessing game,” Hainline said. “We think we have to get to a more definitive place.”
Hainline also mentioned that the NCAA is working with members of its National Student Athlete Advisory committees to set up a national CPR day for all student athletes. He also would like to set up a registry database of electrocardiograms that could collect data and be used to better interpret electrocardiograms. He anticipates the NCAA will continue to work with the ACC, AHA and other cardiac and sports medicine organizations on issues related to cardiovascular care for student athletes.
“This is really a collaborative effort,” Hainline said. “It’s not the NCAA standing alone. We realize this is a very important public health issue. We want to get it right. You don’t put out a major public health document if you don’t have widespread consensus and a pathway forward. That’s the way we tried to do it.”