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Incidence of sudden cardiac arrest in high school studentathletes on school campusBrett G. Toresdahl, MD, Ashwin L. Rao, MD, Kimberly G. Harmon, MD,Jonathan A. Drezner, MD

From the Department of Family Medicine, University of Washington, Seattle, Washington.

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BACKGROUND An accurate estimate of the incidence of suddencardiac arrest (SCA) in high school student athletes is needed toguide prevention strategies.

OBJECTIVE To prospectively investigate SCA rates in high schoolstudent athletes vs student nonathletes.

METHODS A prospective observational study of 2149 US highschools participating in the National Registry for AED Use in Sportswas conducted from August 2009 to July 2011. Schools werecontacted quarterly to collect and review SCA cases occurring onschool campus. Ninety-five percent of the schools confirmedparticipation for the entire 2-year period.

RESULTS The average numbers of total students and studentathletes per school were 963 and 367, respectively, providing morethan 4.1 million total student-years and more than 1.5 millionstudent athlete-years of surveillance. Twenty-six cases of SCAoccurred in students, including 18 cases in student athletes—allduring exercise. The incidence of SCA in all students was 0.63 per100,000; in student athletes, 1.14 per 100,000; and in student

This work was supported by the National Operating Committee onStandards for Athletic Equipment. Address reprint requests and corre-spondence: Dr Jonathan A. Drezner, Department of Family Medicine,University of Washington, Box 354060, Seattle, WA 98195. E-mail address:jdrezner@uw.edu.

1547-5271/$-see front matter B 2014 Heart Rhythm Society. All rights reserved.

nonathletes, 0.31 per 100,000. The relative risk of SCA in studentathletes vs nonathletes was 3.65 (95% confidence interval 1.6–8.4;P o .01). Sixteen of 18 student athletes with SCA were males,resulting in an incidence of 1.73 per 100,000 in males and 0.31 per100,000 in females and a relative risk in male compared with femalestudent athletes of 5.65 (95% confidence interval 1.3–24.6; Po .01).

CONCLUSION The incidence of SCA in high school student athletesis higher than previous estimates and may justify more advancedcardiac screening and improved emergency planning in schools.

KEYWORDS Sudden cardiac death; Sports; Screening; Adolescence;Exercise; Automated external defibrillator

ABBREVIATIONS AED ¼ automated external defibrillator; CI ¼confidence interval; NCAA ¼ National Collegiate AthleticAssociation; PPE ¼ preparticipation physical evaluation; SCA ¼sudden cardiac arrest; SCD ¼ sudden cardiac death

(Heart Rhythm 2014;0:-1–5) I 2014 Heart Rhythm Society. Allrights reserved.

555657585960616263646566676869707172

IntroductionSudden cardiac death (SCD) in high school students andstudent athletes is a tragic event with devastating impact onthe family, school, and community. The incidence of suddencardiac arrest (SCA) in this population is the subject ofcurrent debate, and estimates vary widely depending on thestudy population and methodology. Young athletes havereceived particular attention, as SCA can be triggered byexertion in individuals with underlying cardiac pathology.1–4

An accurate understanding of SCA incidence in students andstudent athletes is needed to guide appropriate screeningprograms and emergency planning in schools.

The reported incidence of SCA in young athletes rangesfrom 0.24 to 9.80 per 100,000 per year.4–11 Initial estimatesin the United States were reliant on searches of newspaperclippings, media reports, and catastrophic insurance claims,

and those estimates likely underestimated the true incidencebecause of incomplete case identification.5,6 Other studiesare limited by their survey or cross-sectional design.7,8 Arecent study performed with an internal reporting systemfrom the National Collegiate Athletic Association (NCAA)found an overall annual incidence of SCD of 2.28 per100,000.10 No US study has prospectively performed activesurveillance of a predefined population, and no study hascompared SCA rates in US athletes with those in age-matched nonathletes.

The purpose of this study was to prospectively monitor alarge cohort of US high schools to more accurately determinethe incidence of SCA in high school students and studentathletes.

7374757677

MethodsStudy designThe National Registry for AED Use in Sports was created toinvestigate emergency planning and to monitor SCA and useof automated external defibrillators (AEDs) in the highschool and university athletic settings. A total of 2149 high

http://dx.doi.org/10.1016/j.hrthm.2014.04.017

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Heart Rhythm, Vol 0, No 0, Month 20142

schools enrolled in the registry agreed to participate in a2-year prospective observational study.

School representatives provided information regardingstudent and student athlete enrollment and emergencypreparedness for SCA at the school. From August 1, 2009,through July 31, 2011, any potential cases of SCA thatoccurred on school campuses were reported. School repre-sentatives, including school administrators, athletic direc-tors, nurses, and certified athletic trainers, were contactedquarterly by e-mail as a reminder to report all potential cases.At the end of the study period, the school representativeswere contacted by e-mail and phone to confirm the numberof cases (if any) that occurred during the study period.

When a potential case of SCA was reported, the details ofthe case were reviewed over the phone with the schoolrepresentative or another staff member who had witnessedthe event or was involved in the emergency response. Insome cases, media reports were used to clarify victim’sdemographics or supplement the information provided. Acase was classified as SCA if (1) the victim was determinedunconscious with the absence of pulse and respirations, (2)cardiopulmonary resuscitation was provided or an AEDdeployed a shock, (3) a primary cardiac etiology was found,or (4) a traumatic blow to the chest occurred and wasconsistent with commotio cordis. Only those cases occurringon school campus during the study period were included.The study design did not allow for active surveillance ofSCA cases occurring off school campus, at home, or outsidethe school setting.

For gender-specific incidence calculations in student ath-letes, gender demographics were obtained from the NationalFederation of State High School Associations 2010-11 HighSchool Athletics Participation Survey results.12 This nation-wide survey reported that 58.6% of high school sportparticipations were in males and 41.4% were in females.

The study was approved by the Human Subjects Divisionat the University of Washington.

Study outcomesThe primary outcome measure was the occurrence of SCA ina 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 studentathlete, and the sport or activity at the time of arrest. Astudent athlete was defined as a student participating in anyofficial school sponsored interscholastic team or individualsport requiring regular practice and competition. Data onemergency preparedness, the emergency response, andsurvival outcomes have been reported previously.13

Statistical analysisDescriptive statistics such as proportions and means wereused to describe the data, as appropriate. Incidence con-fidence intervals (CIs) were calculated using the Byarapproximation of a Poisson distribution. χ2 analysis wasused to calculate the relative risk of SCA between

populations. The number of SCA cases in year 1 vs year 2of the study was compared to examine the consistency ofreported cases between the 2 study years.

ResultsParticipantsA total of 2149 US high schools distributed throughout all 50states participated in the study. The mean number of studentsand student athletes per school as reported by the schoolrepresentative were 963 and 367, respectively. For the 2-yearstudy period, this provided more than 4.1 million totalstudent-years and more than 1.5 million student athlete-years of surveillance. Eighty-six percent of the participatingschools were public and 14% private; 48% of schools wererural, 33% suburban, 15% urban, and 4% inner city. At theend of the study, 2045 of 2149 (95%) schools confirmedparticipation for the entire 2-year study period and thepresence or absence of SCA cases on school campus. Theremaining school representatives could not be contacted byphone and e-mail despite multiple attempts.

Cases of SCAOne hundred twenty-nine potential cases of SCA werereported by school representatives. Fifty-nine cases met theinclusion criteria. Of the 70 cases that were excluded, 20were determined not to be SCA, 4 were secondary to trauma,13 did not occur on school campus, and 32 occurred outsidethe study period. One potential case was reported, but theschool representative and other witnesses could not becontacted to verify the details and therefore the case wasexcluded. Twenty-six cases of SCA occurred in students.The number of cases was similar during each year of thestudy: 15 cases in year 1 and 11 cases in year 2 (P ¼ .4).

Eighteen (69%) cases occurred in student athletes, and allof them were associated with physical activity. The numberof cases in student athletes was also similar during each yearof the study: 10 cases in year 1 and 8 cases in year 2 (P ¼.64). Sixteen (89%) cases of SCA in student athletesoccurred in males and 2 (11%) cases in females. There were4 cases each in males and females among the studentnonathletes with SCA. Of the student athlete victims, 12(67%) were Caucasian, 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 SCAThe overall annual incidence of SCA in all high schoolstudents occurring on school campus was 0.63 per 100,000(95% CI] 0.41–0.92; Table 1). The incidence of SCA instudent 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 per100,000; 95% CI 0.04–1.11). The relative risk of SCA inmale vs female student athletes was 5.65 (95% CI 1.3–24.6;P o .01). Of the 18 cases of SCA in student athletes,

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Table 1 Incidence of SCA in high school students

Population

Cases ofSCAover2 y

Population(peryear)

Annualincidence(per100,000)

95%confidenceinterval

Male studentathletes

16 462,269 1.73 0.99–2.81

Student athletes 18 788,683 1.14 0.68–1.80Students 26 2,069,487 0.63 0.41–0.92Male studentnonathletes

4 572,474 0.35 0.10–0.89

Studentsnonathletes

8 1,280,804 0.31 0.13–0.62

Female studentathletes

2 326,414 0.31 0.04–1.11

Female studentnonathletes

4 708,330 0.28 0.08–0.72

SCA ¼ sudden cardiac arrest.

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3Toresdahl et al Incidence of SCA in High School Student Athletes

6 occurred in football, 3 basketball, 2 baseball, 2 track, and 1each in cheer leading, cross country, hockey, lacrosse, andswimming. The incidence of SCA in student athletes byomitting 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).

The incidence of SCA in student nonathletes was 0.31 per100,000 (95% CI 0.13–0.62). The relative risk of SCA instudent athletes vs student nonathletes was 3.65 (95% CI1.6–8.4; P o .01). The relative risk of SCA in male studentathletes vs male student nonathletes was 4.95 (95% CI

Table 2 Comparison of incidence studies of SCA in young athletes

Study Location Population Age (y)

Marijon et al4 France Competitive athletesduring sport

10–35

Corrado et al15 Italy (Veneto) Competitive athletes(1979–1982)

12–35

Steinvil et al33 Israel Athletes age 10–44

Harmon et al10 United States College studentathletes

17–23

Corrado et al2 Italy (Veneto) Athletes 12–35

Holst et al14 Denmark Athletes 12–35

Maron et al9 United States Competitive athletes o40

Maron et al6 United States(Minnesota)

High school studentathletes

13–19

Van Camp et al5 United States High school andcollege athletes

13–24

Roberts et al11 United States(Minnesota)

High school studentathletes

12–19

EMS ¼ XXXX; NCAA ¼ National Collegiate Athletic Association; SCA ¼ sudden

1.6–14.8; P o .01) and in female student athletes vsfemale student nonathletes was 1.09 (95% CI 0.20–5.92;P ¼ .92).

There were 2 deaths in the student athletes who sufferedSCA (both males) and 2 deaths in the student nonathletes(both females). The incidence of SCD occurring on schoolcampus in student athletes was 0.13 per 100,000 (95% CI0.02–0.46) and 0.43 per 100,000 (95% CI 0.12–1.11) formale student athletes. The incidence of SCD in studentnonathletes was 0.08 per 100,000 (95% CI 0.01–0.28).

DiscussionThis is the first study to prospectively measure the incidenceof SCA in US high school students and student athletes. Pastestimates vary widely on the basis of study methodology, thereliability of case identification, use of unconfirmed athletepopulation statistics, differences in age range and athletelevels, and inclusion of all SCA cases vs only SCD cases(Table 2). This study focused on high school students andstudent athletes by closely monitoring a large predefinedpopulation for 2 years. With more than 4 million total student-years of active surveillance, this study found the incidence ofSCA in high school student athletes to be higher than otherUS estimates based on searches of public media reports andcatastrophic insurance claims,5,6,9,11 even though this studycaptured only SCA cases occurring on school campus.

The limitations of using media reports or catastrophicinsurance claims as the primary method for case identificationis highlighted by a study using an internal reporting structure

278279280281282283284285286287288289290291292293294295296297298299300301302303304305

Eventtype

Reporting system andmethodology

Incidence(per 100,000)

SCA Prospective study using an EMSdatabase and media reports

9.8

SCD Prospective study using amandatory forensic database

3.8

SCA Retrospective study usingreports from 2 newspapers

2.6

SCD Retrospective study usingNCAA database, mediareports, and insuranceclaims

2.3

SCD Prospective study using amandatory forensic database

2.2

SCD Retrospective study usingmedia reports, hospital andautopsy databases

1.2

SCA Retrospective study usingmedia reports and otherelectronic databases

0.6

SCD Retrospective study usingcatastrophic insuranceclaims

0.5

SCD Retrospective study of mediareports

0.3

SCD Retrospective study usingcatastrophic insuranceclaims

0.2

cardiac arrest.

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for the NCAA, demonstrating that intensive search of publicmedia reports missed 44% and analysis of catastrophicinsurance claims missed 80% of SCD cases, despite the highprofile nature of collegiate athletics.10 Holst et al14 also foundthat search of media reports identified only 20% of sports-related SCD in Denmark. The higher incidence of SCAobserved 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. Thecardiovascular health benefits of regular exercise and phys-ical activity are unequivocal; however, exercise can also be atrigger for SCA in individuals with underlying pathologicalcardiac conditions.16 In a prospective cohort study byCorrado et al,2 a higher risk of SCD (relative risk 2.5) wasfound in competitive athletes in the Veneto region of Italythan in age-matched sedentary controls (age 12–35 years).Marijon et al4 performed a 5-year prospective observationalstudy in France and reported that the relative risk of suddendeath was 4.5 times higher in competitive young athletes(age 10–35 years) than in recreational sports participants ofthe same age. In contrast, in a retrospective review14 of deathcertificates in Denmark, investigators reported a rate of SCDin athletes aged 12–35 years that was 3.3 times lower than inthe general population.

This is the first US study directly comparing the rate ofSCA in athletes with that in nonathletes. The risk of SCA inhigh school student athletes was nearly 4 times higher thanthat in student nonathletes, and male student athletes weremore than 5 times more likely to suffer SCA than did femalestudent athletes.

The results of this study may have important implications onrecommendations for cardiovascular screening in athletes. Highschool athletes in the United States are required to undergo apreparticipation physical evaluation (PPE) every 1–3 years(depending on state requirements). While there is universalsupport from national medical organizations for preparticipa-tion cardiovascular screening in athletes, the optimal screeningtechniques are still unclear and agreement on the best protocolremains an area of continued debate within the primary care,sports medicine, and cardiology communities.17–20

The traditional model of screening as recommended bythe American Heart Association includes a comprehensivepersonal history, family history, and physical examination.17

Although a PPE requirement of any type creates a separatescreening procedure for athletes that is not required innonathletes, the ethics of employing a more intensivescreening program only for athletes has been questioned,especially if there is no evidence that athletes are at higherrisk than their nonathlete counterparts.17,19 Proponents ofmore intensive screening contend that the current model isineffective owing its poor sensitivity to detect athletes withunderlying conditions associated with SCA.20–23 The limi-tations of screening by history and physical examinationwere recognized in a 1996 review of 134 cases of SCD in USathletes in which only 1 athlete was diagnosed correctlythrough preparticipation screening.24

Routine screening with a 12-lead electrocardiogram isrequired and standard practice in all major US professionalsports and many NCAA Division I athletic programs.25 Thehigh incidence of SCD documented in collegiate athletes hasprompted calls for more intensive screening, specifically in thehighest-risk groups including male athletes (3.02 per 100,000),African American/black athletes (5.65 per 100,000), and men’sbasketball (14.3 per 100,000).10 Similar to the findings incollegiate athletes, the high event rate in this study was founddespite each of the athletes receiving a PPE consisting, at aminimum, of a history and physical examination. The high rateof SCA in male high school student athletes may justify moreintensive, targeted screening programs. In addition, 50% of theSCA cases in high school athletes occurred in only 2 sports—boys basketball and football—a finding consistent with pastreports.9 More intensive screening programs may not beindicated in female student athletes with a lower risk of SCAequal to their nonathlete counterparts.

Some authorities argue that the current screening model issufficient because the incidence of SCD in young athletes inthe United States is already low and approximates incidencerates in countries with electrocardiogram-inclusive screeningprograms.9,15,17,26,27 Recent cost-effectiveness studies haveacknowledged the lack of prospective incidence data toguide recommendations.28–30 As this study demonstrates,reports examining only death rates may greatly underesti-mate the incidence of SCA and falsely assume that currentscreening strategies are effective.11,31

The incidence of SCA on school campuses is also used toguide recommendations for emergency planning and theimplementation of school-based AED programs. AED pro-grams provide a means of early defibrillation not just forstudent athletes but for all students and adults on a schoolcampus. While the prevalence of AEDs in schools isincreasing, this public safety measure is not yet a universalstandard. The high survival rate and the resulting lowincidence of SCD in this cohort are influenced by a selectionbias of schools that elected to participate in this study. AEDprograms were present in 87% of the participating schoolsand in all but one of the schools reporting a case of SCA.13

These schools are more prepared to respond to SCA, and thehigh survival rate may not be reproducible in a broadersample of schools across the United States.13

While emergency planning and school-based AED pro-grams are strongly encouraged, the potential for successfulresuscitation in student athletes does not eliminate the needor requirement for primary prevention. Student athletes mustreceive medical clearance before participating in high schoolsports, and the objective of this evaluation is the earlydetection of conditions at risk for catastrophic injury orsudden death.17,32 The current model of screening does notprevent SCA in a high number of student athletes, andrefinement 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 inathletes.

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5Toresdahl et al Incidence of SCA in High School Student Athletes

Study limitationsAlthough this study provides the first prospective surveil-lance of SCA in US athletes, study limitations must berecognized, especially if comparing incidence rates withthose presented in prior reports. This study underestimatesthe true incidence of SCA in high school students andstudent athletes because it accounts for only those cases thatoccurred on high school campuses. This study does notaccount for cases that occurred outside the school campus, athome, on weekends, or when school was not in session. Inprior studies, up to 20% of the cases of SCD in youngathletes included in the incidence calculations occurred whileaway from school, at rest, or during sleep.9 Because of thestudy design and lack of a mechanism for surveillanceoutside the school campus, this study does not include casesin student athletes while participating in “away” compet-itions, during recreational sports or with select/club teamsnot playing at a school facility, and individual trainingsessions outside the school. Thus, incidence rates in thisstudy should be considered a minimum estimate of theannual risk of SCA in a student athlete. There also remains apossibility that additional cases of SCA were not reported,though this possibility is minimized by the frequent contactwith school representatives, 2-year follow-up rate of 95%,and consistency of reported cases between the 2 study years.

ConclusionThe incidence of SCA in high school athletes is higher thanprevious estimates, particularly among male student athletes.The results justify consideration for more advanced cardio-vascular screening in high-risk groups as well as universalstandards for emergency planning for SCA in schoolsincluding access to AEDs at school sporting facilities. Moreresearch is needed to better detail sex, race, etiology, andsport-specific differences in risk that could influence pre-vention strategies and improved safety in schools.

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