Sudden cardiac death is the number one cause of exercise related death in young athletes in the United States
While incidence rates vary and are affected by differing study methodologies, the commonly accepted annual incidence of all sudden cardiac arrest/death (SCA/D) is approximately 1 in 80,000 high school athletes and 1 in 50,000 college athletes.(Drezner et al.)
Taking these rates a step further, male college basketball players have the highest reported overall risk of SCD at 1 in 9,000 per year and African American male college athletes have a reported SCD risk of 1 in 16,000 per year.
Furthermore, it is consistently reported in the literature that two sports, male basketball and football, make up 50% – 61% of all identified cases of SCA/D.
As athletic trainers, we are often one of the first lines of defense for mitigating risk and making participation as safe as possible.
HOW ARE WE IDENTIFYING RISK FACTORS
While the majority of secondary schools, colleges, and universities require all student athletes to obtain a pre-participation evaluation performed by a licensed medical doctor or doctor of osteopathic medicine, these evaluations are not standardized and their purpose is not clearly defined.
I think we can all agree that these examinations exist to help identify risk factors that may make participation in certain activities unsafe for an individual. More specifically, they serve to identify possible cardiovascular abnormalities/diseases that could result in sudden cardiac arrest.
According to a consensus statement from the American College of Cardiology (ACC) and the American Heart Association (AHA), it is recommended that examination of all individuals aged 12-25 include the AHA’s 14-element checklist. This is something that should be added into all pre-participation evaluations.
Another screening tactic that can be utilized, though it remains hotly debated, is a 12-lead ECG.
At this time, the AHA and ACC do not recommend mandatory and universal mass screening with 12-lead ECG in large populations of young healthy people aged 12-25 years whether an athlete or not. It would be prudent, however, to utilize the 14-element checklist as part of a detailed history to identify any possible cardiac red flags that would indicate a more comprehensive evaluation.
There is an increasing number of institutions that have the ability and resources to conduct ECGs on all athletes in conjunction with a comprehensive history and physical examination as part of a pre-participation evaluation. For any institution engaging in this practice, or investigating its implementation, it is important to remember a few things.
Sports Cardiology is a highly specialized field and not all physicians have the knowledge, skill, and experience to accurately interpret an athlete’s ECG. Objections to utilizing ECGs as a screening tool have always included a high rate of false positives resulting in costly follow ups and unnecessary disqualification of otherwise healthy individuals. It can be difficult to accurately differentiate findings that may indicate a potentially serious condition from a normal physiologic adaptation resulting from regular training.
To help improve the accuracy of ECG interpretation in athletes, an international group of experts met in Seattle, WA to review and update standards for ECG interpretation in athletes. The resulting international standards, or, “Seattle Criteria” have been able to balance improving the specificity of the ECG without decreasing sensitivity.
If your institution is performing these screenings, or if you have a patient undergoing cardiac testing, it is paramount that the physician group that you are working with have the training and experience necessary to utilize standards meant to improve detection and limit false-positives.
Unfortunately, regardless of how thorough the screening/evaluation process is, we cannot 100% eliminate SCA from occurring.
What we CAN control is making sure that as athletic trainers, we have a well thought out emergency action plan to respond to these events if/when they happen. This should be written for, and posted at, all venues as well as rehearsed AT LEAST annually with all parties responsible for care. Involve team physicians, any local EMS group that may respond, AT staff, AT students, coaches, and anyone else that may have a role during a cardiac/emergent event.
This is an excellent opportunity to collaborate with other healthcare providers and educate on the level of training and capabilities of ATs, as well as the education level and capabilities of EMS personnel.
Things to consider:
- What equipment does AT staff have/will be available during the event?
- What equipment will EMS have?
- What equipment is necessary?
- What is role delineation for each party at all different times of the EAP
- Immediate care
- Equipment retrieval
- EMS activation
- Direction of EMS to scene
- Family, Spectators, Media etc.
- Before EMS arrives
- After EMS arrives
- Where will the patient be transported to
The importance of practicing for these situations cannot be overstated. Ron Courson, Executive Associate Athletic Director at University of Georgia has said:
“Athletic teams excel because they practice. It is not conceivable that personnel responsible for emergency management cannot practice and expect to excel at the time of an emergency.”
Please do not practice your EAP to check off an annual requirement. Practice it so that you can save a life. In a time of high stress, you will fall to the level of your training, not rise to the level of your expectations.
For more information and resources regarding EAPs, check out the links below.
NATA Position Statement – Emergency Planning in Athletics
Korey Stringer Institute
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