Q&A: ‘We can do better’ preventing, managing sudden cardiac death among US athletes
Click Here to Manage Email Alerts
Key takeaways:
- The Lancet issued a contemporary review of trends in sudden cardiac arrest among athletes.
- Incidence of sudden cardiac death reportedly varied by age, race and type of sport played.
Sudden cardiac death among athletes, both recreational and master level, remains a public health issue, disparately affecting players of certain sports and athlete demographics, researchers reported.
On behalf of the American College of Cardiology Sports and Exercise Leadership Council, Jonathan H. Kim, MD, council chair and director of sports cardiology and associate professor of medicine in the division of cardiology at Emory University, and colleagues conducted an expansive review of contemporary trends in incidence of sudden cardiac death among athletes.
In the review, published in The Lancet, Kim and colleagues evaluated incidence and etiology of sudden cardiac death across ranges of athleticism, age, race and sex and detailed clinical considerations for the primary prevention and management of sudden cardiac death among athletes.
Healio spoke with Kim, who is also head team cardiologist for the NFL’s Atlanta Falcons, NBA’s Atlanta Hawks, MLB’s Atlanta Braves and WNBA’s Atlanta Dream about the review, trends in sudden cardiac death and “controversial” topics in athlete screening for sudden cardiac death risk factors.
Healio: Can you give some background on why you and your colleagues conducted this review and what you hope to establish with it?
Kim: This is not the first review on sudden cardiac death among athletes. There have been great reviews over the years, but like any topic, there is evolution and new science.
Higher profile cases, like Damar Hamlin (of the Buffalo Bills) and Bronny James (of the Los Angeles Lakers), generate a visceral response from the general public. People are wondering how common, what causes and how can we prevent sudden cardiac death? Compound that with the new emphasis on legislative advocacy on automated external defibrillator access and emergency action planning, it seemed like a good time to do a contemporary update.
There have been a couple of reviews in the past year on the general topic of sudden cardiac death, but this one is more expansive. We not only talk about young athletes, but there’s discussion of older, masters athletes. There has not previously been as comprehensive a review with the inclusion of both young and older athletes. I am not sure if there has ever been a review on older athletes. Most are generally on young athletes.
Our goal was to provide a contemporary update on the big picture. Not just talking about young athletes, but older athletes, contemporary uncertainties and the disparities that have not been discussed in prior sudden cardiac death reviews.
Healio: What is the historic prevalence of sudden cardiac death among athletes and what are some of the primary causes?
Kim: It is hard to know a precise incidence because in the U.S. there is no mandatory reporting system. In many countries around the world, there is no mandatory reporting system. We’re reliant on studies and how they decide they want to define the incidence of sudden cardiac death. That is going to be dependent on two things: What group are you looking at and how do you know you have identified all the right cases? Are we talking about cases that only occurred during sport? What about cases of athletes who may die in their sleep? An additional factor is the inclusion of resuscitated sudden cardiac arrest cases. Because of the emphasis on emergency action plans, there are athletes who don’t die, thankfully. That is important to look at as well because it is still a sudden cardiac arrest.
It is hard to put a number on the rate of sudden cardiac death, but we give ranges. The NCAA data are quite good because they address a lot of these study definition uncertainties in a very well-defined population. Their 20-year data just published last year showed an incidence of sudden cardiac death of about one in 64,000. Another study looking at a smaller timeframe of sudden cardiac arrest among younger athletes, both high school and college athletes, showed the incidence that was a little bit higher, because those researchers incorporated resuscitated sudden cardiac arrest cases.
It is fair to say that cases are uncommon. That is important to state because a subtle change in the study methodology will give you wide shifts, or cause variance in terms of the incidence. However, just because something is uncommon, it doesn’t mean it is not a public health issue. The No. 1 medical cause of death among athletes is sudden cardiac death. The No. 1 overall cause of death is death through accidents.
In terms of the most common causes, it depends on what type of athlete you are. If you are a young athlete, the differential diagnosis is pretty wide. It is generally either a structural abnormality, an arrhythmia syndrome or something acquired, like myocarditis. There are obviously many specific etiologies within each of those three bins.
The most common cause overall is an autopsy-negative case. For the masters athlete, aged 35 years of age or older, the most common cause is coronary artery disease.
Healio: Could you provide more details about any other differences in causes of cardiac death between master athletes and recreational players?
Kim: Etiologies are the same and age-dependent. Whether you are a competitive master’s athlete or a recreational master’s athlete, you will investigate the same potential causes. For older athletes, the cause of sudden cardiac death is generally going to be atherosclerosis. Similarly, when you look at the younger individuals who experienced sudden cardiac death, you are going to explore one of the three bins I mentioned.
The age cutoff is really the basis of separation of different causes, not necessarily how intensely athletic someone is.
Healio: Among some of the subgroups, be it by sex or race, were there any significant differences compared with other demographics?
Kim: Men are higher risk overall compared with women, but we also do not have the underlying explanation. There are a lot of theories, but in terms of the actual reasons why men experience sudden cardiac death more than women, it is still uncertain.
Self-identified Black athletes are at higher risk for sudden cardiac death compared with white athletes. The reasons for that are unknown as well. We talk about that in the review. In the general population, we do know that disparities in outcomes are driven by social determinants of health has not been explored well among young athletes, and that should change. We need to explore these potential causes, mechanisms or factors that may be related as to why we see the difference in risk between different self-identified constructs.
Healio: Did you observe any specific differences by type of sport played? At the recreational or master level?
Kim: From the NCAA data, for whatever reason, basketball appears to be the sport where risk for sudden cardiac death seems higher.
Basketball is followed by American football and soccer, where you also see higher levels of risk compared with other sports. In terms of why, it is not clear. From a sports stress standpoint, basketball has similarities with other sports, so it is just not clear why we see sports-specific differences.
Healio: Do you have any specific screening or management recommendations for clinicians with master-level athlete patients?
Kim: When you talk about master-level athletes, you want to go through standard risk stratification as you would with the general population. Risk factors, family history, BP, cholesterol, etc.
Where it gets to be more controversial is when you find risk factors. How much more screening should you do with exercise testing? When you look at the general population, there are not data to support asymptomatic cardiac screening. However, for master’s athletes, considering a more individualized approach to risk management and screening is not unreasonable.
Healio: Do these data inform any recommendations for clinicians seeing patients who are recreational athletes?
Kim: You want to be careful when trying to provide recommendations for recreationally active individuals. Obviously, we encourage recreational physical activity or moderate exercise for everybody. Generally speaking, you do not need to do more intensive screening beyond what we do for any other patient. Just standard risk assessments.
The consideration of doing more intensive screening should be reserved for individuals who are much more intensive as it relates to how competitive they are.
Healio: Are there any lingering questions about the etiology or prevention of sudden cardiac death among athletes that remain unanswered by current clinical research?
Kim: There are plenty of uncertainties. Best practices for primary prevention; the ongoing debate about ECG screening; specific factors associated with outcomes; and now having more athletes returning to play with cardiac risk factors.
There is an active registry called Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) that is recruiting high school and collegiate athletes with heart conditions and tracking their long-term outcomes. Registries like this will help provide more precision when we counsel athletes and, if with adverse events, be able to look for factors potentially associated with outcomes. We still have a lot to learn.
The disparities question is important. What explains these disparate outcomes? Evaluation of social determinants of health is important as well.
From an etiology standpoint, the most common cause of death is autopsy-negative sudden unexplained death. There should be an emphasis on molecular autopsy and, for unexplained cases, looking for pathogenic genetic variants.
We all agree on the importance of emergency action planning and AEDs, but there is work to do there as well. We can do better in this country. There are many advocacy groups trying to push laws for better AED access across all 50 states, CPR training and ensuring that there is law mandating emergency action plans. We just passed a law in Georgia about mandating practice plans for emergency action plans, which is not common across the U.S.
If you look back over the last 40 years, you can appreciate how much we learned. But there is still more to be learned and much more work to do as it pertains to improving outcomes.
References:
- Emory-led Lancet review highlights racial disparities in sudden cardiac arrest and death among athletes. https://www.sca-aware.org/sca-news/emory-led-lancet-review-highlights-racial-disparities-in-sudden-cardiac-arrest-and-death. Published Nov. 28, 2024. Accessed Nov. 28, 2024.
- Kim JH, et al. Lancet. 2024;doi:10.1016/S0140-6736(24)02086-5.
For more information:
Jonathan H. Kim, MD, can be reached at Emory Sports Medicine Center, 1968 Hawks Lane Northeast, Brookhaven, GA 30329.
Collapse
Healio Interviews
Click Here to Manage Email Alerts