Letter by Corrado et al Regarding Article, “Sudden Deaths in Young Competitive Athletes: Analysis of 1866 Deaths in the United States, 1980–2006”
To the Editor:
We write about the important article from Maron et al1 reporting the results from a 27-year registry on sudden cardiac arrest in US athletes. We appreciate the effort of the authors to provide an estimate of the absolute number of fatal events that occur annually, and we recognize that the study results provide the best data available on the US experience with cardiac events in athletes. In Figure 3, the authors show the distribution over the time of 1866 fatal events. The graphic demonstrates a clearly increasing time trend of sudden cardiac arrest in the US athletes. It is highly impressive that 576 (31%) occurred in the 1980 to 1993 time interval and 1290 (69%) between 1994 and 2006. By comparing this increasing mortality trend with the sharp decline (by 90%) of the incidence of sudden cardiac death reported in Italian athletes over a comparable period of observation,2 the reader instinctively wonders whether the contrasting time trends between the United States and Italy are the result of the different screening strategies in practice in these countries—ie, no screening or screening program without ECG in the United States versus systematic preparticipation ECG screening in Italy. However, a more reasoned explanation, which was shared by the authors, is that the study data were largely limited to sudden deaths that became part of the public domain and records. Thus, the increase in the number of fatal events observed over the 27 years of this registry simply reflects enhanced public recognition caused by increased media attention. This limitation, inherent in the data collection, raises a reasonable concern about the reliability of the estimation of athletes’ sudden cardiac death, leading to an incorrectly low number of events and underestimation of mortality rates. The accuracy of determination of sudden cardiac death rates was further hampered by the inability to obtain a reliable denominator for the overall at-risk athletic population in the United States during the 27 years. In the study, denominator data did not reflect the real number of active athletes in each year but rather reflected the total participation figures divided by an estimate of the average number of sports in which each athlete participated.
Thus, in our opinion, it is premature to conclude (1) that sudden cardiac death in US athletes is a low-frequency event, which occurs at a rate similar to that reported in young competitive athletes from the Veneto region of northeastern Italy, who underwent systematic preparticipation ECG screening for more than 25 years2; (2) that no screening or less formal screening in the United States might have been as effective as the Italian program3; and (3) that the low overall event rate reported should reassure competitive athletes about their negligible risk of sudden death and thus lead to questioning the need for a national preparticipation screening program, including ECG.
We think that the most significant implication of the study by Maron et al is that major limitations exist in providing reliable data on the true absolute number of fatal events and in estimating the athletic population per year in the United States. As suggested by the authors, there is a need for a “national government-subsidized program with mandatory reporting, a centralized database, and dedicated resources” aimed at establishing the precise incidence of sudden death in young athletes.1