Letter by Angelini et al Regarding Article, “Incidence of Sudden Cardiac Death in the National Collegiate Athletic Association”
To the Editor:
We read with great interest the report by Harmon et al1 on sudden cardiac death (SCD) in the National Collegiate Athletic Association (NCAA), a potentially important statement on the incidence of SCD in the young. We would like to offer some comments.
The complex question of how best to estimate the risk of SCD does not seem to have been precisely addressed in this article. The authors used the number of students registered annually with the NCAA over a 5-year period (yielding about 2 million candidates) as the denominator of the risk fraction; the numerator is the number of SCD events that occurred during that period (45), producing a comprehensive “incidence of 2.3/100 000/yr.” We see 3 important potential limitations in this approach: First, most NCAA student-athletes compete for >1 year, so the 2 million years of observation do not represent 2 million different students (but probably half that number). Second, the risk of SCD among athletes, we currently understand, is attributable mainly to (subclinical) cardiovascular defects and maximal physical exertion, not to chance. Third, precertification screening (unreported) for cardiac defects that could cause either SCD or substantial physical limitations during an athlete's initial year(s) of competition will remove that athlete from the study cohort, thereby changing the cohort's risk profile in subsequent years; to quantify the risk, it would probably be better to look only at each athlete's first year of competition.2
If we assume that the risk for SCD is higher in athletes than in others because of athletes' exposure to competitive exercise, then exercise intensity and duration would be important features to report. A comparison with the incidence of SCD in non–athlete-students would also be useful.
It is not clear why an SCD study should examine generic causes of death (cardiac and noncardiac; see Figure 1) but not the specific cardiac causes that define SCD. Not knowing the causes of death (traditionally established by autopsy) makes it difficult to assess the incidence of SCD (ie, sudden death with a specifically cardiac cause).3
Interestingly, the study found that SCD was 7 times more frequent in basketball players than in football players. This is a potentially important observation, especially because basketball players are taller and more often have marfanoid features than football players, potentially increasing their risk of SCD related to aortic dissection4 or coronary artery anomalies that involve an intramural course,5 a potentially important issue worthy of study.
Finally, the “Memorial Resolution List” kept by the NCAA “to honor the memory of the victims” is unlikely to capture all cases of SCD, and adding data from the Parent Hearts Watch database and from insurance claim records does not seem to have made the mortality estimate more accurate. Reporting such serious events should probably become mandatory in the NCAA.
The authors should be commended for the extensive body of work they have published on an underserved area of cardiology, and we encourage them to further refine their analyses.
Paolo Angelini, MD
MacArthur A. Elayda, MD, PhD
Center for Coronary Artery Anomalies
Texas Heart Institute at St. Luke's Episcopal Hospital
Christine E. Lawless, MD
Sports Cardiology Consultants, LLC
- © 2011 American Heart Association, Inc.
- Harmon KG,
- Asif IM,
- Klossner D,
- Drezner JA
- Maron BJ,
- Thompson PD,
- Ackerman MJ,
- Balady G,
- Berger S,
- Cohen D,
- Dimeff R,
- Douglas PS,
- Glover DW,
- Hutter AM Jr.,
- Krauss MD,
- Maron MS,
- Mitten MJ,
- Roberts WO,
- Puffer JC
- Angelini P