Author + information
- †Department of Family Medicine, University of Washington, Seattle, Washington
- ‡Midwest Heart Foundation, Oakbrook Terrace, Illinois
- ↵∗Department of Family Medicine, Box 354060, University of Washington, Seattle, Washington 98195
To the Editor:
An accurate understanding of the incidence of cardiovascular events in athletes is central to the development and evaluation of screening guidelines. A recent study by Roberts and Stovitz (1) reported a remarkably low rate of sudden cardiac death (SCD) in Minnesota high school athletes on the basis of analysis of catastrophic insurance claims. The low rate of SCD was linked to a statewide pre-participation screening process involving a standardized history and physical examination conducted every 3 years (1). However, critical examination of the study methodology raises important concerns about the validity of the study findings and conclusions. This letter draws attention to major flaws and presents an alternative incidence of sudden cardiac arrest (SCA) in Minnesota high school athletes on the basis of a search of public media reports.
The authors searched catastrophic insurance claims over a 19-year period (1993 to 2012) to identify cases of SCD during high school athletic practices and games. The reported incidence of SCD in Minnesota high school athletes was 0.24 per 100,000 athlete-years over 19 years and 0.11 per 100,000 athlete-years over the last decade (1). The methodology is analogous to a widely cited 1998 study that reported an incidence of SCD in Minnesota high school athletes of 0.46 per 100,000 athlete-years (2). The study does not include cases resulting in death outside of an official high school–sponsored sporting event such as unofficial training sessions or participation with club/select teams. The report briefly mentions cases of SCA in which the persons were saved but implies they were not athletes or at least the cases did not happen during school-sponsored events.
The authors associate a standardized pre-participation evaluation with the low rate of SCD, a conclusion further promoted by a corresponding editorial (3). However, the study provides no data as to the results of the screening evaluations performed or the cardiac conditions identified. If the rate of cardiovascular events in Minnesota high school athletes is truly as low as reported, one possible conclusion is that no cardiovascular screening of any type is actually needed.
We conducted a review of public media reports by searching the Parent Heart Watch database over the last 10 years of the study period in which the authors report only a single case of SCD. The Parent Heart Watch database tracks cases of SCA through systematic Internet search protocols. Each case was reviewed to assess the circumstances of the event and confirm participation on a Minnesota high school athletic team.
Between 2003 and 2012, public media reports identified 13 cases of SCA in Minnesota high school athletes (all in males), including 6 cases of SCD and 7 cases of SCA in student athletes who survived. Roberts and Stovitz (1) document 917,069 unduplicated high school athletes in Minnesota from 2003 to 2012. Thus, the incidence of all SCA in Minnesota high school athletes is 1.4 per 100,000 athlete-years, and the incidence of SCD 0.65 per 100,000 athlete-years. Of the 6 deaths documented in media reports, only 1 would have been eligible for death benefits from an insurance claim, yet 4 of 6 deaths occurred during sports participation. An alarming 46% of cases (6 of 13) occurred in boys' basketball. The incidence of SCA in Minnesota high school boys' basketball is ∼4.7 per 100,000 athlete-years.
Search of catastrophic insurance claims is not an accurate method to conduct death surveillance in athletes. The Minnesota pre-participation evaluation did not prevent at minimum 13 cases of SCA between 2003 and 2012. There remains no evidence that a screening program on the basis of history and physical examination alone is effective in identifying athletes with at-risk conditions or in preventing SCA. Reports examining only death rates will underestimate the incidence of life-threatening cardiovascular events and falsely assume that current screening strategies are effective. To suggest that catastrophic insurance claims are a reliable measure of incidence in support of current screening strategies is unsubstantiated. Although many questions and challenges to more intensive cardiovascular screening in athletes exist, we must recognize that scientific limitations and misinterpretations have perpetuated an underestimate of SCA in athletes and perhaps impeded progress toward the evaluation and implementation of more effective preventive programs.
- American College of Cardiology Foundation
- Roberts W.O.,
- Stovitz S.D.
- Maron B.J.,
- Gohman T.E.,
- Aeppli D.
- Lawless C.E.