Author + information
- William O. Roberts, MD, MS∗ ( and )
- Steven D. Stovitz, MD, MS
- ↵∗Department of Family Medicine and Community Health, University of Minnesota Medical School, Phalen Village Clinic, 1414 Maryland Avenue East, St. Paul, Minnesota 55106
We thank Dr. Weinrauch for highlighting the complexity of obtaining accurate assessments of sudden cardiac death (SCD) rates in sports.
As we stated, the number of SCDs used in our calculations (i.e., the numerator) “does not include athletes who experienced a sudden cardiac arrest during MSHSL [Minnesota State High School League] practice or games and lived, nor does it include SCDs that occurred outside the auspices of MSHSL” (1). Dr. Weinrauch implies that we should be counting deaths that occur “outside of the few hours per week of sports exposure.” We are unaware of data to suggest that, when not participating in sports, high school athletes are at greater risk than their nonathlete peers. The data from Corrado et al. (2) found that >90% of SCDs in athletes occurred during sports and nearly 90% of deaths in nonathletes were during sedentary activities. Counting deaths outside of high school sports suggests that we apply electrocardiographic (ECG) screening to all students and view it from a public health perspective. It is important to recall that many more students and athletes die of causes unrelated to SCD (e.g., alcohol and drug, motor vehicle accidents, and suicide) than of SCD. From a public health perspective, it may be wiser to put more capital into preventing those noncardiac causes of death through thorough pre-participation evaluations (PPEs) and developing emergency action plans with automatic external defibrillators for each school.
The denominator in this study is likely the most accurate reflection of MSHSL athlete-years available. The unduplicated athlete number is a summation of 19 years of all athletes. To be included in this pool, an athlete must be cleared to participate with a PPE using a standardized form that was introduced in 1992, coincidentally the first year that the unduplicated athlete number was tracked by the MSHSL, and make the limited rosters of one of the high school teams (freshman, B squad, junior varsity, or varsity). In a Venn diagram, there would be an undetermined overlap between the sets of athletes in organized programs and athletes in MSHSL programs. Dr. Weinrauch notes that some students may have had a PPE and made a team, but then not participated; we agree that that is possible, but likely rare. Previous studies of Minnesota athletes by Maron et al. (3,4) and highlighted by Dr. Weinrauch all used participant estimates for the denominators.
We concur with Dr. Weinrauch’s call for improved databases to accurately track both the numerator and denominator with regard to sudden cardiac arrest in young athletes, but the numerator and denominator must be concordant to reflect the actual population at risk. We would suggest that the issue be addressed with respect to age groups (6 to 10, 11 to 14, 15 to 18, 19 to 25, and 26 to 35 years of age), sex, ethnicity, and intensity of activity. Using electronic versions of the PPE tied to injury tracking programs may make large-scale studies of interventions such as electrocardiography for cardiac screening plausible. Rather than jumping headlong into ECG screening of all athletes with the accompanying ramifications of false positives and negatives, it would seem prudent to uniformly use standardized PPEs across the country and to begin to study the outcomes in athletes with and without ECG screening.
- American College of Cardiology Foundation
- Roberts W.O.,
- Stovitz S.D.
- Corrado D.,
- Basso C.,
- Pavei A.,
- Michieli P.,
- Schiavon M.,
- Thiene G.