Ashwin L. Rao

Effectiveness of Emergency Response Planning for Sudden Cardiac Arrest in United States High Schools With Automated External Defibrillators

Background— US high schools are increasingly adopting automated external defibrillators (AEDs) for use in campus settings. We analyzed the effectiveness of emergency response planning for sudden cardiac arrest (SCA) in a large cohort of US high schools that had onsite AED programs. Methods and Results— A cohort of US high schools with at least 1 onsite AED was identified from the National Registry for AED Use in Sports. A school representative completed a comprehensive survey on emergency planning and provided details of any SCA incident occurring within 6 months of survey completion. Surveys were completed between December 2006 and July 2007. In total, 1710 high schools with an onsite AED program were studied. Although 83% (1428 of 1710) of schools have an established emergency response plan for SCA, only 40% practice and review the plan at least annually with potential school responders. A case of SCA was reported by 36 of 1710 schools (2.1%). The 36 SCA victims included 14 high school student athletes (mean age, 16 years; range, 14 to 17 years) and 22 older nonstudents (mean age, 57 years; range, 42 to 71 years) such as employees and spectators. No cases were reported in student nonathletes. Of the 36 SCA cases, 35 (97%) were witnessed, 34 (94%) received bystander cardiopulmonary resuscitation, and 30 (83%) received an AED shock. Twenty-three SCA victims (64%) survived to hospital discharge, including 9 of the 14 student athletes and 14 of the 22 older nonstudents. Conclusions— School-based AED programs provide a high survival rate for both student athletes and older nonstudents who suffer SCA on school grounds. High schools are strongly encouraged to implement onsite AED programs as part of a comprehensive emergency response plan to SCA.

Incidence, cause, and comparative frequency of sudden cardiac death in national collegiate athletic association athletes a decade in review

Background— The incidence and cause of sudden cardiac death (SCD) in athletes is debated with hypertrophic cardiomyopathy often reported as the most common cause. Methods and Results— A database of all National Collegiate Athletic Association deaths (2003–2013) was developed. Additional information and autopsy reports were obtained when possible. Cause of death was adjudicated by an expert panel. There were 4 242 519 athlete-years (AY) and 514 total student athlete deaths. Accidents were the most common cause of death (257, 50%, 1:16 508 AY) followed by medical causes (147, 29%, 1:28 861 AY). The most common medical cause of death was SCD (79, 15%, 1:53 703 AY). Males were at higher risk than females 1:37 790 AY versus 1:121 593 AY (incidence rate ratio, 3.2; 95% confidence interval, 1.9–5.5; P<0.00001), and black athletes were at higher risk than white athletes 1:21491 AY versus 1:68 354 AY (incidence rate ratio, 3.2; 95% confidence interval, 1.9–5.2; P<0.00001). The incidence of SCD in Division 1 male basketball athletes was 1:5200 AY. The most common findings at autopsy were autopsy-negative sudden unexplained death in 16 (25%), and definitive evidence for hypertrophic cardiomyopathy was seen in 5 (8%). Media reports identified more deaths in higher divisions (87%, 61%, and 44%), whereas the percentages from the internal database did not vary (87%, 83%, and 89%). Insurance claims identified only 11% of SCDs. Conclusions— The rate of SCD in National Collegiate Athletic Association athletes is high, with males, black athletes, and basketball players at substantially higher risk. The most common finding at autopsy is autopsy-negative sudden unexplained death. Media reports are more likely to capture high-profile deaths, and insurance claims are not a reliable method for case identification.Background —The incidence and etiology of sudden cardiac death (SCD) in athletes is debated with hypertrophic cardiomyopathy (HCM) often reported as the most common etiology. Methods and Results —A database of all NCAA deaths (2003 - 2013) was developed. Additional information and autopsy reports were obtained when possible. Cause of death was adjudicated by an expert panel. There were 4,242,519 athlete-years (AY) and 514 total student athlete deaths. Accidents were the most common cause of death (257, 50%, 1:16,508 AY) followed by medical causes (147, 29%, 1:28,861 AY). The most common medical cause of death was SCD (79, 15%, 1:53,703 AY). Males were at higher risk than females 1:37,790 AY vs. 1:121,593 AY (IRR 3.2, 95% CI, 1.9-5.5, p < .00001), and black athletes were at higher risk than white athletes 1:21,491 AY vs. 1:68,354 AY (IRR 3.2, 95% CI, 1.9-5.2, p < .00001). The incidence of SCD in Division 1 male basketball athletes was 1:5,200 AY. The most common findings at autopsy were autopsy negative sudden unexplained death (AN-SUD) in 16 (25%) and definitive evidence for HCM was seen in 5 (8%). Media reports identified more deaths in higher divisions (87%, 61%, and 44%) while percentages from the internal database did not vary (87%, 83%, and 89%). Insurance claims identified only 11% of SCDs. Conclusions —The rate of SCD in NCAA athletes is high, with males, black athletes and basketball players at substantially higher risk. The most common finding at autopsy is AN-SUD. Media reports are more likely to capture high profile deaths, while insurance claims are not a reliable method for case identification.

Accuracy of ECG interpretation in competitive athletes: the impact of using standardised ECG criteria

Background Interpretation of ECGs in athletes is complicated by physiological changes related to training. The purpose of this study was to determine the accuracy of ECG interpretation in athletes among different physician specialties, with and without use of a standised ECG criteria tool. Methods Physicians were asked to interpret 40 ECGs (28 normal ECGs from college athletes randomised with 12 abnormal ECGs from individuals with known ciovascular pathology) and classify each ECG as (1) ‘normal or variant – no further evaluation and testing needed’ or (2) ‘abnormal – further evaluation and testing needed.’ After reading the ECGs, participants received a two-page ECG criteria tool to guide interpretation of the ECGs again. Results A total of 60 physicians participated: 22 primary care (PC) residents, 16 PC attending physicians, 12 sports medicine (SM) physicians and 10 ciologists. At baseline, the total number of ECGs correctly interpreted was PC residents 73%, PC attendings 73%, SM physicians 78% and ciologists 85%. With use of the ECG criteria tool, all physician groups significantly improved their accuracy (p<0.0001): PC residents 92%, PC attendings 90%, SM physicians 91% and ciologists 96%. With use of the ECG criteria tool, specificity improved from 70% to 91%, sensitivity improved from 89% to 94% and there was no difference comparing ciologists versus all other physicians (p=0.053). Conclusions Providing standised criteria to assist ECG interpretation in athletes significantly improves the ability to accurately distinguish normal from abnormal findings across physician specialties, even in physicians with little or no experience.

Outcomes from sudden cardiac arrest in US high schools: a 2-year prospective study from the National Registry for AED Use in Sports

Background Sudden cardiac arrest (SCA) is the leading cause of death in athletes during exercise. The effectiveness of school-based automated external defibrillator (AED) programmes has not been established through a prospective study. Methods A total of 2149 high schools participated in a prospective observational study beginning 1 August 2009, through 31 July 2011. Schools were contacted quarterly and reported all cases of SCA. Of these 95% of schools confirmed their participation for the entire 2-year study period. Cases of SCA were reviewed to confirm the details of the resuscitation. The primary outcome was survival to hospital discharge. Results School-based AED programmes were present in 87% of participating schools and in all but one of the schools reporting a case of SCA. Fifty nine cases of SCA were confirmed during the study period including 26 (44%) cases in students and 33 (56%) in adults; 39 (66%) cases occurred at an athletic facility during training or competition; 55 (93%) cases were witnessed and 54 (92%) received prompt cardiopulmonary resuscitation. A defibrillator was applied in 50 (85%) cases and a shock delivered onsite in 39 (66%). Overall, 42 of 59 (71%) SCA victims survived to hospital discharge, including 22 of 26 (85%) students and 20 of 33 (61%) adults. Of 18 student-athletes 16 (89%) and 8 of 9 (89%) adults who arrested during physical activity survived to hospital discharge. Conclusions High school AED programmes demonstrate a high survival rate for students and adults who suffer SCA on school campus. School-based AED programmes are strongly encouraged.

Incidence of sudden cardiac arrest in high school student athletes on school campus

BACKGROUND An accurate estimate of the incidence of sudden cardiac arrest (SCA) in high school student athletes is needed to guide prevention strategies. OBJECTIVE To prospectively investigate SCA rates in high school student athletes vs student nonathletes. METHODS A prospective observational study of 2149 US high schools participating in the National Registry for AED Use in Sports was conducted from August 2009 to July 2011. Schools were contacted quarterly to collect and review SCA cases occurring on school campus. Ninety-five percent (2045) of the schools confirmed participation for the entire 2-year period. RESULTS The average numbers of total students and student athletes per school were 963 and 367, respectively, providing more than 4.1 million total student-years and more than 1.5 million student athlete-years of surveillance. Twenty-six cases of SCA occurred in students, including 18 cases in student athletes-all during exercise. The incidence of SCA in all students was 0.63 per 100,000; in student athletes, 1.14 per 100,000; and in student nonathletes, 0.31 per 100,000. The relative risk of SCA in student athletes vs nonathletes was 3.65 (95% confidence interval 1.6-8.4; P < .01). Sixteen of 18 (89%) student athletes with SCA were boys, resulting in an incidence of 1.73 per 100,000 in boys and 0.31 per 100,000 in girls and a relative risk in male compared with female student athletes of 5.65 (95% confidence interval 1.3-24.6; P < .01). CONCLUSION The incidence of SCA in high school student athletes is higher than previous estimates and may justify more advanced cardiac screening and improved emergency planning in schools.

Cardiovascular screening in adolescents and young adults: a prospective study comparing the Pre-participation Physical Evaluation Monograph 4th Edition and ECG

Background This study compares the accuracy of cardiovascular screening in active adolescents and young adults using a standardised history, physical examination and resting 12-lead ECG. Methods Participants were prospectively screened using a standardised questionnaire based on the Pre-participation Physical Evaluation Monograph 4th Edition (PPE-4), physical examination and ECG interpreted using modern standards. Participants with abnormal findings had focused echocardiography and further evaluation. Primary outcomes included disorders associated with sudden cardiac arrest (SCA). Results From September 2010 to July 2011, 1339 participants underwent screening: age 13–24 (mean 16) years, 49% male, 68% Caucasian, 17% African-American and 1071 (80%) participating in organised sports. Abnormal history responses were reported on 916 (68%) questionnaires. After physician review, 495/916 (54%) participants with positive questionnaires were thought to have non-cardiac symptoms and/or a benign family history and did not warrant additional evaluation. Physical examination was abnormal in 124 (9.3%) participants, and 72 (5.4%) had ECG abnormalities. Echocardiograms were performed in 586 (44%) participants for abnormal history (31%), physical examination (8%) or ECG (5%). Five participants (0.4%) were identified with a disorder associated with SCA, all with ECG-detected Wolff-Parkinson-White. The false-positive rates for history, physical examination and ECG were 31.3%, 9.3% and 5%, respectively. Conclusions A standardised history and physical examination using the PPE-4 yields a high false-positive rate in a young active population with limited sensitivity to identify those at risk for SCA. ECG screening has a low false-positive rate using modern interpretation standards and improves detection of primary electrical disease at risk of SCA.

Sudden cardiac death in young athletes: what is the role of screening?

Purpose of review To review the recent literature and recommendations for cardiovascular screening in young athletes. Recent findings The primary purpose of the preparticipation examination is to detect the cardiovascular disorders known to cause sudden cardiac arrest in the athlete. Studies demonstrate that the traditional history and physical-based examination has a limited sensitivity, does not detect the majority of athletes with at-risk conditions, and may provide false reassurance for athletes with disorders that remain undetected. Electrocardiogram (ECG) screening increases the sensitivity of the examination to detect disease, and cost modeling suggests protocols inclusive of ECG are the only screening strategies to be cost-effective. Proper ECG interpretation that distinguishes physiologic cardiac adaptations in athletes from findings suggestive of underlying cardiac pathology is essential to avoid high false-positive rates. Summary The goal of cardiovascular screening is to maximize athlete safety. This includes the detection of underlying cardiac disease associated with sudden cardiac death and reduction of risk through both medical management and activity modification. Greater physician education and research are needed to improve the preparticipation examination in athletes.

The psychological impact of cardiovascular screening: the athlete's perspective

Background Published guidelines suggest that ECG screening in US athletes may cause excessive anxiety, especially in those with false-positive findings. However, this has never been formally evaluated. Methods and study design Prospective, non-randomised controlled trial. High school athletes received a standardised history and physical examination (control) or a history and physical examination with an ECG (experimental). Prescreen and postscreen assessments for health attitudes, anxiety and impact of screening on sport were conducted. Results 952 athletes (49.7% girls, mean age 15.5 years) participated (control=150; experimental=802). 4.4% worried about having an underlying cardiac condition, and 73% wanted to learn if they had a cardiac abnormality prior to competition. In the experimental group, 576 had normal screens, 220 had an abnormal screen (by history 15.8%, physical examination 6.2% or ECG 1.7%) but normal work up (false-positive) and 6 were identified with a serious cardiac condition (true-positive, 0.75%). Compared with the control group, those who received an ECG were more likely to: (1) be significantly more satisfied with their screening (p<0.001), (2) feel safer during competition (p<0.01), (3) support that all athletes should receive cardiac screening (p<0.001) and (4) state the ECG positively impacted their training (p<0.001). False-positive athletes did not report anxiety during or after screening. Distress levels did not differ based on reason for needing further evaluation (history, physical examination or ECG, p=0.311). Compared with control participants, individuals with false-positive results: (1) reported no difference in postscreen anxiety (p=0.775), (2) felt safer during competition (p<0.001), (3) would recommend ECG screening to others (p<0.001) and (4) expressed a positive impact on training (p<0.001). Conclusions Excessive anxiety should not be used as a reason to forego ECG screening in athletes.

Incidence, Etiology, and Comparative Frequency of Sudden Cardiac Death in NCAA Athletes: A Decade in Review

Background— The incidence and cause of sudden cardiac death (SCD) in athletes is debated with hypertrophic cardiomyopathy often reported as the most common cause. Methods and Results— A database of all National Collegiate Athletic Association deaths (2003–2013) was developed. Additional information and autopsy reports were obtained when possible. Cause of death was adjudicated by an expert panel. There were 4 242 519 athlete-years (AY) and 514 total student athlete deaths. Accidents were the most common cause of death (257, 50%, 1:16 508 AY) followed by medical causes (147, 29%, 1:28 861 AY). The most common medical cause of death was SCD (79, 15%, 1:53 703 AY). Males were at higher risk than females 1:37 790 AY versus 1:121 593 AY (incidence rate ratio, 3.2; 95% confidence interval, 1.9–5.5; P<0.00001), and black athletes were at higher risk than white athletes 1:21491 AY versus 1:68 354 AY (incidence rate ratio, 3.2; 95% confidence interval, 1.9–5.2; P<0.00001). The incidence of SCD in Division 1 male basketball athletes was 1:5200 AY. The most common findings at autopsy were autopsy-negative sudden unexplained death in 16 (25%), and definitive evidence for hypertrophic cardiomyopathy was seen in 5 (8%). Media reports identified more deaths in higher divisions (87%, 61%, and 44%), whereas the percentages from the internal database did not vary (87%, 83%, and 89%). Insurance claims identified only 11% of SCDs. Conclusions— The rate of SCD in National Collegiate Athletic Association athletes is high, with males, black athletes, and basketball players at substantially higher risk. The most common finding at autopsy is autopsy-negative sudden unexplained death. Media reports are more likely to capture high-profile deaths, and insurance claims are not a reliable method for case identification.Background —The incidence and etiology of sudden cardiac death (SCD) in athletes is debated with hypertrophic cardiomyopathy (HCM) often reported as the most common etiology. Methods and Results —A database of all NCAA deaths (2003 - 2013) was developed. Additional information and autopsy reports were obtained when possible. Cause of death was adjudicated by an expert panel. There were 4,242,519 athlete-years (AY) and 514 total student athlete deaths. Accidents were the most common cause of death (257, 50%, 1:16,508 AY) followed by medical causes (147, 29%, 1:28,861 AY). The most common medical cause of death was SCD (79, 15%, 1:53,703 AY). Males were at higher risk than females 1:37,790 AY vs. 1:121,593 AY (IRR 3.2, 95% CI, 1.9-5.5, p < .00001), and black athletes were at higher risk than white athletes 1:21,491 AY vs. 1:68,354 AY (IRR 3.2, 95% CI, 1.9-5.2, p < .00001). The incidence of SCD in Division 1 male basketball athletes was 1:5,200 AY. The most common findings at autopsy were autopsy negative sudden unexplained death (AN-SUD) in 16 (25%) and definitive evidence for HCM was seen in 5 (8%). Media reports identified more deaths in higher divisions (87%, 61%, and 44%) while percentages from the internal database did not vary (87%, 83%, and 89%). Insurance claims identified only 11% of SCDs. Conclusions —The rate of SCD in NCAA athletes is high, with males, black athletes and basketball players at substantially higher risk. The most common finding at autopsy is AN-SUD. Media reports are more likely to capture high profile deaths, while insurance claims are not a reliable method for case identification.

Stages of psychological impact after diagnosis with serious or potentially lethal cardiac disease in young competitive athletes: A new model☆

IMPORTANCE Sudden cardiac death (SCD) in sports is a tragic event. Pre-participation cardiovascular screening is required before participation in high school and college athletic programs and is universally endorsed by major medical societies. The medical impact of a diagnosis may be life-saving; however, the detection of disease should not be the sole endpoint of care. Physicians have an obligation to attend to both the medical and psychological well-being of their patients. OBJECTIVE To determine the psychological impact of being diagnosed with cardiac disease in young competitive athletes. DESIGN Athletes diagnosed with cardiac conditions were recruited to participate in a semi-structured interview, which was analyzed by sport psychology experts using qualitative research. Individuals shared reactions and experiences regarding diagnosis, lifestyle implications, coping strategies, major concerns, and overall impact on psychosocial functioning. SETTING Young competitive athletes from across the United States. PARTICIPANTS 25 athletes (52% male, 80% Caucasian, median age 17.7) participated. Diagnoses included: 5 hypertrophic cardiomyopathy, 8 Wolff Parkinson White, 4 long QT syndrome, 3 atrial septal defect, 2 supraventricular tachycardia, and 3 other. MAIN OUTCOME MEASURES Interviews were analyzed using consensual qualitative research (CQR) to identify domains, categories, and core ideas. RESULTS Athletes progressed through 4 stages of psychological impact including: 1) immediate reactions and challenge to athlete identity, 2) grief/coping, 3) adaptation, and 4) acceptance. Risk factors for increased psychological morbidity included: higher level of competition, permanent disqualification from sports, persistent reminders (e.g. daily medication, monitoring heart rate during activity), and unanticipated outcomes (e.g. failed procedures). Those undergoing simple corrective procedures came to terms with their diagnosis quickly with little impact on daily life. Few athletes described emotional support mechanisms provided by medical programs. Diagnosis often led to new goals such as mentoring or coaching. All athletes diagnosed through advanced cardiovascular screening stated they would repeat the process. CONCLUSIONS AND RELEVANCE Athletes diagnosed with cardiac disease represent an emotionally vulnerable population and experience 4 stages of psychological adjustment not previously described. This proposed model of psychological impact should be used to develop improved support mechanisms, awareness, and education to assist athletes diagnosed with serious or potentially lethal cardiac disease.