Monica Zigman

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.

The effectiveness of screening history, physical exam, and ECG to detect potentially lethal cardiac disorders in athletes: A systematic review/meta-analysis

BACKGROUND The optimal cardiovascular preparticipation screen is debated. The purpose of this study was to perform a systematic review/meta-analysis of evidence comparing screening strategies. METHODS PRIMSA guidelines were followed. Electronic databases were searched from January 1996 to November 2014 for articles examining the efficacy of screening with history and physical exam (PE) based on the American Heart Association (AHA) or similar recommendations and electrocardiogram (ECG). Pooled data was analyzed for sensitivity, specificity, false positive rates and positive and negative likelihood ratios. Secondary outcomes included rate of potentially lethal cardiovascular conditions detected with screening and the etiology of pathology discovered. RESULTS Fifteen articles reporting on 47,137 athletes were reviewed. After meta-analysis the sensitivity and specificity of ECG was 94%/93%, history 20%/94%, and PE 9%/97%. The overall false positive rate of ECG (6%) was less than that of history (8%), or physical exam (10%). Positive likelihood ratios were ECG 14.8, history 3.22 and PE 2.93 and negative likelihood ratios were ECG 0.055, history 0.85, and PE 0.93. There were a total of 160 potentially lethal cardiovascular conditions detected for a rate of 0.3% or 1 in 294. The most common pathology was Wolff-Parkinson-White (67, 42%), Long QT Syndrome (18, 11%), hypertrophic cardiomyopathy (18, 11%), dilated cardiomyopathy (11, 7%), coronary artery disease or myocardial ischemia (9, 6%) and arrhythmogenic right ventricular cardiomyopathy (4, 3%). CONCLUSIONS The most effective strategy for screening for cardiovascular disease in athletes is ECG. It is 5 times more sensitive than history, 10 times more sensitive than physical exam, has higher positive likelihood ratio, lower negative likelihood ratio and a lower false positive rate. 12-lead ECG interpreted using modern criteria should be considered best practice in screening for cardiovascular disease in athletes while the use of history and physical alone as a screening tool should be reevaluated.

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.

Incidence and Etiology of Sudden Cardiac Arrest and Death in High School Athletes in the United States

OBJECTIVE To determine the incidence and etiology of sudden cardiac arrest and death (SCA/D) in US high school athletes. PATIENTS AND METHODS A prospective media database of SCA/D was queried for cases aged 14 to 18 years from 7 states over 6 school years (September 1, 2007, to August 30, 2013). Event details were investigated to determine participation on a high school athletic team, sex, sport, and occurrence during school-sponsored activity or exertion. National sports participation numbers were used and a conversion factor was applied to account for multisport athletes. Autopsy reports were reviewed and cause of death was adjudicated by an expert panel. RESULTS A total of 16,390,409 million athlete-seasons representing 6,974,640 athlete-years (AY) were examined, encompassing 36% of the total US high school athlete population. A total of 104 cases of SCA/D were identified (35 SCA with survival and 69 sudden cardiac deaths [SCDs]). The rate of SCD was 1:101,082 AY and of SCA/D 1:67,064 AY. Eighty-eight percent (92) of events occurred in male athletes. The rate of SCA/D in male athletes was 1:44,832 AY and in female athletes 1:237,510 AY (incidence rate ratio, 5.3; 95% CI, 2.9-10.6; P<.001). Mens basketball was the highest risk sport with an SCA/D incidence of 1:37,087 AY followed by mens football at 1:86,494 AY. Mens basketball and football athletes accounted for 57% (39) of deaths. Eighty percent of SCDs (55 of 69) were exertional and 55% (38 of 69) occurred while playing for a school-sponsored team. Autopsy reports were obtained in 73% (50) of cases. The most common findings of autopsy were idiopathic left ventricular hypertrophy or possible cardiomyopathy (13 of 50 [26%]), autopsy-negative sudden unexplained death (9 of 50 [18%]), hypertrophic cardiomyopathy (7 of 50 [14%]), and myocarditis (7 of 50 [14%]). CONCLUSION The rate of SCA/D in male high school athletes was 1:44,832 AY, with almost half due to possible or confirmed cardiomyopathy disease. It is likely that many cases were not identified because of reliance on media reports, and these numbers represent a minimum estimate.

Whole Body Vibration Exposures and Health Status among Professional Truck Drivers: A Cross-sectional Analysis

Many professional truck drivers suffer from low back pain (LBP) which is thought to be associated with exposure to whole-body vibration (WBV). The objectives of this study were to: (i) characterize general health, regional body pain and WBV exposures, (ii) evaluate the associations between different WBV parameters and health outcomes, and (iii) determine whether there were factors which affect a truck drivers WBV exposures. This study analyzed WBV exposures from 96 long-haul truck drivers over their regular work shift (6-15h) per International Standards Organization (ISO) 2631-1 and 2631-5 WBV standards. This study also evaluated regional body pain (10-point scale), low back disability (the Oswestry Disability Index), and physical and mental health (the Short Form 12-item Health Survey). The results demonstrated that the daily vector sum WBV exposures [A(8), VDV(8) and Sed(8)] were above action limits while the predominant z-axis exposures were below action limits. Among all the musculoskeletal outcomes, LBP was the most prevalent (72.5%) with average LBP score of 2.9 (SD: 2.0). The SF-12 health scores demonstrated that truck drivers in general had lower physical health status than the general US population (Ps < 0.04) and that physical health status decreased as WBV exposures increased (P = 0.03). In addition, the correlations between the WBV measures and health outcomes indicated that A(8) exposure measures had a stronger link to musculoskeletal (LBP) and other health outcomes than the VDV(8) and Sed(8) measures. Finally, seat manufacturer and seat age were two factors which had a strong influence on WBV exposures.

Whole Body Vibration Exposures in Long-haul Truck Drivers:

Many professional truck drivers experience low back pain (LBP) which is believed to be associated with exposure to whole body vibration (WBV). As a part of a randomized controlled trial, this study measured WBV exposures from 98 professional truck drivers continuously during their regular work shift (8-12 hours). The daily weighted average A(8), vibration dose value VDV(8), and vector sum A(8) and VDV(8) exposures were evaluated for important determinants of WBV exposures including the roads travelled on, year of truck manufacture, truck manufacturer, and seat manufacturer. LBP was also measured using a standardized visual analog scale. The results demonstrated that there were substantial differences in health risk prediction between the predominant axis exposure (advocated by the European Union Vibration Directives) and vector sum exposures. Moreover, VDV(8) measures were above the International Organization for Standardization and European Union daily exposure action limit (9.1 m/s2). The average LBP score on a 0 to 10 point scale was 2.7 (SD: 2.0) ranging from 0 to 8. When comparing the two major manufacturers of truck seats, one truck seat had higher vertical, z-axis A(8) exposures than the other (24%, p =0.01); and this WBV exposure difference appeared to be reflected by the LBP outcomes. These results indicate that there are performance differences between seats in the attenuation of WBV exposures and truck drivers’ impulsive WBV exposure can exceed recommended daily action limits.

Cross-sectional Analysis of Whole Body Vibration Exposures and Health Status among Long-haul Truck Drivers

Exposure to whole body vibration (WBV) is known to be associated with various adverse health outcomes among professional truck drivers. As a part of a randomized controlled trial, this study evaluated WBV exposures and various health outcomes from 96 professional truck drivers. The WBV was measured and analyzed per International Standards Organization (ISO) 2631-1 and 2631-5 WBV standards. This study also measured self-reported regional body pain (10-point scale), low back disability (the Oswestry Disability Index), and physical/mental health (the Short Form 12-item Health Survey). Lastly, this study evaluated associations between the WBV exposure and various health outcomes. The results showed that the predominant z-axis weighted average vibration [A(8)] measure (Mean ± SE: 0.35 ± 0.01 m/s2) was below the ISO and European Union (EU) daily exposure action limits (0.5 m/s2) whereas the vibration dose value [VDV(8)] measure (12.2 ± 0.3 m/s1.75) was above the ISO and EU daily exposure action limit (9.1 m/s1.75). Self-reported low back pain (LBP) was the most prevalent adverse musculoskeletal outcome reported (72.5%) with average LBP score of 2.9 (SD: 2.0). The SF-12 health scores showed that truck drivers’ physical health status was lower than the average US population (p’s < 0.04). Moreover, the Spearman’s correlations (rs ) between the WBV parameters and health outcomes indicated that A(8) measures were associated with LBP (rs = 0.31; r = 0.05) and SF-12 physical composite score (rs = −0.39; r = 0.02); however VDV(8) was not associated with any of the health outcomes. The study findings indicates that although the impulsive exposures [VDV(8)] were more prominent, the continuous, average vibration [A(8)] appears to be more strongly associated with injury risks. This finding supports the practice of EU countries using A(8) as one of the primary measures for characterizing daily WBV exposures but also complements many other studies indicating that the current EU daily action limit value of 0.50 m/s2 for WBV may be too high.

Death by homicide in National Collegiate Athletic Association athletes between 2003 and 2013

Background The incidence of homicide-related death among individuals of college age in the United States population is estimated at 15.5/100 000. The incidence of homicide among National Collegiate Athletic Association (NCAA) athletes is unknown. Aim To investigate the rate of homicide-related death in NCAA athletes and to identify associated risk factors. Methods The NCAA Resolutions list, NCAA catastrophic insurance claims, media reports, and published NCAA demographic data were used to identify student athlete deaths and total participant seasons from 2003–04 through 2012–13. Homicide-related deaths were analysed by sex, race, division, sport, method, location, and circumstance. Internet searches were used to gather case details. Results Forty-two cases of homicide-related death were identified from 4 242 519 individual participant seasons during the ten-year study period. The incidence of homicide-related death in NCAA athletes was 1.0/100 000. The incidence in males was 1.45/100 000 and in females was 0.4/100 000 (relative risk (RR) 2.9, p=0.01). The incidence in black athletes was 4.2/100 000 and in white athletes was 0.4/100 000 (RR 7.0, p<0.001). The highest sport-specific homicide-related death rate was in American football (3.7/100 000), with a RR of 4.4 (p=0.002) compared to all other sports. 88% of cases occurred off-campus. 38% of cases occurred at a social gathering, and 38% of cases occurred in a place of residence. 74% involved a fatal shooting. Conclusions Homicide-related deaths in NCAA athletes occur most commonly in males, black athletes, and American football players. Understanding the incidence, risk factors, and circumstances of homicide-related deaths in college athletes may assist NCAA institutions in developing preventative measures. Trial registration number University of Washington Human Subjects Application, HSD No. 42077.

Incidence, Cause, and Comparative Frequency of Sudden Cardiac Death in National Collegiate Athletic Association Athletes

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.

A Randomized Controlled Trial of a Truck Seat Intervention: Part 1—Assessment of Whole Body Vibration Exposures

Full-time vehicle and heavy equipment operators often have a high prevalence of musculoskeletal disorders, especially low back pain (LBP). In occupations requiring vehicles or heavy equipment operation, exposure to whole body vibration (WBV) has been consistently associated with LBP. LBP is the most common cause of work-related disability and continues to be the leading cause of morbidity and lost productivity in the US workforce. Using a parallel randomized controlled trial design, over a 12-month period, this study evaluated two different seating interventions designed to reduce WBV exposures. Forty professional truck drivers were initially recruited and randomly assigned to one of two groups: (i) a passive suspension/control group-20 drivers who received a new, industry-standard air-suspension seat, and (ii) an intervention group-20 drivers who received an active-suspension seat, which has been shown to reduce vertical WBV exposures by up to 50% compared to passive seats. WBV exposures from the truck seat and floor were collected during drivers full shifts (6-18 h) before (pre-intervention) and after the intervention (0, 3, 6, and 12 months post-intervention) per International Standards Organization (ISO) 2631-1 and 2631-5 WBV standards. After subject dropout and turnover, 16 truck drivers remained in each group. The pre-intervention WBV data showed that there were no differences in the daily equivalent time-weighted average WBV exposures [A(8)], vibration dose values [VDV(8)], and static spinal compression doses [Sed(8)] between the two groups (Ps > 0.36). After the new seats were installed, the A(8) values showed that the active suspension/intervention group experienced much greater reduction in the vertical (z) axis [~50%; P = <0.0001; Cohens d effect size (95% CI) = 1.80 (1.12, 2.48)] exposures when compared to in the passive suspension/control group [~20%; P = 0.23; 0.33 (-0.36, 1.02)]. The post-intervention z-axis VDV(8) and Sed(8) WBV exposure measures were not different between the two seat groups [VDV(8), P = 0.33; 0.35 (-0.32, 1.03); Sed(8), P = 0.61; 0.08 (-0.59, 0.76)]. These study findings indicate that, relative to the current industry-standard, passive air-suspension seats which are ubiquitous in all semi-trucks today, the active suspension seat dramatically reduced average continuous [A(8)] WBV exposures but not periodic, cumulative impulsive exposures [VDV(8) and Sed(8)].