Summit Conference on Sudden Death in the Athlete

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#Statement of the Summit Conference on Sudden Death in the Athlete
WRITING GROUP: Steven P. Van Camp, M.D., Chair; Eugene F. Luckstead, M.D.; Luis Palacios, M.D.; Malissa
Martin, Ed.D., A.T.C.; Herb Amato, D.A., A.T.C.

Three to four million young men and women participate annually in organized high school and
college athletics in the United States. These athletes clearly experience the benefits of
participating in athletics. Unfortunately, each year a small number of athletes suffer
significant sports-related injuries, leading to permanent disability or death (1,2). Sudden
death of athletes is often highly publicized (3,4) heightening public awareness and concern
(5). These tragic deaths have significant impact on athletes, coaches, sports
administrators, sports organizations and entire communities, in addition to the immediate
family.
In October 1996, the National Athletic Trainers' Association Research and Education
Foundation hosted a Summit titled "Sudden Death in the Athlete." Sports and medical
organizations that work with athletes were invited to participate.
The participating organizations developed a consensus on the most appropriate approach to
the problem of sudden death in athletes. While sports-related deaths may be both traumatic
and nontraumatic, it was agreed by the representatives to focus upon nontraumatic deaths
(those resulting from the physical exertion involved in sports, not as the result of direct
bodily injury). It is also recognized that traumatic sports injuries, both fatal and
non-fatal, including non-penetrating blunt chest trauma, represent a serious problem
requiring the attention of medical and sports organizations.
Nontraumatic sports deaths are primarily cardiovascular in nature, however, approximately
20 to 25 percent of these deaths are due to noncardiovascular causes, including
heat-related illness, rhabdomyolysis in individuals with sickle cell trait, and
drug-related deaths (1).
The frequency of nontraumatic sports deaths, while not known with certainty, has been
estimated in a study of high school and college athletes using data obtained through the
National Center for Catastrophic Sports Injury Research (NCCSIR) (1). These data indicate
an occurrence of approximately 16 nontraumatic sports deaths per year in organized high
school and college athletics in the U.S. The estimated annual death rates were 7.5 and 1.3
deaths per million male and female athletes, respectively; 6.6 per million male high school
and 14.5 per million male college athletes; and 1.2 per million female high school and 2.8
per million female college athletes.
With respect to specific sports, the increased frequency of athletes dying while
participating in basketball and football reflects a greater number of participants in those
sports rather than increased risk of nontraumatic deaths (1). The small numbers of deaths,
however, limit statistical comparisons.
Multiple cardiovascular disorders have been found to cause sudden death in athletes (1,2).
These disorders are primarily congenital or familial conditions and, less frequently,
acquired conditions (Table 1).
It has been suggested that one of these cardiovascular disorders (hypertrophic
cardiomyopathy) is disproportionately prevalent in African-American athletes (6). However,
available data do not support the concept that there is an increased prevalence of any of
these cardiovascular disorders within specific racial groups.
The preparticipation physical evaluation of athletes has been addressed by a task force
from multiple medical organizations (7). The specific issue of cardiovascular
preparticipation screening of competitive athletes was addressed by a panel appointed by
the American Heart Association Science Advisory and Coordinating Committee. The
medical/scientific statement from that panel was published by the American Heart
Association (8); endorsed and published by the American College of Sports Medicine (9);
endorsed by the Board of Trustees of the American College of Cardiology; and supported by
the American Academy of Pediatrics Section on Cardiology. The recommendations from the
organizations participating in the Summit on "Sudden Death in the Athlete" go beyond the
cardiovascular preparticipation screening of athletes. They include monitoring of
participating athletes, rapid response to medical emergencies, and appropriate follow-up
for athletes experiencing symptoms suggestive of cardiovascular or other disorders that may
result in a nontraumatic sports death. It is the ultimate purpose of these recommendations
to reduce the frequency of these tragedies.
RECOMMENDATIONS
Preparticipation Screening for Cardiovascular Disorders. Prior to participating in high
school and college sports, athletes should undergo a preparticipation history and physical
examination. Ideally, this examination should be performed at least six weeks prior to the
start of preseason training. With regard to the detection of cardiovascular disorders that
place athletes at risk for sudden death and ultimately the prevention of sudden death,
Summit participants support the American Heart Association (AHA) Panel recommendation (8)
that a preparticipation examination should be "performed by an appropriately trained health
care worker with the requisite training, medical skills, and background to reliably obtain
a detailed cardiovascular history, perform a physical examination and recognize heart
disease." Although there is varied consensus as to the appropriate frequency of
preparticipation examinations, they should be performed as recommended by the AHA Panel
upon entry into the sports program, and then at least every two years with an interim
history obtained annually.
The emphasis of the cardiovascular history should be on questions designed to identify
those individuals at risk for sudden death. These include questions recommended by the AHA
panel (8) regarding: "1) prior occurrences of exertional chest pain/discomfort or prior
exertional syncope/near syncope as well as excessive, unexpected, and unexplained shortness
of breath or fatigue associated with exercise; 2) past detection of a heart murmur or
increased systemic blood pressure; and 3) family history of premature death (sudden or
otherwise), or significant disability from cardiovascular disease in close relative(s)
younger than 50 years old or specific knowledge of the occurrence of certain conditions
(for example, hypertrophic cardiomyopathy, dilated cardiomyopathy, long Q-T syndrome,
Marfan syndrome and clinically important arrhythmias)." In order to obtain accurate
information, athletes and parents and/or guardians should be responsible for completing
history forms for high school athletes.
The physical examination as recommended by the AHA Panel (8) and the Pre Participation
Evaluation Task Force (7) "should be conducted in an environment conducive to optimal
cardiac auscultation... [and] ... should emphasize (but not necessarily be limited to): (1)
precordial auscultation in the supine and standing positions to identify, in particular,
heart murmurs consistent with dynamic left ventricular outflow obstruction [present in some
cases of hypertrophic cardiomyopathy]; (2) assessment of the femoral artery pulses to
exclude coarctation of the aorta; (3) recognition of the physical stigmata of Marfan
syndrome [see Table 2]; and (4) brachial artery blood pressure measurement in the sitting
position."
An athlete identified through the preparticipation history and physical examination, or the
interim history to have evidence of a cardiovascular abnormality should be referred to an
appropriate medical specialist for further evaluation. It may then be determined whether he
or she is eligible to participate in athletics. With regard to the eligibility of athletes
for competition, the 26th Bethesda Conference sponsored by the American College of
Cardiology and the American College of Sports Medicine regarding "Recommendations for
Determining Eligibility for Competition in Athletes With Cardiovascular Abnormalities" (10)
and/or the American Academy of Pediatrics "Medical Conditions Affecting Sports
Participation (11) should be utilized.

Athletic field monitoring and recognition of problems and potential problems. Qualified
personnel (coaches, athletic trainers) should have at the minimum current CPR and first aid
certification. They should be present at all practices and competitions to monitor athletic
participation, including weather conditions, recognition of injuries and other physical
conditions, for example, cardiovascular, heat illness, choking, and dehydration. Ideally, a
certified athletic trainer should be on site to supplement the capabilities of the coaches.
Emergency medical plan. A well-organized and practiced emergency medical plan should be in
place prior to any practice or competition. It should be developed by school
administrators, team physicians, school nurses, athletic trainers, coaches and appropriate
emergency medical service personnel. The emergency plan should include: 1) A written plan
of action for all sports venues (indoor and outdoor); 2) communication capabilities
(availability of telephones and emergency telephone numbers); and 3) equipment, for
example, stretchers, backboards, splints. The plan should be clearly understood by all
coaches and involved personnel, and practiced on a regular basis.
Information cards for all athletes should be kept in a confidential place by the coach or
medical staff. This information should include the athlete's name, address, telephone
number, age, date of birth, parent/guardian's name, with their address and telephone
number, insurance information, specific medical information of importance (such as
allergies, pre-existing medical conditions, eye wear, orthodontics, and prosthetics).

Medical Followup. All athletes who are injured, or who experience exercise-related
difficulties suggestive of cardiovascular or other disorders should receive appropriate
medical evaluation. This applies to orthopedic problems as well as to cardiovascular and
general medical problems, and involves both emergency and non-emergency situations. Parents
should be notified of all significant injuries and exercise-related difficulties. Return to
practice and competition decisions in cases of suspected cardiovascular disorders should be
made by appropriate medical specialists utilizing the 26th Bethesda Conference (10) and/or
American Academy of Pediatrics' Sports Medicine: Health Care for Young Athletes (12)
guidelines.
These recommendations are made in an attempt to provide a safe and healthy environment for
sports participation and to minimize the risk of sudden death in athletes. Parents,
athletes, coaches, athletic trainers, administrators, medical care providers and sports
organizations should understand the risks associated with athletic participation. In
addition to this awareness, it is also important to attempt to minimize the risk of severe
injury and athletic deaths. The benefits of physical activity and sports participation are
great. However, before a young athlete is allowed to participate, he or she should be
evaluated with preparticipation history and physical examination, and subsequently, should
participate in a program that provides on-field monitoring and recognition of problems, an
appropriate emergency medical plan, and appropriate medical follow-up for any incurred
injuries or difficulties.
Clearance for individuals to participate in sports is the responsibility of the team
physician and/or the personal physician of the individual.

PARTICIPATING ORGANIZATIONS
Representatives from the following organizations participated in the Summit on Sudden Death
in the Athlete hosted by the National Athletic Trainers' Association Research and Education
Foundation October 1996, Dallas, Texas: American Academy of Pediatrics (Eugene Luckstead,
M.D.), American College of Sports Medicine (Steven P. Van Camp, M.D.), American Medical
Society for Sports Medicine (Luis Palacios, M.D.), American Orthopaedic Society for Sports
Medicine (Irvin E. Bomberger), Institute for the Study of Youth Sports (Robert Malina,
Ph.D.), Minneapolis Heart Institute Foundation (Barry Maron, M.D.), National Association
for Intercollegiate Athletics (Pat Trainor, ATC), National Association for School Nurses
(Emita Garcia, RN), National Association for Sport and Physical Education (Judith C. Young,
Ph.D.), National Athletic Trainers' Association Clinic/Industrial/Corporate Committee
(Bruce McCrary, ATC), National Athletic Trainers' Association Research and Education
Foundation (Malissa Martin, Ed.D., ATC), National Athletic Trainers' Association Secondary
School Committee (Jon Almquist, ATC), National Collegiate Athletic Association (Bryan
Smith, M.D., Randall W. Dick), National Federation of State High School Associations (John
Heeney), and National Marfan Foundation (Cheryl Gassner, RN).
This statement is a product of the NATA Research and Education Foundation, not the National
Athletic Trainers' Association.
Table 1.
Cardiovascular Disorders Causing Sudden Death in Young Athletes
Hypertrophic cardiomyopathy
Coronary artery anomalies
Myocarditis
Aortic stenosis
Dilated cardiomyopathy
Atherosclerotic coronary artery disease
Aortic rupture
Nonspecific cardiomyopathies
Coronary artery aneurysm
Arrhythmogenic right ventricular dysplasia
Wolff-Parkinson-White syndrome
Long Q-T syndrome
Table 2.
Physical stigmata of Marfan's syndrome
Skeletal abnormalities
Arm span greater than height
Chest wall deformities
Kyphoscoliosis
High-arched palate
Hyperextensible joints
Cardiovascular abnormalities
Murmur of aortic regurgitation
Murmur of mitral regurgitation
Ocular abnormalities
Myopia (nearsightedness)
Ectopia lentis (upward displacement of lens of the eye)

REFERENCES
Van Camp SP, Bloor CM, Mueller FO, Cantu RC and Olson HG. Nontraumatic sports death in high school and
college athletes. Med. Sci. Sports Exerc. 27:641-647, 1995.
Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive
athlete: clinical, demographic and pathological profiles. JAMA 276:199-204, 1996.
Maron BJ. Sudden death in young athletes: lesions from the Hank Gathers affair. N. Engl. J. Med.
329:55-57, 1993.
Van Camp SP. What can we learn from Reggie Lewis' death? Physician Sportsmed. 21:73-97, 1993.
Rhoden WC. Deaths of teen-age athletes raise questions over testing. The New York Times, March 14, 1994;
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death on the athletic field in African-American athletes. J. Am. Coll. Cardiol. 29:462A, 1997.
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American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for
Sports Medicine, American Orthopedic Society for Sports Medicine, American Osteopathic Academy of Sports
Medicine.
American Heart Association Scientific Statement: Cardiovascular preparticipation screening of
competitive athletes. Circulation 94:850-856, 1996.
American Heart Association Scientific Statement: Cardiovascular preparticipation screening of
competitive athletes. Med. Sci. Sports Exerc. 28:1445-1452, 1996.
Maron BJ, Mitchell JH. 26th Bethesda Conference: Recommendations for determining eligibility for
competition in athletes with cardiovascular abnormalities. J. Am. Coll. Cardiol. 24:845-899, 1994.
American Academy of Pediatrics, Committee on Sports Medicine and Fitness. Medical conditions affecting
sports participation. Pediatrics 94:757-760, 1994.
American Academy of Pediatrics. Sports Medicine: Health Care for Young Athletes, 2nd ed. Elk Grove:
American Academy of Pediatrics, 1991.
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