SUDDEN DEATH OF YOUTH ATHLETES

In spite of modern medicine and the most up-to-date Pre-Participation Sports Examination with specialists guidelines, Athlete Sudden Death occurs. However, most Sudden Death is related to trauma unrelated to sports activities.

Causes of all cases of sudden death in NCAA student-athletes from January 2004 through December 2008, 52 (72%) were due to trauma unrelated to sports activity and in football Athletes 20 (28%) were due to medical causes during participation of football. Athlete is more likely to be killed in a car wreck going to practice than the sport.

Sudden Death of Youth Athletes and persons in general happens, in spite of modern medicine. The risk of Sudden Youth Athlete Death is reduced however by competent Pre-Participation Sport Examinations.

Opinions vary on the cost effectiveness of routine ECG and other special testing in addition to the Pre-Participation Examinations.

Some doctors say, “There Is Not Enough Evidence to Support Including routine ECG in the Pre-participation Sports Evaluation.” [Should Preparticipation Cardiovascular Screening of Athletes Include ECG? No: There Is Not Enough Evidence to Support Including ECG in the Preparticipation Sports Evaluation.Wexler R1, Estes NA 3rd1. Am Fam Physician. 2015 Sep 1;92(5):343-4]

Other doctors say, “Yes: Screening ECG Is Cost-Effective in Pre-Participation Examinations.”
[Should Preparticipation Cardiovascular Screening of Athletes Include ECG? Yes: Screening ECG Is Cost-Effective by Sharma S1, Millar L1. Am Fam Physician. 2015 Sep 1;92(5):338-40]

For sure, however, if symptoms and signs are suggestive of a disease or disorder and/or there is a strong family history for a disease or disorder, further blood, urine, laboratory, scans, EKG, Echo and x-rays, as indicated by the history taken during the examination, should be recommended and performed prior to sport participations.

2 of the leading causes of Sudden Death of Youth Athletes are Sickle Cell Trait and Hypertrophic Cardiomyopathy.

Baring abnormal Coaching Behaviors during practice and play of games, most parents and Athletes are willing, for example, to risk the minuscule estimated 0.00074% chance for Sudden Athlete Death (calculated for SCT 273 deaths and a total of 1,969,663 athlete-participant-years) because of the overwhelming benefits of Sports, this reporter included. The benefits far outweigh the risks.

Sadly, an Athlete suddenly died during basketball open gym. “Paul Laurence Dunbar boys’ basketball player Star Ifeacho died Wednesday, April 27, 2017, after collapsing during open gym at the school, according to the Fayette County coroner’s office.

“The cause of death was not immediately known. An autopsy will be performed Thursday on Star, who was pronounced dead at University of Kentucky Hospital at 5:47 p.m.

“Star, 15, was a sophomore at Dunbar.

Fayette County schools spokeswoman Lisa Deffendall said some basketball players were working on drills and playing two-on-two basketball games in the presence of coaches and an athletic trainer.

“Star had stopped shooting baskets and was with the athletic trainer when he collapsed in the locker room,” Fayette schools Superintendent Manny Caulk said in a news release. “The athletic trainer immediately provided emergency care, including CPR and the use of the AED (automated external defibrillator), while 911 was called. When paramedics arrived, they took over his care and transported him to the hospital.”

“Caulk said counselors would be made available to students and staff on Dunbar’s campus Thursday.

[Dunbar basketball player collapses during open gym at school, dies BY VALARIE HONEYCUTT SPEARS APRIL 26, 2017 10:55 PM LEXINGTON HERALD LEADER vhoneycutt@herald-leader.com]
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Introduction

“The sports pre-participation physical (or pre-participation physical examination [PPE]) is a clinical examination used to evaluate athletes for injuries, illnesses, or other conditions that might increase the risk of harm to themselves or others when participating in sports. [1] [2] [3] [4] [American Medical Society for Sports Medicine: pre-participation physical evaluation history form] Although the PPE is often considered a screening tool, it can also be used to evaluate the suitability of athletes with known conditions in order for them to participate in a particular athletic endeavor.

A PPE is a legal or administrative requirement for many competitive athletes in the US. It can be an excellent vehicle for discussing health promotion and maintenance issues with young athletes. However, there is great variability in the way PPEs are performed and little objective data demonstrating that it leads to improved health outcomes. Adding a screening ECG to a history and physical increases the likelihood of detecting potentially life-threatening cardiovascular conditions, and has been associated with a decrease in the rate of sudden cardiac death in athletes in Italy. [5] [6] [7] [8] However, it is debatable whether implementing standard ECG screening in PPEs across the US would show similar benefit and the debate on augmented cardiac screening continues. [9] [10] [11][12] [13] [14] There is a growing body of evidence suggesting possible benefit from augmented screening, [15] [16] with a study demonstrating higher rates of ECG abnormalities in young males of black African descent. [17] Possibly legal and social pressures may result in a change of attitude in the US regarding this issue. However, the costs, ramifications of false positives, and lack of appropriate health system infrastructure to manage the athletes involved make it difficult to apply in the US, and these issues are likely to prevent widespread adoption of an Italian-style program in the near future. [18] The American Heart Association recommendations remain unchanged on this issue. While recognizing the limitations of the standard history and physical PPE, the AHA does not recommend routine augmented screening with ECG or other cardiovascular testing as part of the PPE at present. [19]

Despite lack of objective data, the PPE may be an excellent vehicle for screening athletes for high-risk behaviors and medical conditions that would otherwise have a profound effect on their lifelong health, if not directly on their short-term athletic performance.

Although estimates vary, most studies find only a small percentage of athletes (0.3% to 1.9%) are denied clearance to participate. [1][20]

Citations Key Articles
•Lombardo JA, Badolato SK. The preparticipation physical evaluation. Clin Cornerstone. 2001;3:10-25.
•Wingfield K, Matheson GO, Meeuwisse WH. Preparticipation evaluation: an evidence-based review. Clin J Sport Med. 2004;14;109-122.[Abstract]
•Maron BJ, Douglas PS, Graham TP, et al. Task Force 1: preparticipation screening and diagnosis of cardiovascular disease in athletes. J Am Coll Cardiol. 2005;45:1322-1326.[Abstract]
•Rice SG; American Academy of Pediatrics Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics. 2008;121:841-848.[Abstract] [Full Text]
Other Online Resources
•American Medical Society for Sports Medicine: preparticipation physical evaluation history form
•The Americans with Disabilities Act: technical assistance manual covering state and local government programs and services
•US Preventive Services Task Force: screening for testicular cancer
•National Collegiate Athletic Association: sickle cell trait

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Abstract

“Background This study examines sickle cell trait (SCT) as a cause of sudden death in National Collegiate Athletic Association (NCAA) athletes and explores the cost-effectiveness of different screening models.

Methods The authors reviewed the cause of all cases of sudden death in NCAA student-athletes from January 2004 through December 2008. The authors also explored the cost-effectiveness of screening for this condition in selected populations assuming that identifying athletes with SCT would prevent death.

Results
There were 273 deaths and a total of 1 969 663 athlete-participant-years.
Five (2%) deaths were associated with SCT. In football athletes, there were 72 (26%) deaths.
Of these, 52 (72%) were due to trauma unrelated to sports activity
and 20 (28%) were due to medical causes;
nine deaths were cardiac (45%),
five were associated with SCT (25%).
Thirteen of the 20 deaths due to medical causes occurred during exertion; cardiac (6, 46%)
SCT associated (5, 39%),
and heat stroke unrelated to SCT (2, 15%).
All deaths associated with SCT occurred in black Division I football athletes.

The risk of exertional death in Division I football players with SCT was 1:827 which was 37 times higher than in athletes without SCT.
The cost per case identified varied widely depending on the population screened and the price of the screening test.

Conclusions Exertional death in athletes with SCT occurs at a higher rate than previously appreciated. More research is needed to (1) understand the pathophysiology of death in SCT-positive athletes and (2) determine whether screening high-risk populations reduces mortality.
[Sickle cell trait associated with a RR (Rates Report) of death of 37 times in national collegiate athletic association football athletes: a database with 2 million athlete-years as the denominator by Kimberly G Harmon1, Jonathan A Drezner1, David Klossner2, Irfan M Asif3 Journal of Sports Medicine Volume 46, Issue 5 2011]
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“Cardiovascular diseases responsible for sudden unexpected death in highly conditioned athletes are largely related to the age of the patient. In most young competitive athletes (<35 years of age) sudden death is due to congenital cardiovascular disease. Hypertrophic cardiomyopathy appears to be the most common cause of such deaths, accounting for about half of the sudden deaths in young athletes. Other cardiovascular abnormalities that appear to be less frequent but important causes of sudden death in young athletes include congenital coronary artery anomalies, ruptured aorta (due to cystic medial necrosis), idiopathic left ventricular hypertrophy and coronary artery atherosclerosis. Diseases that appear to be very uncommon causes of sudden death include myocarditis, mitral valve prolapse, aortic valve stenosis and sarcoidosis. Cardiovascular disease in young athletes is usually unsuspected during life, and most athletes who die suddenly have experienced no cardiac symptoms. In only about 25% of those competitive athletes who die suddenly is underlying cardiovascular disease detected or suspected before participation and rarely is the correct clinical diagnosis made. In contrast, in older athletes (≥35 years of age) sudden death is usually due to coronary artery disease, and rarely results from congenital heart disease. [Stephen E. Epstein, Barry J. Maron Sudden death and the competitive athlete: Perspectives on preparticipation screening studies Journal of the American College of Cardiology, 1986, pp. 220-230] ___________________________________________________________________________________________________________________________ Abstract "Sudden death in young competitive athletes has become a highly visible and substantial issue within cardiovascular medicine of interest both to the general public and to the practicing community. At this time, it is instructive to revisit the evolution of this clinical problem over the past 35 years starting with introduction into the public and medical consciousness by the unexpected sudden deaths of 2 college basketball players within 8 weeks of each other in 1976, 1 with Marfan syndrome and the other with hypertrophic cardiomyopathy. Subsequently, over the next years, a number of elite athletes died suddenly, raising public visibility and awareness of these tragic events: Len Bias, "Pistol" Pete Maravich, Hank Gathers, Reggie Lewis, Kori Stringer, Jason Collier, and Thomas Herrion. Intense interest in these and many other athlete deaths has led to a considerable understanding regarding the demographics, incidence, and causes of these deaths, which include a variety of genetic and/or congenital cardiovascular diseases (most commonly hypertrophic cardiomyopathy), blunt trauma, commotio cordis, and sickle cell trait. Ultimately, initiatives emerged creating consensus guidelines for disqualification versus eligibility decisions, and pre-participation screening to detect unsuspected cardiac abnormalities. This journey of now >3 decades has generated voluminous data and even controversy, but continues to hold great interest in clinical scientists, medical practitioners, and the general public.[Historical Perspectives on Sudden Deaths in Young Athletes With Evolution over 35 Years Maron BJ1.Am J Cardiol. 2015 Nov 1;116(9):1461-8]
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PRE-PARTICIPATION EXAMINATION

Abstract

“The pre-participation physical evaluation is a commonly requested medical visit for amateur and professional athletes of all ages. The overarching goal is to maximize the health of athletes and their safe participation in sports. Although studies have not found that the pre-participation physical evaluation prevents morbidity and mortality associated with sports, it may detect conditions that predispose the athlete to injury or illness and can provide strategies to prevent injuries. Clearance depends on the outcome of the evaluation and the type of sport (and sometimes position or event) in which the athlete participates. All persons undergoing a pre-participation physical evaluation should be questioned about exertional symptoms, presence of a heart murmur, symptoms of Marfan syndrome, and family history of premature serious cardiac conditions or sudden death. The physical examination should focus on the cardiovascular and musculoskeletal systems. U.S. medical and athletic organizations discourage screening electrocardiography and blood and urine testing in asymptomatic patients. Further evaluation should be considered for persons with heart or lung disease, bleeding disorders, musculoskeletal problems, history of concussion, or other neurologic disorders.

Laboratory and Imaging Studies

“Laboratory and imaging studies should be used as an extension of the history and physical examination when additional information is needed to evaluate a concern. Screening blood and urine tests are not recommended for asymptomatic athletes.37 Athletes with previously treated or chronic conditions may require further testing.11,38”

11. Lombardo JA, Badolato SK. The preparticipation physical examination. Clin Cornerstone. 2001;3(5):10–25.
37. Clem KL, Borchers JR. HIV and the athlete. Clin Sports Med. 2007;26(3):413–424.
38. Rice SG; American Academy of Pediatrics Council on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics. 2008;121(4):841–848.
[The Preparticipation Sports Evaluation by Mirabelli MH1, Devine MJ1, Singh J2, Mendoza M1. Am Fam Physician. 2015 Sep 1;92(5):371-6]

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