Executive summary: interassociation consensus statement on cardiovascular care of college student-athletes

Introduction

The National Collegiate Athletic Association (NCAA) convened a multidisciplinary task force at its headquarters in Indianapolis, Indiana, from 23 to 24 September 2014, to address cardiovascular care in the collegiate student-athlete (see online supplementary appendix for a list of participants). The purpose of the task force was to discuss and evaluate cardiovascular concerns in collegiate student-athletes, and to develop an interassociation consensus statement and recommendations for the future. The primary focus was sudden cardiac death (SCD), and the usefulness of screening with or without ECG (not including echocardiogram). Other more general cardiovascular issues were discussed in breakout groups. This document summarises the task force and follow-up discussions with task force members during the review process. The document addresses:

1. Cardiovascular risk in collegiate student-athletes

2. The preparticipation evaluation

3. Evidence evaluating the efficacy of preparticipation screening for detection of cardiovascular risk

4. ECG as a screening tool for SCD risk prediction

5. Regional referral centres for evaluation of athletes suspected or known to have a cardiovascular condition

6. Recognition and response to cardiac arrest

7. Cardiac research initiatives.

This document also includes an Executive Summary of recommendations and a checklist of best practices for NCAA member institutions (box 1).

Cardiovascular risk in collegiate student-athletes

Whereas there is a general health benefit from regular exercise,5 sports participation presents additional risk for injuries.6 ,7 Although sports activity during exertion, including both training and competition, has been reportedly associated with an increased risk for SCD,8 ,9 the issue remains incompletely resolved.10

For the purposes of this document, SCD is defined as an unexpected death due to cardiac causes that occurs in a short time period in a person with or without previously known cardiovascular disease. SCD should be differentiated from exertion-related death in athletes that is not from a primary cardiac cause, for example, heat stroke and rhabdomyolysis.11 SCD in NCAA student-athletes is variously cited as either an uncommon event12–14 or as an event that occurs with such regularity that it demands further scrutiny.15–17 As with many epidemiological debates, the truth depends on how the question is framed, the methodological approach used, and the determination of whether SCD occurred during or soon after sport participation, or occurred as part of the larger population-risk of SCD. Estimates of SCD for US college athletes range from 1 in 43 000 (0.0023%) to 1 in 83 000 (0.0012%), and some athlete groups appear to be at a higher risk;12 ,15 ,17 the SCD mortality rate is lower when postmortem data is used to establish cardiovascular diagnosis.10 The most common non-traumatic cause of death among college athletes is SCD,17 and SCD represents ∼75% of fatalities in college student-athletes during sport and exercise.15 For over 30 years, 5–10 NCAA student-athletes have died per year of SCD; however, the number of athletes with cardiac arrest who survived is unknown.18

NCAA-focused research led to an analysis of SCD in NCAA athletes over a 10-year period (2003–2013).15 ,17 The analysis was conducted using cases identified in the NCAA Memorial Resolutions list, media reports and NCAA catastrophic insurance data. Autopsy reports were reviewed when possible, and only cases with confirmed cardiac aetiologies or circumstances consistent with SCD were included. The overall risk of SCD in an NCAA student-athlete during or soon after exertion is estimated at 1 in 54 000 athletes/year (0.0019%). The exertion-related risk of SCD in a male athlete is 1 in 38 000 (0.0026%), which is higher than the 1 in 122 000 (0.00082%) risk for a female athlete, although SCD in female athletes still accounts for 20% of all cases. African-American athlete SCD risk is 1 in 22 000 (0.0045%), which is three times higher than the 1 in 68 000 (0.0015%) risk in a Caucasian athlete.17

Some athlete groups are at higher risk than others. A male basketball student-athlete has an exertion-related SCD risk of 1 in 9000 (0.011%), which is higher than any other athlete group.17 The risk of SCD in Division I men’s basketball, or in an African-American male basketball player from any division is as high as 1 in 5200 (0.019%). Other athlete groups with higher than average risk include men‘s soccer (1 in 24 000 or 0.0042%), football (1 in 36 000 or 0.0028%), and women‘s cross-country (1 in 47 000 or 0.0021%).17 Men’s basketball accounts for only 4% of male NCAA athletes, but nearly 20% of all SCD cases. Men’s basketball and football together represent 23% of all male NCAA athletes, but these two sports alone account for 50% of all SCD cases. These values should be interpreted with some caution, given the low absolute number of annual SCD occurrences, which makes accurate assessment of the rate of SCD in subgroups subject to large yearly variations.

The preparticipation evaluation

The NCAA currently requires every student-athlete to undergo a preparticipation evaluation conducted by a licensed medical doctor, or doctor of osteopathic medicine prior to participation in an NCAA sport. The preparticipation evaluation is required on matriculation to an institution (administered within 6 months prior to the student-athlete’s participation in any practice, competition or out-of-season conditioning activities for the applicable academic year) with an annually updated health history questionnaire and blood pressure measurement. The 2014–2015 NCAA Sports Medicine Handbook19 stipulates that the medical evaluation should include a comprehensive health history, an immunisation history, and a relevant physical examination, concentrating on the cardiac, neurological and musculoskeletal systems. The medical evaluation must also include confirmation of sickle cell trait status, a solubility test for sickle cell trait, or a release declining the test. In addition, the Inter Association Consensus: Diagnosis and Management of Sport-Related Concussion Guidelines,20 which was released in July 2014, recommends that all student-athletes undergo a one-time baseline concussion assessment inclusive of concussion history, symptom evaluation and cognitive and balance assessment. With regard to the preparticipation cardiac evaluation, the 2014–2015 NCAA Sports Medicine Handbook19 states that consideration should be given to implementing the recommendations from the AHA or the PPE-4.21 ,22

The NCAA currently does not define the purpose of the preparticipation evaluation. Furthermore, the NCAA does not currently require: (1) that the institution’s team physician conduct the medical evaluation; (2) that the institution’s team physician and/or director of medical services review preparticipation evaluations performed by outside physicians; or (3) that preparticipation evaluations fulfil established criteria.

Various medical societies and authorities have characterised the screening objective of the preparticipation evaluation as a means to identify or raise suspicion of cardiovascular abnormalities and diseases that are associated with unsafe sport participation in general or SCD in particular,10 ,21–25 and as a way to enhance the safety of athletic participation.26 ,27 These screening objectives differ from general education and wellness goals. Specifically, all these screening objectives share a common element: the identification of potentially life-threatening conditions for which participation in competitive sports would place the athlete at a level of increased risk that some might find unacceptable, given the potential consequences.

The AHA issued recommendations for the preparticipation screening of competitive athletes in 199626 and in 2007.28 These recommendations included a 12-point personal and family history and physical examination, and were promoted as a potentially effective strategy to raise the suspicion of cardiovascular disease in athletes.28 In 2014, the AHA published updated preparticipation recommendations regarding cardiovascular screening and extended the scope to include all generally healthy young people between the ages of 12 and 25 years.10 The 2014 recommendations did not recommend large-scale, general population and universal cardiovascular screening with history and physical examination, citing no evidence of benefit. However, if done in athletes or other relatively small cohorts of young healthy people 12–25 years of age, the AHA recommendations affirmed the use of the previous screening guidelines and added two more questions that led to a 14-point history and physical evaluation to raise the suspicion of cardiovascular disease (table 1). Additionally, the AHA recommended standardisation of forms used to guide the examination for high school and college athletes.

The Pre-Participation Physical Evaluation Monograph was first published in 1992, and has undergone periodic revisions, with the latest (fourth) edition published in 2010.21 The Monograph is a joint project of six medical organisations representing a wide range of physicians who perform preparticipation evaluations, with the latest edition endorsed by the AHA. The monograph includes a recommended standardised history questionnaire; there are 12 personal and family history questions related to cardiovascular screening on the basis of the AHA guidelines. The history questions from the PPE-4 and the AHA 14-point recommendations use slightly different wording and syntax, and are compared in table 1.

Importantly, the preparticipation evaluation offers many opportunities beyond screening for the identification of serious cardiovascular conditions. As noted in the IOC Consensus Statement on Periodic Health Evaluation of Elite Athletes,24 the preparticipation/periodic health evaluation can also serve the following functions:

1. To ensure that current health problems are managed appropriately.

2. To identify conditions that are barriers to performance.

3. To allow the athlete an opportunity to establish a relationship with the health personnel who will be involved in providing continuing care.

4. To look for characteristics that may put the elite athlete at risk for future injury or disease.

5. To review medications and/or supplements, including addressing possible therapeutic use exemption requests.

6. To educate athletes regarding health risks and health-related behaviour.

The preparticipation evaluation does not need to focus exclusively on current health and performance issues, but can also provide an opportunity to assess the risk for future health and quality-of-life matters.24 For example, hypertension stage 1, or early metabolic syndrome, conditions that predispose to subsequent cardiovascular disease,29 ,30 may be noted and addressed. Such anticipatory care can prevent future medical problems.

With regard to education, platforms can be developed that allow dissemination of information about key areas of student-athlete health, such as tobacco and recreational drug use, dietary patterns, performance-enhancing supplement use, concussion, weight management and mental health.31 Finally, the preparticipation evaluation offers an opportunity to encourage compliance among team physicians with consensus recommendations and legislation (eg, sickle cell trait).1 ,32 To ensure that team physicians are chosen and retained on the basis of broadly accepted criteria, member institutions that choose, appoint and oversee team physicians should be familiar with the Team Physician Consensus Statement: 2013 Update.1

Evidence evaluating the efficacy of preparticipation screening for detection of cardiovascular risk

Preparticipation screening has been conducted in the USA for more than 50 years. However, there is limited evidence supporting the effectiveness of preparticipation screening to achieve the generally agreed-on primary objective: the prevention of sports-related death in athletes. The history questions designed to detect previously undiagnosed cardiovascular conditions were developed through expert consensus and have never been validated scientifically. The generally broad and non-specific questions also elicit a high number of positive responses in athletes. In college athletes, at least one positive cardiovascular symptom, or family history response, was reported by 24–43% of athletes during preparticipation evaluations using either the AHA 12-point or PPE-4 questionnaires.33 ,34 In high school athletes, initial positive history responses were reported by 68% of athletes undergoing a heart screen using the PPE-4 history questions.35 These responses have been considered ‘false positive’ responses by some investigators,34 but a positive response on a screening questionnaire must be differentiated from a true positive response on the basis of careful follow-up questions by the clinician. The AHA recommends review of positive questionnaire responses by physicians to determine if further evaluation is warranted; however, the ability of practitioners to discern true positive from false positive responses has also never been studied prospectively in a large-scale clinical trial.

Similarly, the addition of a resting 12-lead ECG to screening protocols has also never been shown, in an adequately designed study, to prevent SCD in athletes. Nevertheless, some authorities do recommend the use of a resting 12-lead ECG during the preparticipation cardiovascular screening of athletes.33 ,34 ,36 Several studies have examined the ability of history, physical examination, and ECG to detect potentially life-threatening cardiovascular disease (which does not necessarily equate with identifying individuals who will actually experience a cardiac event). In general, the preparticipation history and physical examination have shown low sensitivity, high specificity, and a very low positive predictive value for identifying potentially lethal cardiac disorders (table 2).37 The majority of athletes (60–80%) who experience SCD do not have recognised warning signs or symptoms prior to their event; therefore, this group will go undetected when screened by a protocol primarily reliant on questioning about prior symptoms.38 ,39 Since there is a high initial positive response rate to the recommended screening questions, and because symptoms leading up to SCD may be subtle or absent, it is critical that physicians conducting preparticipation examinations be well trained. Some data suggests that symptoms in patients with primary structural, functional or electrical cardiac abnormalities may, in fact, be misinterpreted or disregarded by medical staff.40

ECG as a screening tool for SCD risk prediction

The addition of a resting 12-lead ECG to a screening history and physical examination increases the sensitivity to identify many of the cardiac conditions associated with SCD, specifically cardiomyopathies, myocarditis, ion-channel disorders and ventricular pre-excitation.41 Nonetheless, two important causes of SCD in young athletes, anomalous aortic origin of a coronary artery and aortic root dilation, are not detected by ECG.26 ,42 Just as importantly, physician-to-physician variability in interpreting the ECG in elite athletes can be considerable.43 ,44 Although there is increasing momentum to standardise ECG interpretation in elite athletes,45 ,46 the acceptance of such standardisation, the dissemination of an agreed-on knowledge base for such standardisation, and the infrastructure to support such an approach are widely variable across the USA in general, and across NCAA member institutions in particular. This alone may have an effect on both the capacity and ability to implement any type of effective screening for SCD. Therefore, if ECG is included in the cardiovascular screening of athletes, it should be:

1. Disclosed that the ECG has limits for positive and negative predictive accuracy for SCD risk.

2. Interpreted with the current (and future evolving) state of knowledge that distinguishes physiological cardiac remodelling from findings suggestive of underlying cardiac pathology.

3. Conducted with adequate cardiology oversight and resources to assist with the secondary investigation of ECG abnormalities. The ECG should be obtained with equipment and by persons trained according to ACC/AHA/Heart Rhythm Society recommendations.2

4. Paralleled by the development of a registry for research into new knowledge regarding sensitivity and specificity of history, physical examination and ECG findings to the screening process.

Data suggests that screening by history and physical examination alone has a low sensitivity to detect conditions associated with SCD,33 and that the addition of ECG, when properly interpreted and with skilled cardiology resources available, improves cardiovascular screening if the measurable endpoint is considered the detection of silent or congenital cardiac conditions associated with SCD46 (see box 2 for preliminary findings from an NCAA-funded research study addressing the feasibility of ECG screening). Although the AHA does not support a mandatory, nationalised ECG screening programme for athletes, it has long supported, in principle, ECG screening programmes that are well designed, prudently implemented and include adequate cardiology resources and expertise.10 ,26 ,28 Even though the addition of an ECG may improve the sensitivity of detecting potentially fatal cardiovascular abnormalities, it may increase false-positive results, particularly if updated ECG screening criteria are not used.47 ,48 The false-positive rate can be reduced from 17% to 4.2% without affecting sensitivity when updated ECG screening criteria are used.47 Nevertheless, the observation that 0.25% of screened athletes have potentially dangerous cardiac conditions,49 and yet the number of deaths among NCAA athletes both in and out of competition has averaged 7.9 deaths/year over the past decade,17 suggests that ECG screening may detect cardiac conditions that would not lead to adverse events. The possibility that these individuals could receive apparently appropriate, but ultimately unnecessary interventions concerns some experts. There is an additional concern that ECGs routinely read in clinical practice, not by trained clinicians, are interpreted by ECG machine computer algorithms, which may increase the false positive rate. However, the long-term implications of whether early detection truly saves lives or, perhaps, causes harm through adverse medical events from secondary cardiac testing or procedures require additional study.

Furthermore, the potential gap between those member schools that offer ECG and/or echocardiogram screening and those that do not, represents not only a philosophical/medical variation, but also a potential difference in infrastructure support and available expertise. This presents a further limitation to understanding if broader ECG screening across NCAA member institutions will achieve the desired goal of preventing SCD in student-athletes. Clarification of these uncertainties, in light of the current data cited previously, would come from a ‘big data’ initiative that includes a large registry of ECG data and outcomes, such as recommended by the Institute of Medicine (IOM) for cardiac arrest generally,50 and new research funding strategies focused on such issues.51

Regional referral centres for evaluation of athletes suspected or known to have a cardiovascular problem

Cardiovascular issues associated with SCD can be addressed in a cardiovascular centre with or without a formal sports cardiology programme. Sports cardiology is a highly specialised segment of cardiovascular medicine that has achieved recognition by major cardiovascular organisations, such as the ACC. However, relatively few individual practitioners or institutions have embraced the knowledge base, practice skills and experience applicable to this discipline. This limitation is magnified for the circumstances of college athletics by the geographic and population dispersion of colleges and universities with athletic programmes. Certainly, most colleges and universities in major metropolitan areas, university-based medical centres, and many major community medical centres have access to the expertise needed to evaluate athletes who are determined by screening programmes to require further evaluation, or who develop symptoms potentially due to cardiovascular problems during training or competition. Many of the smaller colleges and universities in low-density population areas do not have local access to such expertise. Accordingly, it is rational to consider developing regional referral centres to serve these functions. Their functions should include, but not be limited to:

1. Providing electronically accessible consultative resources for preparticipation ECG interpretation when local expertise for this specialised skill is not available.

2. Clarifying the cardiovascular status of athletes found to have a suspicious personal history, family history, physical examination, or ECG during routine preparticipation screening.

3. Evaluating new symptoms developing during training or competition, or in association with intercurrent illness, at any time.

4. Consulting regarding clearance to participate, or limitations on levels of intensity, for training and competition by athletes with identified inherited, developmental or acquired disorders, or to return to training or competition after resolution of an acquired cardiovascular problem, such as myocarditis.

Cardiovascular centres, as described, should be guided by specific standards for personnel, accessibility and resources. In addition, both cardiology centres and institutions/individuals with the knowledge base, practice skills and experience to evaluate and make recommendations for athletes with cardiac conditions should strive to follow consensus recommendations and guidelines principally addressing criteria for eligibility and disqualification from organised competitive sports for the purpose of ensuring the health and safety of athletes.23 ,52–60

Recognition of, and response to, cardiac arrest

Cardiac arrest is defined as a severe malfunction or cessation of the electrical and mechanical activity of the heart, and results in almost instantaneous loss of consciousness and collapse.50 Cardiac arrest in athletes can be effectively treated through prompt recognition, early cardiopulmonary resuscitation (CPR), and early use of an automated external defibrillator (AED). A written emergency action plan (EAP) for treatment of cardiac arrest that is well rehearsed will help to ensure an efficient and structured response to an athlete with a cardiac emergency who has collapsed, is not breathing normally or is only gasping (ie, agonal respirations), and who is unresponsive. Essential elements of such an EAP include:61 ,62

1. Training of anticipated responders in CPR and AED use (eg, other athletes, coaching staff, referees and so forth).

2. Establishing an effective emergency communication system.

3. Ensuring quick access to early defibrillation from collapse to first shock.

4. Ensuring that on-site AEDs are properly charged and functioning.

5. Integrating on-site responder and AED programmes with the local EMS system.

6. Practicing and reviewing the emergency response plan at least annually.

Prompt recognition of cardiac arrest is the first step to an efficient emergency response.50 ,62 Although many cases of athlete collapse are transient and are from benign causes, cardiac arrest should be assumed in any student-athlete who has collapsed, is not breathing normally or only gasping and is unresponsive, and the EAP for cardiac arrest should be activated. Gasping and agonal respirations can occur in the first minutes after cardiac arrest and should not be interpreted as normal breathing. Brief seizure-like activity or involuntary arm and leg movements occur in ∼50% of individuals with cardiac arrest.63 ,64 Therefore, cardiac arrest should not be mistaken for a seizure or syncope. In young athletes (<35 years of age), the most common causes of SCD are related to the following cardiovascular conditions: hypertrophic cardiomyopathy, congenital coronary anomalies, arrhythmogenic right ventricular cardiomyopathy, commotio cordis and ion channelopathies.65 Survival from cardiac arrest declines from 7% to 10% for every minute that defibrillation is delayed.66 Cardiac arrest in student-athletes is a more survivable event through prompt recognition and treatment with CPR and an AED, with survival rates as high as 89%.63 ,67

It is not sufficient to have in place a general protocol for treatment of cardiac arrest. Protocols must be situation-specific.61 For example, treatment of cardiac arrest in the basketball gymnasium during a routine practice will differ from treatment in the same gymnasium during a sold-out basketball game that results in traffic delays and access problems. Thus, coordination with emergency medical services (EMS) must be done beforehand, both to cover practice-related and game/championship events. Planning for emergency access by EMS must be an essential element of planning for all competition/championship events.

Whenever an athlete collapses and appears unresponsive, first responders should:68

1. Make sure the scene is safe.

2. Tap and shout at the unresponsive individual. If there is no breathing or only gasping, and if there is no definite pulse felt within 10 s, then:

3. Call for help and activate the local EMS system (ie, call 911 or the local emergency services number). Access points for EMS to enter and exit the stadium, facility or other venue should be made clear to EMS and the facilities manager, and should be easily accessible for unimpeded entry and exit.

4. If an AED is known to be in the immediate vicinity, retrieve and apply the AED as soon as possible, and apply shock if there is a shockable rhythm. Then, follow the AED prompts regarding CPR and further shocks.

5. If an AED is not immediately available, begin chest compressions/CPR until an AED arrives.

The debate about the effectiveness of various screening examinations and tools to prevent SCD in student-athletes will undoubtedly continue. However, there is no debate that a well-rehearsed and effectively implemented EAP for treatment of cardiac arrest is effective at reducing the risk of death.

Cardiac research initiatives

The NCAA is committed to expanding the understanding of SCD and advancing the cardiovascular care of athletes through education, research and creation of new resources. With the enactment of NCAA legislation that mandates catastrophic injury reporting,69 NCAA member institutions are required to report all catastrophic injuries occurring in student-athletes (including events that occur outside of athletic training and competition); sudden death and near-fatalities from cardiac arrest are counted as catastrophic injuries. Although SCD event reporting is mandatory for NCAA athletes, collecting information on sudden cardiac events for all college-aged and younger individuals would be informative for a greater understanding of incidence and prevention. Thus, future research on the incidence of life-threatening cardiovascular events in NCAA student-athletes will be directed by more precise data.

More accurate information is also needed on the specific aetiologies of SCD in college student-athletes. After the sudden death of any athlete, there is an opportunity to perform a comprehensive and expert forensic examination. This includes gross anatomical autopsy by a cardiovascular pathologist experienced in the distinction of athletic heart changes from structural pathologies associated with SCD. In the case of a negative or indeterminate autopsy, genetic testing can be conducted for known pathogenic gene mutations associated with ion-channel disorders, cardiomyopathies and other established causes of SCD in young persons. The NCAA has pledged to fund a study in which expert forensic examination and genetic testing will be available in cases of SCD. This means that postmortem tissue samples will be preserved to protect the quality of extracted DNA, and heart tissue will be preserved in accordance with methods that permit expert cardiac pathology examination that can identify specific cardiac conditions associated with SCD.

Additional research is needed to improve cardiovascular screening strategies. The standardisation of personal and family history questions requires additional study to determine both accuracy and efficacy. In addition, the feasibility, cost implications and downstream diagnostic testing yield of different screening strategies needs to be assessed, including those confined to history and physical examination versus those that also use testing, such as ECG and echocardiogram. Industry partnerships can be explored that may make more accurate and consistent ECG interpretation more widely available. Research can extend above and beyond preparticipation cardiovascular disease screening to include the effect of early life choices and habits on cardiovascular disease risk throughout the lifespan. Lifestyle issues related to tobacco, dietary patterns, physical activity and medical conditions (such as hypertension, dyslipidemia, metabolic syndrome and key cardiovascular adaptations to sport) are incompletely understood among NCAA student-athletes, both during college and later in life. Future research dedicated to understanding the scope and long-term clinical implications of these issues is important.

The NCAA is committed to partnering with national organisations dedicated to the continued education of primary care, sports medicine and cardiology physicians to enhance the cardiovascular care of athletes. Within this context, the NCAA has an important public health opportunity to better understand early markers of cardiovascular disease that may be present during college. It is entirely conceivable that precursors or early manifestations of cardiovascular disease in college student-athletes may lead to death on a substantially larger order of magnitude than SCD. The development of preventive care strategies and long-term surveillance will help to establish improved long-term cardiovascular health. In addition, the opportunity to use findings in college student-athletes for application to the ‘college-aged’ general population cohort cannot be understated.

Last, the IOM report, Strategies to Improve Cardiac Arrest Survival: A Time to Act,50 provides recommendations that can serve as collaborative opportunities for NCAA member institutions. Pertinent recommendations that are applicable across member schools include:

1. Establish a national cardiac arrest registry. The IOM recommends that the Centers for Disease Control and Prevention should expand and coordinate cardiac arrest data collection through a publicly reported and available national cardiac arrest registry. The National Center for Catastrophic Sport Injury Research can develop collaborative data collection strategies with the Centers for Disease Control and Prevention.

2. Foster a culture of action through public awareness and training. The IOM recommends partnerships that promote public awareness of the signs, symptoms and treatment of cardiac arrest, noting that such efforts require public CPR and AED training. This awareness and training creates a culture of action that prepares and motivates bystanders to respond immediately on witnessing a cardiac arrest. Member schools may be in a unique position to become a key component of such a culture of action. Every member school should have a cardiac emergency response plan and protocol. Online resources are available from the AHA.4

3. Adopt continuous quality improvement programmes. The IOM recommends an integrated healthcare adoption of continuous quality improvement programmes for cardiac arrest response. Member schools can become part of such programmes.

4. Accelerate research on pathophysiology, new therapies and translation of science for cardiac arrest. The IOM recommends a collaborative effort to build the nation’s infrastructure that will support and accelerate innovative research on the causal mechanisms of onset, pathophysiology, treatment and outcomes of cardiac arrest. Coordinated data collection at NCAA member schools represents a unique opportunity to help advance such an effort.

5. Create a National Cardiac Arrest Collaborative. The IOM recommends the establishment of a National Cardiac Arrest Collaborative that will unify the cardiac arrest field, identify common goals, and build momentum within the field to ultimately improve survival from cardiac arrest with good neurological and functional outcomes. NCAA member schools are uniquely positioned to become part of this collaborative.

Conclusions

Cardiac arrest during training and sports participation is a leading cause of unexpected deaths and postarrest disabilities in NCAA athletes. The risk of SCD is higher in male and African-American athletes, and appears to be disproportionately high in men’s basketball players. Cardiovascular screening in athletes should include a standardised personal and family history and a physical examination. ECG screening can increase the sensitivity to detect potentially lethal cardiac conditions if physician training is improved and cardiology expertise is available. If ECG screening is used, ECGs should be interpreted with modern standards that distinguish physiological changes from findings associated with pathological cardiac disorders. Secondary testing of screening abnormalities and management of identified cardiac disorders should be carried out in consultation with skilled cardiovascular specialists. All NCAA member institutions should have an established EAP to respond to an athlete with a cardiac emergency who has collapsed, is not breathing normally or only gasping, and is unresponsive, including the availability of AEDs at all sporting facilities. Although NCAA member institutions report all SCD events in student-athletes, collecting information on sudden cardiac events for all college-aged and younger individuals would be informative for greater understanding of incidence and prevention.

Together, NCAA member institutions have an opportunity to train coaching staff, referees and student-athletes to recognise and respond to a cardiac emergency on the field and in the community, and to become CPR ambassadors between the athletic programmes and the larger student population. Management of cardiac arrest with prompt recognition, early activation of the emergency response system, early CPR and early use of an AED provides the best chance of survival (figure 1).

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Figure 1

Central illustration. A summary of cardiovascular priorities in collegiate student-athletes. Cardiovascular priorities in college student-athletes range from more accurately defining the risk of SCD to developing and implementing referral centres and emergency action plans. AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; SCD, sudden cardiac death.