Objective To explore the association of socioeconomic deprivation and racialised outcomes in competitive athletes with sudden cardiac arrest (SCA) in the USA. Methods SCA cases from the National Center for Catastrophic Sports Injury Research (July 2014 to June 2021) were included. We matched Area Deprivation Index (ADI) scores (17 metrics to grade socioeconomic conditions) to the 9-digit zip codes for each athlete's home address. ADI is scored 1-100 with higher scores indicating greater neighbourhood socioeconomic deprivation. Analysis of variance was used to assess differences in mean ADI by racial groups. Tukey post hoc testing was used for pairwise comparisons. Results 391 cases of SCA in competitive athletes (85.4% male; 16.9% collegiate, 68% high school, 10.7% middle school, 4.3% youth) were identified via active surveillance. 79 cases were excluded due to missing data (19 race, 60 ADI). Of 312 cases with complete data, 171 (54.8%) were white, 110 (35.3%) black and 31 (9.9%) other race. The mean ADI was 40.20 (95% CI 36.64, 43.86) in white athletes, 57.88 (95% CI 52.65, 63.11) in black athletes and 40.77 (95% CI 30.69, 50.86) in other race athletes. Mean ADI was higher in black versus white athletes (mean difference 17.68, 95% CI 10.25, 25.12; p=0.0036) and black versus other race athletes (mean difference 17.11, 95% CI 4.74, 29.47; p<0.0001). Conclusions Black athletes with SCA come from areas with higher neighbourhood socioeconomic deprivation than white or other race athletes with SCA. Our findings suggest that socioeconomic deprivation may be associated with racialised disparities in athletes with SCA.

HomeCirculation: Cardiovascular Quality and OutcomesVol. 15, No. 8Differences in Survival Outcomes in Adolescent Male Basketball Players at School-Sponsored Versus Select Club-Sponsored Events and Implications for Racial Disparities Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBDifferences in Survival Outcomes in Adolescent Male Basketball Players at School-Sponsored Versus Select Club-Sponsored Events and Implications for Racial Disparities Ashley V. Austin, MD, Randi N. DeLong, MPH, Kristen L. Kucera, PhD, MSPH, ATC, Jared Schattenkerk, BS and Jonathan A. Drezner, MD Ashley V. AustinAshley V. Austin Department of Family Medicine and the Center for Sports Cardiology, University of Washington, Seattle (A.V.A., J.A.D.). Search for more papers by this author , Randi N. DeLongRandi N. DeLong https://orcid.org/0000-0002-1376-7839 National Center for Catastrophic Sport Injury Research, Department of Exercise & Sport Science University of North Carolina at Chapel Hill (R.N.D., K.L.K.). Search for more papers by this author , Kristen L. KuceraKristen L. Kucera National Center for Catastrophic Sport Injury Research, Department of Exercise & Sport Science University of North Carolina at Chapel Hill (R.N.D., K.L.K.). Search for more papers by this author , Jared SchattenkerkJared Schattenkerk https://orcid.org/0000-0002-6736-0954 University of Rochester School of Medicine and Dentistry, Rochester, New York (J.S.). Search for more papers by this author and Jonathan A. DreznerJonathan A. Drezner Correspondence to: Jonathan A. Drezner, MD, Director, Center for Sports Cardiology, Professor, Department of Family Medicine, University of Washington, Box 354060, Seattle, WA 98195. Email E-mail Address: [email protected] https://orcid.org/0000-0003-3519-9120 Department of Family Medicine and the Center for Sports Cardiology, University of Washington, Seattle (A.V.A., J.A.D.). Search for more papers by this author Originally published5 Jul 2022https://doi.org/10.1161/CIRCOUTCOMES.121.008640Circulation: Cardiovascular Quality and Outcomes. 2022;15Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: July 5, 2022: Ahead of Print Sudden cardiac arrest (SCA) accounts for 75% of all fatalities during sports and is the leading cause of exercise-related sudden death in young athletes.1 Epidemiological data demonstrate that Black male basketball players are at highest risk of SCA compared with other athlete groups.1,2 Efforts to improve emergency response planning for SCA in athletes have primarily focused on secondary school and collegiate settings.3 Emergency planning within select club programs, such as the Amateur Athletic Union, is less widely known. This study examined and compared survival outcomes in competitive adolescent male basketball players with SCA during school-sponsored versus select club-sponsored events.This study uses data from the National Center for Catastrophic Sports Injury Research from July 1, 2014 to June 30, 2020, and was approved by the institutional review board at the University of North Carolina at Chapel Hill. Episodes of exercise-related SCA in adolescent male basketball players were prospectively identified through longitudinal surveillance of traditional and social media sources and direct reporting from the National Federation of State High School Associations, National Athletic Trainers’ Association, and state high school athletic associations.The primary outcome was survival to hospital discharge. Univariable and multivariable log-binomial models quantified differences in survival and emergency response (bystander cardiopulmonary resuscitation [CPR], on-site automated external defibrillator [AED] use, and presence of an athletic trainer) based on event type and race using risk ratios with 95% CI. Analysis was conducted using SAS 9.4 (SAS Institute, Inc, Cary, NC). The authors declare that all supporting data are available within the article.Sixty cases of SCA occurred in male adolescent basketball players during this 6-year study period (mean age 15.4 years, range 12-19; 45% Black, 38% White, 3% Asian, 2% Native American/Alaska Native, 2% ≥2 races, 10% unknown race). Twenty-five (42%) cases occurred during games and 35 (58%) during practice. Thirty-four (57%) cases occurred during a high school event, 8 (13%) during a middle school event, and 18 (30%) during a select club event. Of the 18 select club events, 16 (89%) were sponsored by the Amateur Athletic Union, and 2 (11%) were sponsored by other organizations. Black athletes comprised 61% of cases at select club events and 38% of cases at school events.Provision of CPR was confirmed in 90% of cases occurring at middle/high school events versus 56% of cases at select club events, although performance of bystander CPR was unknown in 10% and 44% of cases at school and club events, respectively (Table). Use of an on-site AED was confirmed in 64% of cases at school events versus 22% of cases at select club events. Overall survival for cases occurring at select club events versus middle/high school events was 39% and 67%, respectively (P=0.05). Survival was lower in athletes of Black (37%) and other race (50%) versus White athletes (74%; P=0.02). The unadjusted and adjusted risk ratios for Black versus White athlete survival were 0.50 (95% CI, 0.29–0.87; P=0.01) and 0.61 (95% CI, 0.35–1.07; P=0.09), respectively. Among only high school athletes, survival (71% versus 39%; P=0.04), reported bystander CPR (91% versus 54%; P=0.004), and reported AED use (79% versus 31%; P=0.002) were higher in cases occurring during school versus select club events.Table. Resuscitation Details and Survival by Event Type and Race Among Male Adolescent Basketball Athletes With Exercise-Related Sudden Cardiac Arrest, July 2014–June 2020N (%) 95% CI*P value†‡N (%) 95% CI*P value†‡§Total (n=60)Middle/high school (n=42)Select club (n=18)White race (n=23)Black race (n=27)Other race (n=4)Bystander CPR performed∥ Yes48 (80)38 (90)10 (56)…¶21 (91)17 (63)4 (100)…¶70–9082–9933–7980–10045–81… No000000 Unknown12 (20)4 (10)8 (44)2 (9)10 (37)0Certified ATC on-site Yes14 (23)12 (29)2 (11)0.996 (26)6 (22)00.3813–3415–420–268–447–38 No27 (45)22 (52)5 (28)13 (57)7 (26)3 (75)32–5837–687–4936–779–4333–100 Unknown19 (32)8 (19)11 (61)4 (17)14 (52)1 (25) RR# (95% CI)1.00 (ref)0.81 (0.23–2.84)0.741.00 (ref)1.46 (0.60–3.54)…¶0.40, … Adjusted RR (95% CI)**1.00 (ref)1.10 (0.24–5.08)0.901.00 (ref)1.44 (0.57–3.63)…¶0.44, …On-site AED used Yes31 (52)27 (64)4 (22)0.0715 (65)10 (37)1 (25)0.3939–6450–793–4146–8519–550–67 No6 (10)3 (7)3 (17)2 (9)2 (7)1 (25)2–180–150–340–205–170–67 Unknown23 (38)12 (29)11 (61)6 (26)15 (56)2 (50) RR# (95% CI)1.00 (ref)0.630.171.00 (ref)0.940.570.72–0.43(0.33–1.22)(0.69–1.28)(0.14–2.29) Adjusted RR (95% CI)**1.00 (ref)0.560.411.00 (ref)1.021.020.89–0.98(0.14–2.26)(0.78–1.34)(0.14–7.38)Athlete survival Yes35 (58)28 (67)7 (39)0.0517 (74)10 (37)2 (50)0.0246–7152–8116–6156–9219–551–99 No25 (42)14 (33)11 (61)6 (26)17 (63)2 (50)29–5419–4839–848–4445–811–99 RR# (95% CI)1.00 (ref)0.580.091.00 (ref)0.500.680.01–0.45(0.31–1.08)(0.29–0.87)(0.25–1.86) Adjusted RR (95% CI)**1.00 (ref)0.520.161.00 (ref)0.610.790.09–0.63(0.21–1.29)(0.35–1.07)(0.31–2.05)AED indicates automated external defibrillator; ATC, certified athletic trainer; CPR, cardiopulmonary resuscitation; and RR, risk ratio.* Wald 95% CIs are presented as percentages.† If ≥20% of expected cell counts were <5, Fisher exact test was used.‡ P values are shown for Fisher exact test or χ2 test between event type and athlete race, excluding unknown as a category.§ There are 6 cases with unknown race excluded from race comparisons.∥ Bystander CPR is defined as CPR performed by anyone present at the event, including athletic trainers, coaches, and parents.¶ No statistical analysis was performed because ≥1 rows had no values.#Unknown values were excluded from risk ratio calculations.** Adjusted RRs were calculated with a multivariable model including race and event type.Adolescent male basketball players with exercise-related SCA were more likely to survive in school-sponsored versus select club-sponsored events, and survival was higher in White versus Black athletes. Lower rates of reported bystander CPR and AED use at select club events were associated with decreased survival and suggest less emergency preparation. These findings are especially important given the Amateur Athletic Union has over 85 000 registered youth male basketball players across the United States.Limitations of this study include the potential for missed cases of SCA and missing data due to low follow-up and response rates. While this study compares racial differences in survival, it does not examine potential causes for the higher incidence of SCA in Black athletes.1,2 On univariable analysis, survival in schools versus clubs and Black athletes versus White athletes were both statistically significant. While our sample size is likely underpowered to detect an effect when adjusting for other variables, we chose to present the multivariable models for transparency and completeness. The adjusted risk ratio for Black versus White athlete survival (adjusted risk ratio, 0.61 [95% CI, 0.35–1.07]) is still indicative of a potential effect. Other factors not examined in this study could also mediate racial disparities in survival outcomes.SCA in young athletes is largely a survivable event with prompt CPR and early defibrillation and presents a unique opportunity for rapid recognition and response. Studies report survival rates above 80% when an on-site AED is used or an athletic trainer is present.4,5 Black male basketball players represent the highest risk athlete group for SCA.1,2 However, potential relationships to explain this have not been investigated.Racial disparities in health care have gained increased recognition as important determinants of health outcomes. Relevant to the prevention of sudden death in sports, future studies should aim to examine systemic or structural inequities in resources, training, and/or emergency preparedness that may exist in club programs with a higher proportion of minority athletes. The presence of such disparities could contribute to the lower survival rate observed in Black male basketball players. Our study calls for new strategies to increase survival from SCA in youth basketball. Specifically, urgent attention is needed to improve emergency response planning for SCA in select club basketball programs.Article InformationSources of FundingSupported by the National Center for Catastrophic Sports Injury Research (University of North Carolina at Chapel Hill), funded in part by the National Collegiate Athletic Association, the National Federation of State High School Associations, the American Football Coaches Association, the National Athletic Trainers’ Association, the National Operating Committee on Standards for Athletic Equipment, and the American Medical Society for Sports Medicine.Nonstandard Abbreviations and AcronymsAEDautomated external defibrillatorCPRcardiopulmonary resuscitationSCAsudden cardiac arrestDisclosures None.FootnotesFor Sources of Funding and Disclosures, see page 671.Correspondence to: Jonathan A. Drezner, MD, Director, Center for Sports Cardiology, Professor, Department of Family Medicine, University of Washington, Box 354060, Seattle, WA 98195. Email [email protected]eduReferences1. Harmon KG, Asif IM, Maleszewski JJ, Owens DS, Prutkin JM, Salerno JC, Zigman ML, Ellenbogen R, Rao AL, Ackerman MJ, et al. Incidence, cause, and comparative frequency of sudden cardiac death in national collegiate athletic association athletes: a decade in review.Circulation. 2015; 132:10–19. doi: 10.1161/CIRCULATIONAHA.115.015431LinkGoogle Scholar2. Peterson DF, Kucera K, Thomas LC, Maleszewski J, Siebert D, Lopez-Anderson M, Zigman M, Schattenkerk J, Harmon KG, Drezner JA. Aetiology and incidence of sudden cardiac arrest and death in young competitive athletes in the USA: a 4-year prospective study.Br J Sports Med. 2021; 55:1196–1203. doi: 10.1136/bjsports-2020-102666CrossrefMedlineGoogle Scholar3. Drezner JA, Courson RW, Roberts WO, Mosesso VN, Link MS, Maron BJ. Inter-association task force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement.Heart Rhythm. 2007; 4:549–565. doi: 10.1016/j.hrthm.2007.02.019CrossrefMedlineGoogle Scholar4. Drezner JA, Peterson DF, Siebert DM, Thomas LC, Lopez-Anderson M, Suchsland MZ, Harmon KG, Kucera KL. Survival after exercise-related sudden cardiac arrest in young athletes: can we do better?Sports Health. 2019; 11:91–98. doi: 10.1177/1941738118799084CrossrefMedlineGoogle Scholar5. Drezner JA, Toresdahl BG, Rao AL, Huszti E, Harmon KG. Outcomes from sudden cardiac arrest in US high schools: a 2-year prospective study from the National Registry for AED Use in Sports.Br J Sports Med. 2013; 47:1179–1183. doi: 10.1136/bjsports-2013-092786CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails August 2022Vol 15, Issue 8 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.121.008640PMID: 35862004 Originally publishedJuly 5, 2022 Keywordsriskathletedeath, sudden, cardiacbasketballdefibrillatorsPDF download Advertisement SubjectsCardiopulmonary ArrestCardiopulmonary Resuscitation and Emergency Cardiac Care

Objective Minority student-athletes have a lower survival rate from sudden cardiac arrest (SCA) than non-minority student-athletes. This study examined the relationship between high school indicators of socioeconomic status (SES) and survival in student-athletes with exercise-related SCA. Methods High school student-athletes in the USA with exercise-related SCA on school campuses were prospectively identified from 1 July 2014 to 30 June 2018 by the National Center for Catastrophic Sports Injury Research. High school indicators of SES included the following: median household and family income, proportion of students on free/reduced lunch and percent minority students. Resuscitation details included witnessed arrest, presence of an athletic trainer, bystander cardiopulmonary resuscitation and use of an on-site automated external defibrillator (AED). The primary outcome was survival to hospital discharge. Differences in survival were analysed using risk ratios (RR) and univariate general log-binomial regression models. Results Of 111 cases identified (mean age 15.8 years, 88% male, 49% white non-Hispanic), 75 (68%) survived. Minority student-athletes had a lower survival rate compared with white non-Hispanic student-athletes (51.1% vs 75.9%; RR 0.67, 95% CI 0.49 to 0.92). A non-significant monotonic increase in survival was observed with increasing median household or family income and with decreasing percent minority students or proportion on free/reduced lunch. The survival rate was 83% if an athletic trainer was on-site at the time of SCA and 85% if an on-site AED was used. Conclusions Minority student-athletes with exercise-related SCA on high school campuses have lower survival rates than white non-Hispanic athletes, but this difference is not fully explained by SES markers of the school.

Objective To investigate the aetiology and incidence of sudden cardiac arrest and death (SCAM) in US competitive athletes. Methods Prospective surveillance was conducted from 1 July 2014 to 30 June 2018 through the National Center for Catastrophic Sports Injury Research in collaboration with national sports organisations. Autopsy reports, death certificates, and medical records were reviewed by an expert panel to determine aetiology. Athlete participation statistics from the National Federation of State High School Associations and the National Collegiate Athletic Association (NCAA) were used to calculate incidence rates per athlete-years (AY). Comparisons of incidence rates were calculated using incidence rate ratios (IRR) with 95% CIs. Results 331 cases of confirmed SCA/D (158 survivors; 173 fatalities) were identified; 15.4% in middle school 61.6% in high school and 16.6% in college and professional athletes. Average age was 16.7 (11-29) years, and the majority were in male (83.7%), basketball (28.7%) or American football (25.4%) athletes. Common causes included hypertrophic cardiomyopathy (20.6%), idiopathic left ventricular hypertrophy (13.4%), coronary artery anomalies (12.0%) and autopsy-negative sudden unexplained death (9.6%). Coronary anomalies were more common in middle school athletes (28%), while cardiomyopathies (hypertrophic, arrhythmogenic, dilated, non-compaction or restricted) accounted for 47% of cases in college and professional athletes. Incidence was higher in male versus female athletes at the high school (1:43 932 AY (95% CI 1:38101 to 1:50 907) vs 1:203 786 AY (95% CI 1:145 251 to 1:293 794); IRR 4.6 (95% CI 3.1 to 7.2)) and NCAA (1:34 906 AY (95% CI 1:25 385 to 1:49 173) vs 1:123 278 AY (95% CI 1:66 078 to 1:249 853); IRR 3.5 (95% CI 1.5 to 9.5)) levels. African American male NCAA Division I basketball players had the highest annual incidence rate of SCA/D (1:2087 AY (95% CI 1:1073 to 1:4 450)). Conclusions Cardiomyopathies account for nearly half of SCA/D cases in college and professional athletes, while coronary artery anomalies play a more prominent role than expected in middle school athletes. Over half of SCA cases in athletes result in sudden death, calling for improved prevention strategies.