S0735-1097(14)01087-0
DOI:
10.1016/j.jacc.2014.01.041
Reference:
JAC 19881
To appear in:
15 January 2014
Please cite this article as: Maron BJ, Haas TS, Murphy CJ, Ahluwalia A, Rutten-Ramos S, Incidence
and Causes of Sudden Death in U.S. College Athletes, Journal of the American College of Cardiology
(2014), doi: 10.1016/j.jacc.2014.01.041.
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Barry J. Maron MD, FACC, Tammy S. Haas RN, Caleb J. Murphy BS,
Aneesha Ahluwalia, Stephanie Rutten-Ramos DVM, PhD
Disclosures: none
Barry J. Maron, MD
Hypertrophic Cardiomyopathy Center
Minneapolis Heart Institute Foundation
920 East 28th Street, Suite 620
Minneapolis, MN 55407
Tel: 612-863-3996/Fax: 612-863-3875
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Corresponding Author:
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ABSTRACT
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Objectives. Reliably define the incidence and causes of sudden death in college student-athletes.
Background. Frequency with which cardiovascular-related sudden death (SD) occurs in
competitive athletes importantly impacts considerations for preparticipation screening strategies.
Methods. We assessed databases (including autopsy reports) from both the U.S. National
Sudden Death in Athletes Registry and National Collegiate Athletic Association (NCAA) (20022011).
Results. Over the 10 year period, 182 SDs occurred (ages 20 1.7; 85% males; 64% white): 52
resulting from suicide (n = 31) or drug abuse (n = 21), and 64 probably or likely attributable to
cardiovascular causes (6/year). Of the 64 athletes, 47 had a confirmed post-mortem diagnosis
(4/year), most commonly hypertrophic cardiomyopathy in 21, and congenital coronary anomalies
in 8. The 4,052,369 athlete participations (in 30 sports over 10 years) incurred mortality risks
of: suicide and drugs combined, 1.3/100,000 athlete-participation-years (5 deaths/year); and
documented cardiovascular disease, 1.2/100,000 (4 deaths/year). Notably, cardiovascular deaths
were 5-fold more common in African-American athletes than whites (3.8 vs. 0.7/100,000;
p <0.01), but did not differ from the general population of the same age and race (p = 0.6).
Conclusions. In college student-athletes, SD risk due to cardiovascular disease is relatively low,
with mortality rates similar to suicide and drug abuse, and less than expected in the general
population, although highest in African-Americans. A substantial minority of confirmed
cardiovascular deaths would not likely have been reliably detected by preparticipation screening
with 12-lead ECGs.
Keywords: athletes; sudden death; ECGs; suicide
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ABBREVIATIONS
ARVC
arrhythmogenic right ventricular cardiomyopathy
ECG
electrocardiogram
FBN1 gene fibrillin 1 gene
HCM
hypertrophic cardiomyopathy
IRB
Institutional Review Board
LQTS
long QT syndrome
NC
North Carolina
NCAA
National Collegiate Athletic Association
SD
sudden death
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Sudden death (SD) in young competitive athletes has become a highly visible issue
attracting substantial public interest within communities and in cardiovascular medicine (1-10).
Much of the current debate regarding preparticipation screening concerns selection of the most
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effective and practical strategy for identifying (or raising suspicion of) a diverse array of
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Most mortality data in young athletes suggest these catastrophes occur with relatively low
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event rates (1,3,6,9,11,15). However, a recent non-forensic based analysis in college studentathletes reported a relatively high frequency of 2.3/100,000/athlete-years for deaths believed to
be of cardiovascular origin (7). Such data have heightened concern in the college sports
community that intercollegiate student-athletes have uniquely high (even excessive) risks
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Athlete deaths
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METHODS
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U.S. National Registry of Sudden Death in Athletes was instituted at the Minneapolis
Heart Institute Foundation in 1992 to systematically assemble prospectively and retrospectively
data on young athletes participating in organized competitive sports. Subjects are considered for
inclusion when a participant in an organized team or individual sport requiring regular training
and competition (15). Deaths occurring in club or intramural sports, or from automobile
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accidents, homicides, cancer or systemic diseases were not tabulated. This project was approved
by Allina IRB.
For the years 2002 to 2011, we used a variety of sources to identify deaths in
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intercollegiate athletes active in competitive organized programs (but not necessarily occurring
on the athletic field) (Table 1). Systematic tracking was established to obtain for each case
available clinical data and/or the circumstances of death, as well as complete autopsy reports
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with gross, histopathologic, and toxicologic data from the medical examiner of record. Postmortem findings were adjudicated by one senior investigator (BJM) with > 30 years experience
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and expertise in this discipline (1,8,15-17). When necessary, autopsy findings were verified by
communication with medical examiners. Detailed information on demographics, circumstances
of death, and pertinent clinical data was assembled, sometimes from written accounts or
telephone interviews with family members, witnesses or coaches.
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The NCAA is a governing body for colleges and universities with organized competitive
athletic programs, comprising 1,273 member institutions, representing 85% of students
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competing in college. For 2002-2011, participation data was tabulated from the comprehensive
NCAA Sports Sponsorship and Participation Rates Report (18), but which does not take into
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initial interrogation, the Registry method recognized 56 SDs (88%) including 14 not represented
on the NCAA List. The NCAA included 50/64 cases (78%), including 8 not recognized by
initial Registry searches, due to absence within the media reports of key words prospectively
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Mortality rates in NCAA athletes were compared to available data for suicide, drugs,
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drowning and cardiovascular causes in the general population: (1) U.S. National Vital Statistics
Reports (20) with all causes of death for ages 15-24 years during 2006, the most recent year in
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which causes of mortality were tabulated according to age and race; (2) data reported for suicide
in U.S. college students, ages 18-24 years, for 2009-2010 (21). Extent of one athlete-year was
defined as participating in a sport from August to July.
Mortality rates were estimated by Poisson regression, and compared across populations
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and subpopulations. Mortality rates, incidence, and 95% confidence intervals were reported as
deaths/100,000 athlete participation-years (or person-years). All analyses were performed in SAS
9.3 (SAS Institute; Cary, NC). Statistical significance was defined as p <0.05.
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RESULTS
NCAA student-athletes
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Over the 10-year study period, the total number of student-athlete participations in 30
intercollegiate sports was 4,052,369, ranging from 367,653 (2001-2002) to 449,576 (2010-2011)
(mean 405, 237/year). Age at death was 17 to 26 years (mean 20 1.7); 154 (85%) were male;
116 (64%) were white and 60 (33%) were African-American, with 6 (3%) of other races.
Epidemiology of SDs
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There was a total of 182 SDs recorded during the 10 year study period (0.004% of
4,052,369), or 18/year (Table 2; Figure 1). Events occurred at a similar rate over time (p = 0.61),
but were highest in 2004 and 2007 (n = 22 each), and lowest in 2006 (n = 11).
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Causes of death
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mortem examination either was not performed (n = 2), it was not possible to obtain autopsy
findings due to state confidentiality restrictions (n = 6), or the report was ambiguous without
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sufficient detail to reliably assign the cause of death (n = 8). These 16 deaths occurred while
sedentary (or during sleep), and unrelated to sports or physical exertion.
Non-cardiovascular disease-related SD. Of the 182 deaths, 118 (65%) were due to
causes other than cardiovascular disease (Table 2; Figure 2). Most common of these was suicide
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commotio cordis); sickle cell trait (n = 11) (17); drowning (n = 11), heat stroke (n = 5).
Cardiovascular disease-related SD. In 64 athletes, a cardiovascular abnormality was
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judged the likely or probable cause of death. Most common sports were basketball (n = 23) and
football (n = 16) (Table 2); 29 collapsed with physical exertion during competition (n = 6) or
practice (n = 23), 14 others during recreational sports, and 21 while sedentary. Of these, 58%
were white and 41% were African-American.
In 47 of the 64 athletes, a post-mortem examination documented a cardiovascular
abnormality considered responsible for SD. Most common were: HCM (n = 21; 12 African6
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3; including 2 positive for a FBN1 mutation); ARVC with right ventricular enlargement and
extensive fatty infiltration (n = 3); healed myocarditis with patchy myocardial fibrosis (n = 2);
dilated cardiomyopathy with 4-chamber enlargement (n = 2); myxomatous mitral valve (n = 1);
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myocardial infarction (n = 1; Kawasaki syndrome), and one athlete with a structurally normal
heart and family history of SDs due to LQTS which strongly suggested LQTS as the cause of
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death could not be established, either because a postmortem examination was not performed (n =
3), the autopsy report was inconclusive - - i.e., judged inadequate to reliably assign the specific
cause of SD (n = 12), or because confidentiality considerations restricted access to the report (n =
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2). Also included in this group are 3 athletes in whom the sole pathologic abnormality was
myocardial bridging of left anterior descending coronary artery (22).
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SD incidence
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Mortality from suicide and drugs combined did not differ from the 47 confirmed
cardiovascular causes (p = 0.39), but was less than confirmed/presumed cardiovascular disease
(p < 0.0006). Deaths due to confirmed cardiovascular disease were 2.5-fold more common in
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the general population of similar age, either for the 47 athletes with confirmed diagnoses (p <
0.0001), or the 64 athletes with combined confirmed/presumed cardiovascular diseases (p <
0.0007) (Tables 3 and 4). Suicide rates in the general population are significantly higher than in
NCAA athletes (p < 0.0001); however, suicide was less common in college athletes than other
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college students (p < 0.0001). Drug-related deaths occurred with similar frequency in NCAA
athletes and in the general population of comparable age and gender (p = 0.32).
Impact of race and gender
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general black population of the same age (4.3/100,000; p = 0.6) (Table 4). In contrast, the
suicide rate was similar in African-Americans and white athletes (1.0 vs. 0.8/100,000; p = 0.7),
but in both instances significantly less common than in the general population (p < 0.0001).
Drug-related death rates also were similar in African-American (0.6/100,000) and white athletes
(0.5/100,000; p = 0.75), but no different than the general population (p > 0.2).
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Gender. Cardiovascular deaths were 6-fold more common in male than in female athletes
(1.8/100,000 [95% CI: 0.3, 9.3] vs. 0.3/100,000 [95% CI: 0.2, 0.8]; p < 0.0001), but lower than
the general male population of the same ages (2.8/100,000; 95% CI: 0.6, 14; p < 0.001). Suicide
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rate was 3-fold higher in males than females (1.1/100,000 [95% CI: 0.2, 5.8] vs. 0.3/100,000
[95% CI: 0.2, 0.8]; p < 0.01), but much lower than in the general male population of same age
(16/100,000; p <0.0001). Drug deaths were more common in males than females (0.9/100,000
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[95% CI: 0.6, 1.4) vs. zero; p < 0.0001), but similar to the general male population of the same
We estimated reliability of the 12-lead ECG for diagnosis of specific cardiac causes of
SD. Of the 47 diagnoses confirmed at autopsy, 28 (60%) would most likely have been identified
or suspected by the ECG: HCM (n = 19/21) (30); ARVC (n = 3); aortic rupture (n = 2 with
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Marfan); dilated cardiomyopathy (n = 2); LQTS (n = 1); mitral valve prolapse (n = 1).
DISCUSSION
Considerable discussion has emerged over the last several years regarding the impact on
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the general public health of SDs tragically occurring in young competitive athletes (1-16), and
the most effective screening strategy to detect the responsible causes in this population (2-7,9-
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14). Indeed, the justification for broad-based (even national) screening initiatives would appear
to rest importantly on the frequency with which cardiovascular catastrophes do occur in trained
athletes (3,9,11,15,16,23). For example, in Denmark systematic screening of athletes (and
others) is not performed by any method because the SD rate is considered particularly low (11).
In a prior survey of NCAA athletes without forensic (autopsy) confirmation of causes of
death, Harmon et al. (7) reported 9 athlete deaths/year (over a 5 year period) among 400,000
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examination. Perhaps, not unexpectedly, the 2 studies in the literature that report the highest
cardiovascular SD rate in athletes of > 2/100,000 do not include diagnostic autopsy or clinical
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data, i.e., Steinvil, et al. from Israel (6) and the Harmon, et al. study of U.S. college athletes (7).
However, we wish to underscore that the differences in incidence of athletic field deaths
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between Harmon, et al. (7) and the present study are nevertheless relatively small when
compared to the more compelling rates of SD due to the many other risks to living in the general
population of the same age group (Figure 3). Indeed, an important aspect of the present
investigation is the placing of cardiovascular SDs in college athletes within a broader context.
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Our analysis underscores the principle that NCAA athlete SDs represent a numerically low event
rate phenonomen (1,3,6,9,11,15,23); for example, by comparison, annual automobile fatalities in
the same age group are >2,500-fold more common. Furthermore, cardiovascular deaths in
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NCAA athletes are significantly less common than those in the general population but similar to
the unexpectedly high combined suicide and drug-related mortality rates identified in these
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college athletes.
Notably, the cardiovascular SD rate in our college athletes is higher than that previously
reported in a cohort of high school participants (1.2 vs. 0.7/100,000) (9). Although the
determinants are uncertain, these differences are potentially attributable to the longer exposure
by college student-athletes to rigid and rigorous training regimens extended over more
substantial periods of life. SDs were, in fact, most common in Division I (scholarship) athletes
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with proper rest and nutrition, and increased exposure to alcohol and drugs. Such accessibility to
drugs/alcohol in college athletes may be largely responsible for the higher SD rate compared to
high school athletes (9).
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In a sizeable minority of athlete SDs, it was not possible to conclusively determine the
cause of death, even after considering the submitted autopsy findings. This circumstance largely
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reflects the current state-of-the-art in the medical examiner community regarding the reliability
for postmortem diagnoses in SDs due to genetic heart diseases (24,25). Indeed, a minority of our
SD events (n = 17) were considered likely of cardiovascular origin, given the instantaneous
collapse linked to physical exertion, even though a precise cause of death could not be assigned
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due to ambiguous or absent autopsy findings. Nevertheless, some of these latter deaths could
have been due to non-cardiac causes, a potential source for over-estimating our SD rates.
Alternatively, the small subset of athletes for whom diagnosis remains completely unresolved (n
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= 16) could possibly have included cardiovascular disease-related deaths and in this way
underestimated SD incidence.
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Available estimates of the at-risk athlete population (i.e., the denominator) have
limitations, given that we and other investigators (7) are obligated to use NCAA data expressed
as participations, rather than for individual participants. With the possibility of multi-sport
involvement by a small minority of athletes, there is the potential for overestimating the at-risk
population, and thereby underestimating SD incidence.
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characteristic absence of structural cardiac abnormalities. This issue underscores the advantage
of expert cardiac pathologist assessment of autopsy findings in SDs of young athletes or others
(25). Certainly, the general level of expertise for cardiovascular pathology in the U.S. medical
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African-American college athletes were at 5-fold greater risk for cardiovascular SD than
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white athletes (16). However, this SD rate in African-American athletes did not differ from the
general population of the same age and race. For male athletes, mortality rates for
cardiovascular disease, as well as suicide and drugs, exceeded that in female athletes (3 to 6fold), consistent with reports in other athlete populations (1,3,8,9,15,16). Determinants of such
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Our data do not focus primarily on the current controvery regarding the most effective
preparticipation screening strategy for detection of cardiovascular disease (2-7,10-15). However,
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certain inferences are unavoidable. In particular, our findings underscore the frequency and
importance of false negative results whether screening is limited to history-taking and physical
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examination or includes a 12-lead ECG, i.e., the principle that not all at-risk athletes are
detectable by screening (1,3,4,9,26). Based on autopsy confirmation of cause of death, about
60% of the athletes in our study cohort would probably have been identified by a screening 12lead ECG. However, we also estimate that at least 40% would likely have been false
negatives, not reliably suspected by 12-lead ECGs, as part of broad-based screening initiatives
in athletes (26).
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prevention and control of drug use, as well as wider dissemination of automatic external
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defibrillators for secondary prevention of SD. Such initiatives may best serve the public health of
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college student-athletes.
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LEGENDS
Figure 1. Comparative incidence of SD. Comparative incidence of SD due to cardiovascular
disease (CV), suicide, or drugs in NCAA athletes 2001 to 2011, per 100,000 athlete
participation-years.
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Figure 2. SDs in 166 NCAA athletes. Left: All causes. Right: Confirmed cardiovascular
causes in 47 athletes.
Symbols: collapse virtually instantaneous during physical activity, suggesting underlying
cardiovascular disease was responsible, in the absence of a firm post-mortem diagnosis.
Abbreviations: AMI = acute myocardial infarction; ARVC = arrhythmogenic right ventricular
cardiomyopathy; CAD = coronary artery disease; CM = cardiomyopathy; CV = cardiovascular;
HCM = hypertrophic cardiomyopathy; LQTS = long QT syndrome; MVP = (myxomatous)
mitral valve prolapse SCT = sickle cell trait. Not included here are 16 athletes in whom the
cause of death remains completely unresolved.
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Figure 3. Causes of death in young people annually in U.S., including NCAA athletes.
Reference citations are in parentheses.
Symbols: * data for 15-24 year olds (20); data available only for 8-39 year olds (15);
estimated deaths in this age group, from National Weather Service (27); : average annual event
rate for 15-24 year olds (28); : average annual event rate for 16-25 year olds for all activities
performed at time of event (29); : average annual event rate for events involving survivors and
non-survivors of all ages (30); : age 12-22 years (17)
Abbreviations: CV = cardiovascular; MN = Minnesota; NCAA = National Collegiate Athletic
Association.
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February 2010. Data are from the Multiple Cause of Death Files, 2005-2006, as
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3.
4.
5.
6.
Records of National Center for Catastrophic Sports Injury Research (U. North
7.
Symbols:
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2.
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Assembled through Burrelles Informative Services (Livingston, NJ) with access to 18,000 U.S.
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organizations
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Race
No.
Age (y)
Male
Suicide
31
19.9 1.5
25
24
Drugs
21
20.1 1.3
21
16
Confirmed/Presumed CV
64
20.2 1.8
54
10
37
26
Confirmed CV
47
20.3 1.9
41
22
24
Trauma
15
19.1 1.4
13
13
Accidental drowning
11
19.8 1.5
11
11
19.7 1.3
11
Heat stroke
19.8 1.6
Brain aneurysm
20.0 2
Pulmonary
19.7 2.1
Sepsis
20.5 0.7
Other
1
Sports*
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Cause of Death
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African-
NCAA Division
II
III
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33
14
17
25
12
10
track/CC (4); soccer (3); baseball (2); basketball (1); football (1)
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Totally unresolved
16
20.3 2.4
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Abbreviations:
CC = cross-country; CV = cardiovascular; NCAA = National Collegiate Athletic Association; y = years
Symbols:
* 4 most common sports shown
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Deaths/100,000 athlete
Deaths/100,000
participation-years
No.
(95% CI)
person-years
(95% CI)
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Mortality category
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47
Confirmed/Presumed CV
64
Suicide
31
Drugs
21
Suicide/drugs combined
52
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Confirmed CV
Accidental drowning
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16
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Unresolved
P <0.0001 vs. 2009-2010 suicide rate reported for college students 18-24 years (i.e.,
6.2/100,000
person-years; 95% CI: 2.9, 13.2) (21)
Events occurring in a body of water, with or without a non-motorized vessel
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Table 4. Mortality Rates in NCAA Athletes Compared to the General Population Stratified by Race/Ethnicity
African-American
General population
deaths/100,000 athlete
15-24 years
participation-years
deaths/100,000 person-
(95% CI)
General population
deaths/100,000 athlete
15-24 years
participation-years
deaths/100,000 person-
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NCAA athletes
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NCAA athletes
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Mortality Category
White
(95% CI)
Confirmed/presumed CV
Suicide
Drugs
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Confirmed CV
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Abbreviations:
CI = confidence interval; CV = cardiovascular; NCAA = National Collegiate Athletic Association
Symbols:
*
P <0.01:NCAA athletes vs. general population, 15-24 years within race/ethnic category
person-years in the general population (28) are equivalent to athlete participation-years
P <0.0001 between general population strata
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