Sudden Death Associated With Sickle Cell Trait Before and After Mandatory Screening

Abstract

Background: Sickle cell trait (SCT) has been associated with an increased risk of sudden death in athletes during strenuous exercise. In August 2010, the National Collegiate Athletic Association (NCAA) began requiring athletes to be screened for SCT, provide proof of SCT status, or sign a waiver and launched an educational campaign for athletes, coaches, and medical staff. The impact of this program is unknown. The purpose of this study was to determine the incidence of death associated with sickle cell trait (daSCT) in NCAA athletes before and after legislation. Hypothesis: NCAA SCT legislation will decrease the incidence of daSCT. Study Design: Observational study. Level of Evidence: Level 2. Methods: A database of NCAA athlete deaths from 2000 to 2019 was reviewed for daSCT. A total of 8,309,050 athlete-years (AY) were included. Incidence of death was calculated before and after legislation. Results: The incidence of daSCT in Division I (DI) football athletes before legislation (n = 9) was 1:28,145 AY and after legislation (n = 1) was 1:250,468 AY (relative risk [RR], 0.112; 95% CI, 0.003-0.811; P = 0.022), an 89% reduction in risk after legislation was enacted. The incidence of daSCT in African American DI football athletes before legislation (n = 9) was 1:12,519 AY and after legislation (n = 1) was 1:118,464 AY (RR, 0.106; 95% CI, 0.002-0.763; P = 0.017), also an 89% risk reduction after legislation was enacted. For all NCAA athletes, the incidence of daSCT was 1:489,749 AY before legislation (n = 10) and 1:1,705,780 AY after legislation (n = 2) (RR, 0.288; 95% CI, 0.031-1.347; P = 0.146). Conclusion: The incidence of daSCT in DI football athletes has decreased significantly since legislation was enacted. Cases of daSCT outside of football are rare. It is unclear whether the decrease is related to screening for SCT, education, or both. Clinical Relevance: This is the first evidence that NCAA SCT legislation may save lives.

NCAA Division I American football players with sickle cell trait have altered hematological responses and hydration status

“…Another important consideration is the effect of exercise on muscle damage in SCT players because previous studies frequently suggest SCT player are at a greater risk of exertional rhabdomyolysis 7 , 8 , 32 . Exertional rhabdomyolysis is a syndrome caused by the severe breakdown of skeletal muscle tissue leading to acute and chronic kidney failure 33 .…”

“…American football players with SCT have an increased risk of complications due to the exhaustive nature of practice and competitions 6 – 8 . In addition, geographical location, specifically hot and humid environmental climates, provides an extra challenge to the players with SCT 9 .…”

“…Hematological alterations, inflammation, and vascular adhesion have been proposed as potential mediators of the microcirculatory changes that induce sickle cell anemia 11 , 12 . Although a clear relationship exists between SCT and the risk of exertional-related sudden death in American collegiate football, the pathophysiology of sickling-induced hematological alterations is still unknown 8 , 13 . According to the NCAA guidelines, the primary prevention strategies of sickling crisis is includes (1) requiring institutions to confirm SCT status before enrollment in any athletic team and (2) continued education of SCT players to avoid heat stress and dehydration 7 , 8 .…”

“…Although a clear relationship exists between SCT and the risk of exertional-related sudden death in American collegiate football, the pathophysiology of sickling-induced hematological alterations is still unknown 8 , 13 . According to the NCAA guidelines, the primary prevention strategies of sickling crisis is includes (1) requiring institutions to confirm SCT status before enrollment in any athletic team and (2) continued education of SCT players to avoid heat stress and dehydration 7 , 8 . In SCT, acclimatization should be implemented slowly and gradually, allowing players to have ample rest intervals during exercise due to the nature of the deoxygenated form of HbS, and possibly resulting in greater muscle fatigue 4 , 14 .…”

“…In SCT, acclimatization should be implemented slowly and gradually, allowing players to have ample rest intervals during exercise due to the nature of the deoxygenated form of HbS, and possibly resulting in greater muscle fatigue 4 , 14 . In addition, athletic training staff is trained to identify the signs and symptoms of sickle cell crisis and differentiate it from heat cramps 8 , 9 . To our knowledge, no study has investigated the effects of training and competitions across the entire season on SCT players.…”