The leading cause of death isn't football-related trauma, but sudden cardiac arrest.
From 2003 to 2013, there were 514 deaths among NCAA athletes, and 79 cardiac arrests among them, said Dr. Kim Harmon
, a sports medicine doctor with the University of Washington who has tracked sudden deaths in college athletes for the National Collegiate Athletic Association. That's about eight deaths from cardiac arrest every year.
In that same 10-year period, there were four deaths from head injuries, Harmon said
Males and African-American athletes are more susceptible to cardiac arrest than others, and it's more likely to hit football and basketball players, she said.
According to the Centers for Disease Control and Prevention
, about 2,000 people younger than 25 will die from sudden cardiac arrest every year. In 2013, the National Institutes of Health and the CDC announced a registry to track sudden cardiac deaths in people younger than 24, but the data is still limited.
"Right now, there isn't a way to know the magnitude of the problem ... we don't have very good numbers," Harmon said.
A test to find at-risk athletes
Harmon believes that a simple electrocardiogram screening, which measures the heart's electrical activity, could help prevent these deaths. It can seem like a clear solution to a tragic problem.
"When we see young people die suddenly, it leaves all of us with a sick feeling and of course everybody would like to identify some strategy (to keep) the death's from happening, " said Dr. Linda Gillam
, chair of cardiology for the Atlantic Health System and Morristown Medical Center, and the New York Jets' cardiologist. "The EKG part -- it has appeal because it's a test and a computer."
In fact, all athletes in Italy are all screened with EKGs. This year, the NCAA considered mandatory EKG screenings for athletes, and legislators from several states, including Texas and South Carolina, pushed for legislation requiring wide-scale screening of high school athletes. So far, all of these attempts in the United States have failed.
But both the American Heart Association and the American College of Cardiology oppose wide-scale EKG screenings as a way to find athletes at risk for sudden cardiac death.
"The EKG as a test has enormous false positives and false negatives and was never intended to raise suspicions of these complex conditions in the general population," said Dr. Barry Maron
, lead author of the American Heart Association's position statement on the use of EKG screenings among young athletes.
One study found
that as many as one-third of all athlete EKGs yielded false positives results. Nine out of 10 times, EKGs have been found to miss
heart problems such as coronary anomalies, which are the second most-common cause of sudden cardiac death.
In addition, tracking young athletes' hearts can be particularly difficult, said Dr. Damion Martins
, director of internal medicine for the New York Jets.
"Even at the young age, the heart is a muscle ... there are 16-year-olds that can have an enlarged heart from muscle, so it looks like an athlete EKG. It has higher voltage. Pediatricians say this is abnormal, but a sports medicine specialist would say that's the typical pattern of a trained athlete," Martins said. "Untrained physicians overcall abnormality, and that leads to further testing."
Alternatives to EKGs
Martins and Harmon argue that there's not an issue with the test, but with training doctors.
"You need the proper resources to read EKGs properly," Harmon said. With training, "EKG can probably pick up two-thirds of disease that can potentially predispose to sudden cardiac arrest."
But there still isn't an accepted standard for understanding athletes' heart patterns.
Quality control of screenings on a wide scale simply doesn't work well, Marron said. Aside from trying to ensure that trained specialists are reading the EKGs correctly, they can become expensive. "Community screening is very hard to do. Financially hard to support, frequently based on volunteers," he said.
Poorly interpreted results can mean unnecessary testing, which costs money, said Dr. Benjamin Levine
, professor of exercise science at University of Texas Southwestern Medical Center, who argued against the legislation in Texas.
"It falls upon the poorest," he said. "So what do you do with a kid out in West Texas who doesn't have insurance, there isn't a pediatric cardiologist for 500 miles? What's that kid supposed to do? You can't just wave your hands over it."
Instead of community EKG screenings, the American Heart Association and American College of Cardiology advise using a 14-point questionnaire
that asks students about possible symptoms and family health histories.
Lisa Salberg, founder of the Hypertrophic Cardiomyopathy Association
, helped push a law in New Jersey that mandates the screening as part of every student athlete's physical.
"The physician can make the decision about who needs a referral and needs to get additional testing," she said. Later this year, the questionnaire will also be part of every New Jersey child's well visit. After all, there isn't any data that shows sudden cardiac arrest to be less prevalent among non-athletes.
"If Mom and Dad are filling out the forms, when they have the conversation with the provider, then we're doing cascade screening for the family, doing more comprehensive screening," Salberg said. "We need to think of health care as a continuum -- it's about the family."
What can parents do?
For parents who already worry about their kids playing football, sudden death from cardiac arrest might make it feel like the game is too dangerous.
"The risk of being struck by lightning is about the same," said Levine, the UT Southwestern Medical Center professor.
In addition, symptoms such as fatigue and dizziness, which can be attributed to heart issues, can also be reflective of other problems in young athletes. "Kids get sick, so these symptoms are not particularly specific," said Martins, the Jets' doctor.
It's important to focus on the relationships between athletes, parents, doctors and athletic trainers, Martins said.
"The athletic trainer becomes the reference, the point person between the athlete and the parent," he said. "They're there day-to-day. When the athlete complains of symptoms, the athletic trainer needs to identify those and see a physician."