Robert E. Eckart, DO; Stephanie L. Scoville, DrPH; Charles L. Campbell, MD; Eric A. Shry, MD; Karl C. Stajduhar, MD; Robert N. Potter, DVM, MPH; Lisa A. Pearse, MD, MPH; Renu Virmani, MD
Disclaimer: The opinions and research contained herein are the private ones of the authors and are not to be considered as official or reflecting the views of the Department of the Army, Department of the Air Force, or Department of Defense.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Robert E. Eckart, MAJ MC, U.S. Army, Cardiac Arrhythmia Service (Cardiovascular Division), Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115; e-mail, Robert.Eckart@us.army.mil.
Current Author Addresses: Dr. Eckart: Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.
Dr. Scoville: U.S. Army Center for Health Promotion and Preventive Medicine, Directorate of Epidemiology and Disease Surveillance, 503 Robert Grant Avenue, Room 2A31, Silver Spring, MD 20910.
Dr. Campbell: Wilford Hall Air Force Medical Center, 2200 Bergquist Drive, Suite 1, Lackland AFB, TX 78236.
Drs. Shry and Stajduhar: Brooke Army Medical Center, 3851 Roger Brooke, Fort Sam Houston, TX 78234.
Dr. Potter: American Registry of Pathology, 1413 Research Boulevard, Rockville, MD 20850.
Dr. Pearse: Office of the Armed Forces Medical Examiner, 1413 Research Boulevard, No. 102, Rockville, MD 20850.
Dr. Virmani: Armed Forces Institute of Pathology, 6825 16th Street NW, Washington, DC 20306.
Author Contributions: Conception and design: R.E. Eckart, S.L. Scoville, C.L. Campbell, E.A. Shry, K.C. Stajduhar.
Analysis and interpretation of the data: R.E. Eckart, S.L. Scoville, E.A. Shry, K.C. Stajduhar, R. Virmani.
Drafting of the article: R.E. Eckart, S.L. Scoville, C.L. Campbell, E.A. Shry, R. Virmani.
Critical revision of the article for important intellectual content: R.E. Eckart, S.L. Scoville, C.L. Campbell, E.A. Shry, K.C. Stajduhar, R.N. Potter, L.A. Pearse.
Final approval of the article: R.E. Eckart, S.L. Scoville, C.L. Campbell, E.A. Shry, K.C. Stajduhar, R.N. Potter, R. Virmani.
Provision of study materials or patients: S.L. Scoville, R.N. Potter, L.A. Pearse.
Statistical expertise: R.E. Eckart, S.L. Scoville.
Administrative, technical, or logistic support: R.E. Eckart, L.A. Pearse.
Collection and assembly of data: S.L. Scoville, R.E. Eckart, R.N. Potter, L.A. Pearse.
Sudden death among military recruits is a rare but devastating occurrence. Because extensive medical data are available on this cross-sectional and diverse population, identification of the underlying causes of sudden death may promote health care policy to reduce the incidence of sudden death.
To determine the causes of nontraumatic sudden death among a cohort of military recruits.
Retrospective cohort study using demographic and autopsy data from the Department of Defense Recruit Mortality Registry.
Basic military training.
All nontraumatic sudden deaths from a monitored 6.3 million men and women age 18 to 35 years.
Descriptive analysis, crude mortality rates of causes of sudden death, and frequency of events as a function of cause of death.
Of 126 nontraumatic sudden deaths (rate, 13.0/100 000 recruit-years), 108 (86%) were related to exercise. The most common cause of sudden death was an identifiable cardiac abnormality (64 of 126 recruits [51%]); however, a substantial number of deaths remained unexplained (44 of 126 recruits [35%]). The predominant structural cardiac abnormalities were coronary artery abnormalities (39 of 64 recruits [61%]), myocarditis (13 of 64 recruits [20%]), and hypertrophic cardiomyopathy (8 of 64 recruits [13%]). An anomalous coronary artery accounted for one third (21 of 64 recruits) of the cases in this cohort, and, in each, the left coronary artery arose from the right (anterior) sinus of Valsalva, coursing between the pulmonary artery and aorta.
This cohort underwent a preenlistment screening program that included history and physical examination; this may have altered outcomes.
Cardiac abnormalities are the leading identifiable cause of sudden death among military recruits; however, more than one third of sudden deaths remain unexplained after detailed medical investigation.
Sudden nontraumatic death in military recruits may offer insight into the causes and prevention of sudden death in young adults.
Among 6.3 million military recruits age 18 to 35 years, sudden nontraumatic death occurred at a rate of 13.0 per 100 000 recruit-years. Over half of the 126 autopsied decedents had an identifiable cardiac abnormality; one third had an anomalous coronary artery. More than one third of deaths had no explanation.
This study had no control recruits who did not die suddenly.
Sudden nontraumatic death among military recruits occurs rarely. Whether more intensive screening would effectively prevent sudden death is unknown.
Table 1. All-Service Nontraumatic Sudden Death Rates for Recruits by 5-Year Categories, 1977–2001
Table 2. Demographic Characteristics of Recruits with Nontraumatic Sudden Death during Recruit Training, 1977–2001
Table 3. Nontraumatic Sudden Deaths with an Identifiable Cardiac Abnormality during Recruit Training, 1977–2001 (n = 64)
Table 4. Prodromal Symptoms from Autopsy Reports of Nontraumatic Sudden Deaths in Recruits, 1977–2001
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Richard D Ensslen
University of Alberta, Canada
December 17, 2004
Other Screening Possibilities
After the initial history and physical which should on their form address the appropriate issues so they cannot be missed, the simplest screening test that comes readily to mind would be a timed 1 to 2 mile run, followed by a very basic assessment including a confidential self reporting form.
You mentioned the low sensitivity of ECG and stress ECG, and the more sensitive modalities of Ultrasound, CT, and MRI.
Another screening test would be stress Ultrasound, which in cost and availability should compare favorably with CT and MRI.
That would also apply to Thallium stress scintigraphy, planar or SPECT.
At the high tech end would be PET or PET / CT.
Your experience and thoughts would be appreciated. Thank you.
P Dileep Kumar
Port Huron Hospital
January 20, 2005
Cardiac molecular defects might explain 'idiopathic' sudden cardiac death
Eckart and colleagues (1) consider slightly more than one third (44 of 126) of nontraumatic deaths in military recruits as idiopathic or unexplained. The authors base their findings on the gross anatomy exposed at autopsy, but advancement in cardiac molecular pathology has revealed several molecular level defects that can lead to sudden cardiac death. For example, familial polymorphic ventricular tachycardia is characterized by exercise-induced arrhythmias and sudden cardiac death due to missense mutations in the cardiac ryanodine receptor (RyR2), an intracellular Ca2+ release channel required for excitation-contraction coupling in the heart (2). Other possible cardiac causes of sudden death in this setting are inherited ventricular arrhythmias such as the long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, idiopathic ventricular fibrillation, and arrhythmogenic right ventricular cardiomyopathy. It is also interesting that a familial predisposition was noted in several cases of unexplained sudden cardiac death in the study.
1. Eckart RE, Scoville SL, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med. 2004;141:829-34.
2. Lehnart SE, Wehrens XH, Laitinen PJ, et al. Sudden death in familial polymorphic ventricular tachycardia associated with calcium release channel (ryanodine receptor) leak. Circulation. 2004;109:3208-14.
CMSR Veneto Medica
January 15, 2006
ECG in screening strategies
We read with interest the work by Eckart et al (1) reporting the retrospective 25-year review of autopsies in military recruits. Authors state that study results may have been altered by preenlistment screening which, however, did not include electrocardiography (ECG) as a routinary tool. We (2) specifically addressed the effectiveness of pre-participation military evaluation in detecting hypertrophic cardiomyopaty (HCM) in a Italian population of 34,910 male conscripts, demonstrating that screening by 12-lead ECG (as well as history and physical examination) and subsequent referral to echocardiography when cardiovascular abnormalities were suspected, could effectively identify HCM. The power of ECG-based screening for HCM in that study was similar to that reported by Corrado et al. (3) in athletes. Similarly, our follow-up data were consistent with the hypothesis that withdrawal of such individuals from these activities might effectively blunt the occurrence of sudden cardiac death (3,4,5). Moreover, 12-lead ECG offers the potential to raise the clinical suspicion of clinically relevant (other than HCM) diseases, manifesting with ECG abnormalities, such as ARVC/D, dilated cardiomyopathy, long QT syndrome, Brugada syndrome, short QT syndrome, WPW syndrome, LenÃ¨gre syndrome (some of which are unidentifiable at autopsy) (6). The high number of unexplained sudden deaths (35%) could be otherwise properly interpreted if an ECG would have been performed. Sorbo et al. (7) reported the prevalence of WPW syndrome in 116,452 young male conscripts studied by the same ECG- based screening strategy. Both in the WPW and in the HCM study the vast majority of our conscripts were asymptomatic. Therefore, if pre- participation military screening had not been performed in these young men, it is probable that the diagnosis of HCM or WPW would have been delayed, or never accomplished. Recently, the employ of 12-lead ECG has been recommended in a consensus statement proposing a common European protocol to screen young athletes for prevention of sudden death (6). A study reporting the cardiological and genetic assessment of surviving relatives of sudden death victims, demonstrated the high diagnostic yield of ECG (at rest in 8, with exercise or flecainide in 5 subjects), with identification of the disease in 40% of families and 8.9 presymptomatic carriers for family (8).
Thus, we think that the study by Eckart et al. (1) prompts the need to implement 12-lead ECG in each screening policy (together with history and physical examination performed according to current recommendations (9,10)) of large populations (such as the military one). Such screening strategies of apparently healthy young people might be, however, encumbered by a high-frequency of false-positive test results: nonetheless, an early identification of clinically relevant pathological conditions in asymptomatic young people may permit both risk stratification and access to therapeutic interventions, potentially reducing the risk for sudden death.
Stefano Nistri, MD Cardiology Service, CMSR Veneto Medica, Altavilla Vicentina - Italy
Domenico Corrado, MD, PhD; Cristina Basso " , MD, PhD, Gaetano Thiene " , MD FRCP Department of " Pathology and Cardiology, University of Padua "“ Italy
1. Eckart RE, Scoville SL, Campbell CL, Shry EA, Stajduhar KC, Potter RN, Pearse LA, Virmani R. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med. 2004 Dec 7;141:829-34.
2. Nistri S, Thiene G, Basso C, Corrado D, Vitolo A, Maron BJ. Screening for hypertrophic cardiomyopathy in a young male military population. Am J Cardiol. 2003 Apr 15;91:1021-3
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7. Sorbo MD, Buja GF, Miorelli M, Nistri S, Perrone C, Manca S, Grasso F, Giordano GM, Nava A. The prevalence of the Wolff-Parkinson-White syndrome in a population of 116,542 young males G Ital Cardiol 1995;25:681 -7.
8. Tan HL, Hofman N, van Langen IM, van der Wal AC, Wilde AA. Sudden unexplained death: heritability and diagnostic yield of cardiological and genetic examination in surviving relatives. Circulation. 2005;112:207-13
9. Maron BJ, Pfister GC, Puffer JC. Preparticipation cardiovascular screening for young athletes. JAMA. 2000 Aug 23;284:957-8.
10. Glover DW, Maron BJ. Profile of preparticipation cardiovascular screening for high school athletes. JAMA. 1998 Jun 10;279:1817-9.
Eckart RE, Scoville SL, Campbell CL, Shry EA, Stajduhar KC, Potter RN, et al. Sudden Death in Young Adults: A 25-Year Review of Autopsies in Military Recruits. Ann Intern Med. ;141:829–834. doi: 10.7326/0003-4819-141-11-200412070-00005
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Published: Ann Intern Med. 2004;141(11):829-834.
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