










































MANUSCRIPT TYPE


EVIDENCE-TO-PRACTICE REVIEW  

 

36 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 

 
 

Implementing Cardiac Testing to Mitigate the Risk of Sudden Cardiac 
Death: An Evidence-to-Practice Review 
Victoria J. Simpson, MS, ATC*; Zachary K. Winkelmann, PhD, SCAT, ATC* 
*University of South Carolina, Columbia, SC 

  

 
ABSTRACT 
In the United States, sudden cardiac death (SCD) is the 
leading cause of fatality in young athletes during exercise. 
Allied healthcare professionals have used screening tools 
such as the 12-Element American Heart Association 
recommendations, the European Society of Cardiology 
(ESC) recommendations, and the International Olympic 
Committee guidelines to screen for cardiovascular 
abnormalities in athletes. Although each of these protocols 
consist of personal and family history questions 
complemented with a physical examination, a uniform 
screening strategy to identify athletes at risk of SCD does 
not exist. The purpose of this evidence to practice review is 
to summarize a systematic review regarding SCD-related 
abnormalities in young Middle Eastern and African 
competitive athletes and to assess available cardiac 
preparticipation physical examination (PPE) screening 
tools. The authors examined literature that reported the 
prevalence of positive cardiac abnormalities detected with 
history and physical examination tools compared to 
noninvasive cardiac testing, such as electrocardiography. 
The review also highlights the significant number of false 
positives achieved through history and physical 
examination tools only, whereas electrocardiography 
interpretations indicated by the 2014 Refined Criteria are 
superior to the 2013 Seattle Criteria and the 2010 ESC 
Recommendations. The guiding systematic review indicates 
that electrocardiography is sensitive and specific to 
predicting SCD-related abnormalities and should be a tool 
implemented in the PPE.  
  
 
Key Phrases 
Public health, clinician-rated outcomes, patient-
rated outcomes, professional standards 

 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, 
Columbia, SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
 
Full Citation 
Simpson VJ, Winkelmann ZK. Implementing cardiac 
testing to mitigate the risk of sudden cardiac death: 
An evidence-to-practice review. Clin Pract Athl Train. 
2021;4(1): 36-42. 
https://doi.org/10.31622/2021/0004.1.5.   
 
Submitted: December 15, 2020 Accepted: April 4, 2021. 

 
 
 

 
ORIGINAL REFERENCE 
Hallak YO, Battistin U, Al-Masaeed AM. 
Cardiac screening to mitigate the risk of sudden 
cardiac death in Middle Eastern and African 
competitive athletes. A systematic review. J 
Saudi Heart Assoc.  2020; 32(2): 174-185. 
 
SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 

Prior to a competitive season, athletes undergo 

a preparticipation physical examination (PPE). 
The PPE includes vital screening tools utilized by 
allied healthcare professionals to determine 
readiness for a specific sport and identify any 
potential or correctable conditions that may 
impair athletic performance.1 The National 
Athletic Trainers’ Association (NATA) has compiled 
recommendations for items included in a PPE which 
includes personal and family medical history, 
current medical conditions, signs and symptoms 
during exercise, and system-based physical 
examinations (e.g., cardiovascular, central 
nervous system, pulmonary).2 Currently, the NATA 
position statement recommends “noninvasive 
cardiac testing (e.g., echocardiography, ECG, 
exercise stress testing) not be a routine aspect of 
PPE screening unless warranted by findings from 
personal and family history”.2 This position 
statement also indicated the need for continued 
research on cardiac screening methods to 
“improve the ability to identify at-risk individuals  
in a cost-effective manner” with an acceptable 
false-positive rate to be utilized as a screening 
method to reduce the rates of sudden cardiac 
death (SCD).3  

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2021/0004.1.5


Implementing Cardiac Testing to Mitigate the Risk of Sudden Cardiac Death: An Evidence-to-Practice Review 
 

 

37 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

In the United States between 2014-2018, 50% of 
sudden cardiac arrest cases occurred in Caucasian 
competitive athletes with 55% (n=88/164) of 
those cases resulting in survival.4 However, the 
survival rates for African American athletes was 
only 25% (n=39/109) with an accompanied 
incidence rate for a male, African American, 
National Collegiate Athletic Association (NCAA)  
Division 1 basketball player at 1:2087.4 The rates 
in male, African American athletes are 2.4 times 
higher when compared to their Caucasian 
counterparts.1 The NCAA also reports the 
incidence of SCD as higher in Black athletes 
(1:1700) and male basketball players (1:7000).5 
Reports in the United States have estimated an 
incidence of 110 SCD cases each year in young 
athletes, which equates to 1 death every 3 days.5 
Additionally, the literature supports that African 
American/Black athletes are 5 times more likely 
to develop hypertrophic cardiomyopathy (HCM), 
which is the leading cause of SCD in young 
competitive athletes when compared to their Arab 
counterparts.6  

The scarcity of literature reporting the prevalence 
rates of SCD in the Middle East and Africa 
highlight the lack of ethnic-specific cardiac PPE 
screenings in these regions. Therefore, there is a 
need to exploring equitable screening and testing 
practices dependent upon race/ethnicity. The 
purpose of this evidence-to-practice review was 
to assess cardiac PPE screening methods and their 
ability to detect predisposing abnormalities 
correlated with SCD in young Middle Eastern and 
African competitive athletes.  

SUMMARY OF LITERATURE 

The guiding systematic review’s authors conducted 
a systematic search with PubMed (MEDLINE) and 
Google Scholar that examined the findings of 
Middle Eastern and African competitive athletes 
using any cardiac PPE screening method. The 
authors applied the Preferred Reporting Items for 
Systematic Reviews and Meta-Analyses (PRISMA) 

guidelines to conduct their search. The studies 
included in the systematic review had to meet the 
following inclusion criteria: (1) original published 
studies in peer-reviewed journals, in English or 
Arabic, involving PPE cardiac screening in Arab or 
African competitive athletes, (2) study population 
not restricted to gender, or athletic level, but age 
restricted to less than 36 years of age, (3) 
involved no less than 100 participants as sample 
size, (4) included cardiac screening programs and 
African or Middle Eastern Athletes, and (5) articles 
published between January 2009 and March 
2019. 

The PubMed (MEDLINE) and Google Scholar 
database searches identified 17 articles that met 
the initial inclusion criteria. Studies were 
eventually excluded due to their title, abstract 
screening, non-athletic populations, studies 
conducted outside of Arab or African competitive 
athletes, or if they were a book, editorial, case 
report, or review. The number of papers were 
reduced to 6 prior to the authors conducting a full 
text screening for eligibility. Overall, 4 studies 
were included in the qualitative synthesis of this 
systematic review. The inclusion of only 4 studies 
in this systematic review diminished the authors 
potential to generalize this data, yet this 
discrepancy depicts the gap in literature focused 
on PPE screening in athletes in this region of the 
world. The regions where these articles were 
conducted include 2 studies in Qatar, 1 study in 
the United Arab Emirates, and 1 study in Gabon. 
The authors noted that the main limitation of this 
study was the restricted access to only 2 
databases, which may have decreased their 
yielded results. 

SUMMARY OF OUTCOMES 

The authors of the guiding systematic review 
gathered the sample characteristics, sample size 
and population, study setting and focus, screening 
tools, prevalence of cardiovascular abnormalities, 
and personal and family history from the 



Implementing Cardiac Testing to Mitigate the Risk of Sudden Cardiac Death: An Evidence-to-Practice Review 
 

 

38 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

participants in the 4 studies. The authors 
designated the 2010 European Society of 
Cardiology (ESC) as the guideline used to 
interpret ECG findings amongst the studies. The 
study conducted by Alattar et al.7 (listed as 
Maffulli N et al. in the guiding systematic review) 
incorporated the Lausanne recommendations 
along with the ESC for interpretation of United 
Arab Emirates National athletes. This method 
includes collection of personal and family history, 
a physical examination, and a 12-lead ECG.7 The 
abnormalities associated with SCD that were 
examined in these studies included Wolff-
Parkinson-White syndrome (WPW), 
arrhythmogenic right ventricular cardiomyopathy 
(ARVC), HCM, dilated cardiomyopathy, and long 
QT syndrome.  

FINDINGS AND CLINICAL IMPLICATIONS 

The guiding systematic review assessed the 
reported prevalence of cardiac abnormalities 
with the efficacy of various cardiac screening 
methods for Middle Eastern and African athletes. 
The information from the 4 studies compiled to a 
total of 3,655 men, with ages ranging from 12 to 
35 years, who participated in a variety of sports 
including: football, basketball, tennis, volleyball, 
and handball. All studies incorporated the ESC 
recommendations to assess the results of 
cardiovascular screenings of participants. 

There were variations in results pertaining to the 
prevalence of these SCD-related abnormalities, 
which ranged from 0.47%-4.29% across all 
studies. Specifically, Alattar et al.7 reported 5 
Arab athletes (2.17%) with SCD-related 
abnormalities including 2 with WPW, 1 with atrial 
fibrillation, 1 with Long QT syndrome, and 1 with 
ARVC. Riding et al.6 documented SCD-related 
abnormalities in 10 (0.47%) athletes: 5 Black and 
2 Arab athletes with HCM, and 3 Arab athletes 
with WPW.  Wilson et al.8 recorded 7 (0.63%) 
athletes with an SCD-associated abnormality: 1 
Arab and 1 African athlete had WPW, 2 Arab 

and 1 African athlete had HCM, 1 African athlete 
had ARVC, and 1 Arab athlete had Long QT 
syndrome. The final study by Schmied et al.9 
detailed those 9 (4.29%) African athletes had an 
SCD-related abnormality: 5 with Long QT 
syndrome, 3 with WPW, and 1 with HCM upon 
echocardiography.  

The prevalence of SCD-related abnormalities in 
these Arab athletes were 2.17% and produced 
false-positive rates at 20.4 %.7 The Riding et al.6 
study examined false-positive rates when using 
the ESC, Seattle Criteria, and the 2014 Refined 
Criteria in Arab and Black athletes. The ECG 
interpretations by the 2014 Refined Criteria 
decreased false-positives to 3.6% in Arab 
athletes (vs 19.1% using ESC guidelines and 9.7 
% using Seattle criteria) and 10% in Black 
athletes (vs 29.9% using ESC guidelines and 
16.6% using Seattle criteria).6 The 2014 Refined 
Criteria was 100% sensitive in discovering SCD-
related cardiac pathologies, while reducing false-
positives.6   

Alattar et al.7 indicated 2 Arab athletes had a 
positive family history of SCD, 6 (2.6%) Arab 
athletes reported a history of syncope, and 8 
(3.8%) experienced a form of chest discomfort. 
Wilson et al.8 reported 17 west Asian and 14 
Black athletes with a family history of SCD and 8 
(0.66%) athletes reporting cardiovascular 
symptoms during activity. Finally, Schmied at al.9 
shared those 36 (17%) African athletes had a 
family history of SCD with 19 (9%) indicating 
atypical chest discomfort.  

CLINICAL BOTTOM LINE 

The American Heart Association (AHA) estimates 
the prevalence of SCD-related abnormalities that 
predispose young athletes is 0.3%, whereas the 
incidence of potentially lethal SCD consistently 
ranges between 0.2 to 0.7%.1 This correlate to 1 
in 500 athletes with an undetected cardiac 
abnormality.1 The AHA, the ESC, and the 
International Olympic Committee recommend 



Implementing Cardiac Testing to Mitigate the Risk of Sudden Cardiac Death: An Evidence-to-Practice Review 
 

 

39 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

cardiovascular screening for all athletes. 
Nevertheless, these entities do not have a uniform 
protocol, nor do they all advocate for the inclusion 
of a resting 12-lead ECG in PPE.1 Several 
differences exist when comparing the ESC 
recommendations to the 12-Element AHA 
recommendations for cardiac pre-participation 
screening.10  

Based on the findings of the guiding systematic 
review and other supporting evidence, the 
sensitivity of preparticipation protocols that 
simply implement history questions and physical 
examinations do not significantly detect 
predisposing SCD-related abnormalities in young 
athletes. In a previous systematic review 
comparing screening strategies, the most clinically 
sensitive method to rule out a cardiovascular 
condition was an ECG (94%) as compared to 
history (20%) or physical exam (9%).11 However, 
the specificity of each of these methods is similar 
(ECG: 93%, history: 94%, physical exam: 
97%).11 In a report of 115 SCD cases in young 
athletes, only 1 athlete (0.9%) was accurately 
diagnosed with an underlying cardiovascular issue 
when using the history and physical examination 
screening model.1 

Although there is a concern that ECGs produce a 
high number of false-positive results leading to 
unnecessary diagnostic testing, studies have shown 
that the adoption of modern, strict ECG criteria 
have lowered false-positive rates to 6% 
compared to history at 8% and physical 
examination at 10%.1,3 The studies in this review 
highlight that the rate of false-positives are 
greater with a history and physical examination 
model. Another consideration is the cost 
component associated with the implementation of 
ECG to pre-participation screenings. The cost to 
perform the AHA-recommended cardiovascular 
history and physical examination is estimated at 
$0 because it is done in conjunction with a PPE.12 
However when an SCD-related abnormality is 
detected, the athlete will undergo a cardiology 

consultation (average cost of $150), potential 
treadmill testing (average cost of $225), and 2D 
echocardiography (average cost of $350) for an 
average cost of $500 to evaluate an abnormality 
detected with the AHA-recommended screening.12 
Conversely, the estimated cost to perform an ECG 
during mass PPE is $10 with an average cost of 
$365 to evaluate detected abnormalities.12 
Cardiac abnormalities that have gone undetected 
in traditional PPE screenings prior to physical 
activity have resulted in wrongful death lawsuits.13 
In 2012, the family of Ronald Rouse, an 18-year-
old former Hartsville football player, were 
compensated $260,000 to dismiss the wrongful 
death of their son from an undiagnosed cardiac 
arrhythmia that resulted in cardiac arrest.13 
Similar instances of young athletes dying from 
cardiac arrest from detectable abnormalities 
include cases such as Kleinknecht v. Gettysburg 
College with the death of a lacrosse player and 
15-year-old Star Ifeacho at Dunbar High 
School.14,15 This upstream initiative to minimize 
fatalities related to SCD through early detection 
could potentially save young lives at a low 
incremental cost of $10 and negate costly 
wrongful death lawsuits.12 The interpretation of 
the guiding systematic review and supporting 
literature suggests that the addition of the 
updated criteria for 12-lead ECG in PPE could 
potentially positively detect SCD-related 
abnormalities when compared to history and 
physical examinations alone, especially in 
susceptible minority populations. 

Conditions that predispose athletes to SCD are 
preventable if effectively managed through 
activity modification and medical intervention. The 
guiding systematic review reported that the 
prevalence of SCD occurred at higher rates in 
football and basketball as compared to soccer. 
We suggest that clinicians use this data to provide 
a comprehensive, patient-centered PPE exam that 
is reflective of the cultural and ethnic differences 
of the individuals we treat. While equal care 
would incorporate advanced cardiac testing for 



Implementing Cardiac Testing to Mitigate the Risk of Sudden Cardiac Death: An Evidence-to-Practice Review 
 

 

40 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

all, the results of this guiding systematic review 
suggest, at minimum, equitable care be provided 
to the predisposed young individuals of African 
and Middle Eastern descent. However, equitable 
care extends beyond cardiac testing in minority 
populations. Athletic trainers must be cognizant 
how social determinants of health based on a 
patient’s race and ethnicity may influence their 
health outcomes and risks. A prime example of this 
bias in care, involves how Blacks and other 
minority populations in the United States have 
been systemically denied mortgages or approval 
for leased housing in neighborhoods at higher 
rates than Caucasians for decades.16 This housing 
crisis cascaded to create an increasing 
educational gap where Black students are 
inadequately prepared for academic success 
because they attend poorer, disadvantaged 
school systems.16 Overall, this is just one example 
of how Blacks and African Americans have been 
impoverished and unhealthy because of an 
oppressive system established over 300 years 
ago that resulted in racialized institutions and 
further perpetuated white privilege.17  

To provide patient-centered care, we must 
recognize how race and ethnicity, as well as other 
social determinants of health, may change the PPE 
process for some athletes as compared to others. 
Barkley et al.16 discussed how diversity in athletic 
participation is continually increasing in the NCAA, 
but there is a need for sports medicine literature 
to address additional knowledge, skills, and 
abilities in cultural competency and to promote 
health equity.16 Historically in this nation, minority 
populations, especially Black people, have not 
been treated equitably in the healthcare system 
compared to their Caucasian 
counterparts.16,17,18,19 Evidence also suggests that 
health care professionals, such as athletic trainers 
and team physicians, have limited knowledge 
about effectively delivering culturally competent 
care.16 This variance in treatment in minority 
populations, especially in Black communities,  
stems from the higher proportion of minorities 

living in “medical deserts” where communities lack 
health care resources.19 Residential segregation 
and racial disparities are a fundamental cause for 
health disparities and have an association with 
infant mortality, adult mortality, poor health 
status, smoking during pregnancy, poor birth 
outcomes, tuberculosis and other infectious 
diseases, and exposure to cancer-causing air 
toxins.16  The discord in research that quantifies 
these statistics and the effort to combat these 
issues do not align. The majority-white 
decisionmakers include public health researchers, 
policymakers, medical educators, officials, 
hospital administrators, and insurance and 
pharmaceutical executives.17 Caucasians make up 
three quarters of those practicing medicine, 77% 
of American Medical Association delegates, 85% 
of American Medical Association board members, 
23 of 27 directors of the National Institutes of 
Health, 90% of National Institutes of Health 
branch and lab chiefs, and 83% of senior 
investigators.17 These healthcare providers write 
policies from a position of privilege, creating a 
White framework which normalizes discriminatory 
practices and reinforces institutionalized inequity 
in health care and health – a contributing factor 
in the delay to adopt cardiac screening by many 
leading sports organizations.17 Public health 
efforts to reduce SCD in Black athletes is a crucial 
step; however, it is only a small aspect of the 
health disparity issue that needs to be addressed 
holistically for true equality to be achieved.18 
Further research is needed to understand the 
underlying persistent racial differences in SCD-
related abnormalities to mitigate the risk of SCD 
in Black athletes.18  

The profession of athletic training is continuously 
advancing its skillset to minimize patient risk of 
injury and illness. Athletic trainers complete PPEs 
annually to mitigate these risks. In the United 
States, the NATA suggests the implementation of 
the 12-Element AHA recommendations for 
cardiovascular screening to detect potential 
underlying cardiac conditions in young athletes.2 



Implementing Cardiac Testing to Mitigate the Risk of Sudden Cardiac Death: An Evidence-to-Practice Review 
 

 

41 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

However, evidence indicates that questioning an 
athlete about their personal and family history 
paired with a physical examination does not 
accurately detect these fatal disorders.12 A 
parallel example of a lethal medical condition in 
the athletic setting is sickle cell trait, which athletic 
trainers now readily test for. The literature 
provides evidence that ECGs are highly sensitive 
in indicating SCD-related abnormalities and 
should become common practice during PPEs in 
both the collegiate and youth setting. These 
entities should strive to incorporate ECG testing 
into their policies and procedures as a means of 
best practice. The results from the manuscript 
suggest that additional research on the 
prevalence of abnormalities correlated to SCD in 
young Middle Eastern and African competitive 
athletes should be conducted since SCD 
disproportionately impacts athletes of color; 
especially young, African American males. 

REFERENCES 

1. Asif IM, Toresdahl BG, Drezner JA. 
Chapter 3: Prevention of sudden cardiac 
death in young athletes. In: Casa DJ, 
Stearns RL. Preventing Sudden Death. 2nd 
ed. Jones & Bartlett Learning; 2017:33-
50. 

2. Conley KM, Bolin DJ, Carek PJ, Konin 
JG, Neal TL, Violette D. National athletic 
trainers’ association position statement: 
Preparticipation physical examinations 
and disqualifying conditions. J Athl Train. 
2014;49(1):102-120. 
https://doi.org//10.4085/1062-6050-
48.6.05.  

3. Winkelmann ZK, Crossway AK. Optimal 
screening methods to detect cardiac 
disorders in athletes: An evidence-based 
review. J Athl Train. 2017;52(12):1168-
1170. https://doi.org/10.4085/1062-
6050-52.11.24.  

4. 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. 
BJSM. Published Online First: 12 
November 2020. 
https://doi.org/10.1136/bjsports-
2020-102666.  

5. Casa DJ, Guskiewicz KM, Anderson SA, 
Courson RW, Heck JF, Jimenez CC, 
McDermott BP, Miller MG, Stearns RL, 
Swartz EE, Walsh KM. National athletic 
trainers’ association position statement: 
Preventing sudden death in sports. J Athl 
Train. 2012;47(1):96-118. 
https://doi.org/10.4085/1062-6050-
47.1.96.  

6. Riding NR, Sheikh N, Adamuz C, Watt V, 
Farooq A, Whyte GP, George KP, 
Drenzer JA, Sharma S, Wilson MG. 
Comparison of three current sets of 
electrocardiographic interpretation 
criteria for use in screening athletes. 
Heart. 2015;101:384-390. 
https://doi.org/10.1136/heartjnl-2014-
306437.  

7. Alattar A, Ghani S, Mahdy N, Hussain H, 
Maffulli N. Pre-participation 
musculoskeletal and cardiac screening of 
male athletes in the United Arab 
Emirates. Transl Med UniSa. 2014;9:43-
49. PMID: 24809035. 

8. Wilson MG, Chatard JC, Carre F, 
Hamilton B, Whyte GP, Sharma S, 
Chalabi H. Prevalence of 
electrocardiographic abnormalities in 
West-Asian and African male athletes. 
Br J Sports Med. 2012;46:341-347. 

https://doi.org/10.4085/1062-6050-48.6.05
https://doi.org/10.4085/1062-6050-48.6.05
https://doi.org/10.4085/1062-6050-52.11.24
https://doi.org/10.4085/1062-6050-52.11.24
https://doi.org/10.1136/bjsports-2020-102666
https://doi.org/10.1136/bjsports-2020-102666
https://doi.org/10.4085/1062-6050-47.1.96
https://doi.org/10.4085/1062-6050-47.1.96
https://doi.org/10.1136/heartjnl-2014-306437
https://doi.org/10.1136/heartjnl-2014-306437


Implementing Cardiac Testing to Mitigate the Risk of Sudden Cardiac Death: An Evidence-to-Practice Review 
 

 

42 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

https://doi.org/10.1136/bjsm.2010.08
2743.  

9. Schmied C, Di Paolo FM, Zerguini AY, 
Dvorak J, Pelliccia A. Screening athletes 
for cardiovascular disease in Africa: A 
challenging experience. Br J Sports Med. 
2013;47(9):589-584. 
https://doi.org/10.1136/bjsports-
2012-091803.  

10. Lithwick DJ, Fordyce CB, Morrison BN, 
Nazzari H, Krikler G, Isserow S, Heilbron 
B, Taunton J. Pre-participation screening 
in the young competitive athlete: 
International recommendations and a 
Canadian perspective. B C Med J. 
2016;58(3):145-151.  

11. Harmon KG, Zigman M, Drezner JA. The 
effectiveness of screening history, 
physical exam, and ECG to detect 
potentially lethal cardiac disorders in 
athletes: A systematic review/meta-
analysis. J Electrocardiol. 
2015;48(3):329-338. 
https://doi.org/10.1016/j.jelectrocard.
2015.02.001.  

12. Fuller CM. Cost effectiveness analysis of 
screening of high school athletes for risk 
of sudden cardiac death. Med Sci Sports 
Exerc. 2000;32(5):887-890. 

13. Smith C. Parents settle S.C. football 
wrongful death suit for $260,000. USA 
Today. December 14, 2016. Accessed 
April 2, 2021. 
https://usatodayhss.com/2016/parents-
settle-outstanding-football-wrongful-
death-suit-for-just-260000.  

14. Kleinknecht v. Gettysburg, 786 F. Supp. 
449 (M.D. Pa 1992). 

15. Mother of high school athlete who died 
after collapsing at school files lawsuit. 

WKYT. December 11, 2017. Accessed 
April 2, 2021. 
https://www.wkyt.com/content/news/M
other-of-high-school-athlete-who-died-
after-collapsing-at-school-files-lawsuit-
463411543.html.  

16. Barkley L, Taliaferro LA, Baker K, 
Garcia J. The holistic athletic healthcare 
model: Addressing the developmental, 
social, and cultural needs of collegiate 
athletes. JHEAI. 2018;1(3):26-47. 
https://doi.org/10.15763/issn.2376-
5267.2018.1.3.26-47.  

17. Feagin J, Bennefield Z. Systemic racism 
and U.S. health care. Soc Sci Med. 
2014;103:7-14. 
https://doi.org/10.1016/j.socscimed.20
13.09.006.  

18. Deo R, Safford MM, Khodneva YA, 
Jannat-Khah DP, Brown TM, Judd SE, 
McClellan WM, Rhodes JD, Shlipak MG, 
Soliman EZ, Albert CM. Differences in 
risk of sudden cardiac death between 
Blacks and Whites. J Am Coll Cardiol. 
2018;72(20):2431-2439. 
https://doi.org/10.1016/j.jacc.2018.08
.2173.  

19. Gaskin DJ, Dinwiddie GY, Chan KS, 
McCleary RR. Residential segregation 
and the availability of primary care 
physicians. Health Serv Res. 
2012;47(6):2353-2376. 
https://doi.org/10.1111/j.1475-
6773.2012.01417.  

 

 

https://doi.org/10.1136/bjsm.2010.082743
https://doi.org/10.1136/bjsm.2010.082743
https://doi.org/10.1136/bjsports-2012-091803
https://doi.org/10.1136/bjsports-2012-091803
https://doi.org/10.1016/j.jelectrocard.2015.02.001
https://doi.org/10.1016/j.jelectrocard.2015.02.001
https://usatodayhss.com/2016/parents-settle-outstanding-football-wrongful-death-suit-for-just-260000
https://usatodayhss.com/2016/parents-settle-outstanding-football-wrongful-death-suit-for-just-260000
https://usatodayhss.com/2016/parents-settle-outstanding-football-wrongful-death-suit-for-just-260000
https://www.wkyt.com/content/news/Mother-of-high-school-athlete-who-died-after-collapsing-at-school-files-lawsuit-463411543.html
https://www.wkyt.com/content/news/Mother-of-high-school-athlete-who-died-after-collapsing-at-school-files-lawsuit-463411543.html
https://www.wkyt.com/content/news/Mother-of-high-school-athlete-who-died-after-collapsing-at-school-files-lawsuit-463411543.html
https://www.wkyt.com/content/news/Mother-of-high-school-athlete-who-died-after-collapsing-at-school-files-lawsuit-463411543.html
https://doi.org/10.15763/issn.2376-5267.2018.1.3.26-47
https://doi.org/10.15763/issn.2376-5267.2018.1.3.26-47
https://doi.org/10.1016/j.socscimed.2013.09.006
https://doi.org/10.1016/j.socscimed.2013.09.006
https://doi.org/10.1016/j.jacc.2018.08.2173
https://doi.org/10.1016/j.jacc.2018.08.2173
https://doi.org/10.1111/j.1475-6773.2012.01417
https://doi.org/10.1111/j.1475-6773.2012.01417

	ABSTRACT

