COLLEGIATE ATHLETES’ KNOWLEDGE OF SUDDEN CARDIAC DEATH ON
SIGNS & SYMPTOMS AND RISK FACTORS

A THESIS
Submitted to the Faculty of the School of Graduate Studies
and Research
of
California University of Pennsylvania in partial
fulfillment of the requirements for the degree of
Master of Science

by
Brittney Brown, ATC, PES

Research Advisor, Dr. Carol Biddington
California, Pennsylvania
2013

CALIFORNIA UNIVERSITY of PENNSYLVANIA
CALIFORNIA, PA

THESIS APPROVAL

Graduate Athletic Training Education

We hereby approve the Thesis of

Brittney Brown
Candidate for the degree of Master of Science

Date

Faculty

iii
ACKNOWLEDGEMENTS

Firstly, I would like to thank my family. I went back
to school for them, to be everything they ever thought I
could be. To my parents, thank you for sticking by me
while I moved back and forth from home. Mom, I want to
thank you for doing my laundry whenever I came home and
putting up with my late night studying habits. Dad, I
would like thank you for taking me fishing and out to eat
to help relieve some stress from my classes. Ryan, thank
you for dealing with me as another mom while I was home.
To Poppy and Nanny, I am so grateful you were able to see
me graduate from grad school and start my life. You have
pushed me from day one and I appreciate every bit. I love
you all and thank you.
To my thesis advisor, Dr. Carol Biddington, I want to
thank you for putting up with my procrastination and
keeping me on track. Your wisdom and knowledge is a main
reason I was able to understand this process and finish it.
I also would like to thank Dr. Michael Meyer and Dr. Ayanna
Lyles for being on my thesis committee and steering me in
the right direction.
I would also like to thank Westminster College for
agreeing to send my survey out to their student athletes.
Also, thank you to the athletic director Mr. James Dafler.
You were very compliant and helpful in achieving success
with my survey. I would like to thank the athletes who
participated in the survey. Without you, I would not have
completed this thesis.

iv
TABLE OF CONTENTS
Page
SIGNATURE PAGE

. . . . . . . . . . . . . . . ii

AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS
LIST OF TABLES
INTRODUCTION
METHODS

. . . . . . . . . . . . . . iv

. . . . . . . . . . . . . . . vii

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . .

Research Design

. . . . . . . . . . . . . .

Preliminary Research
Subjects

. . .

. . . . . . . . . . . .

. . . . . . . . . . . . .

6
7

Instruments . . . . . . . . . . . . . . . .

Procedures. . . . . . . . . . . . . . . . .

Hypotheses. . . . . . . . . . . . . . . . . 10
Data Analysis
RESULTS

. . . . . . . . . . . . . . . 10

. . . . . . . . . . . . . . . . . . 11

Demographic Data . . . . . . . . . . . . . . 11
Hypothesis Testing

. . . . . . . . . . . . . 13

Additional Findings . . . . . . . . . . . . . 14
DISCUSSION . . . . . . . . . . . . . . . . . 17
Discussion of Results . . . . . . . . . . . . 17
Conclusion

. . . . . . . . . . . . . . . . 20

Recommendations. . . . . . . . . . . . . . . 21

v
REFERENCES . . . . . . . . . . . . . . . . . 25
APPENDICES . . . . . . . . . . . . . . . . . 29
APPENDIX A: Review of Literature

. . . . . . . . 30

Prevention of Sudden Cardiac Death.

. . . . . . 31

Screening . . . . . . . . . . . . . . . . 31
History . . . . . . . . . . . . . . . . . 37
Background of Sudden Cardiac Death in Spor t . 39
Incidence . . . . . . . . . . . . . . . . 39
Pathophysiology.

. . . . . . . . . . . . 43

Collegiate Athletes Knowledge of Healthcare . 45
Summary. . . . . . . . . . . . . . . . . . 49
APPENDIX B: The Problem . . . . . . . . . . . . 52
Statement of the Problem . . . . . . . . . . . 53
Definition of Terms . . . . . . . . . . . . . 53
Basic Assumptions . . . . . . . . . . . . . . 54
Limitations of the Study . . . . . . . . . . . 54
Significance of the Study

. . . . . . . . . . 55

APPENDIX C: Additional Methods .

. . . . . . . . 57

Letter to the Experts (C1) . . . . . . . . . . 58
Collegiate Athletes’ Knowledge on Sudden Cardiac
Death Survey (C2) . . . . .

. . . . . . . . 60

IRB: California University of Pennsylvania (C3) . . 63
Survey Cover Letter (C4) . . . . .

. . . . .

. 70

REFERENCES . . . . . . . . . . . . . . . . . 72

vi
ABSTRACT

. . . . . . . . . . . . . . . . . . 76

vii
LIST OF TABLES
Table

Page

1. Gender of Athlete . . . . . . . . . . . . . .

2. Age of Athlete

. . . . . . . . . . . . . .

3. Ethnicity of Athlete

. . . . . . . . . . . .

4. Sports Participated . . . . . . . . . . . . .

5. CPR/AED Certified . . . . . . . . . . . . . .

6. Formal Education on Sudden Cardiac Arrest/Death . .

7. A MANOVA for Gender and Ethnicity on Cardiac Signs
and Symptoms and Risk Factors . . . . . . . . .
8. Sign and Symptoms Knowledge Answers
9. Risk Factors Knowledge Answers

. . . . . .

. . . . . . . .

1
INTRODUCTION

Many topics are currently being discussed regarding
health care, but one topic that has become more and more
reoccurring is sudden cardiac death.

Sudden cardiac death

is talked about happening from younger athletes all the way
up to professionals.

Even though the actual chance of

sudden cardiac death in athletes is small, the fact that
any athlete can die while playing the sport they love is
horrifying.

Research has been done on cardiac related

issues, but screenings for athletes based on medical
history are costly and time consuming.1-10
The prevention of sudden cardiac death is being
investigated by medical professionals.

One way that has

been found to help limit the chance of death is from health
history and screening.

Obtaining a person’s medical

history is part of a pre-participation exam done when an
athlete enters college.

The history form will identify

previous health problems of the patient, including alarming
conditions, which require special attention.11-13

The items

found that needs special attention would then lead to a
screening.

Screening could be done for any type of problem

including orthopedic along with cardiovascular.

Due to the

cost of different screenings through insurance companies,

2
some programs cannot refer patients who have these possible
life threatening conditions.

The worse part about

screenings is that as much as they may save a life, the
need for mandatory screenings with all athletes are not
being done, some due to a lack of resources.

Usually, only

athletes who are deemed high risk are screened for
different problems.1-10
One way knowledge will be increased in athletes is by
educating the athletes on the background of sudden cardiac
death in sport.

The first thing that needs to be

understood is incidence rate, which deals with
geographical, sex, and age factors.

Incidences of sudden

cardiac death sometimes depend on where the athlete is
participating.

Elevation height along with the weather

conditions could possibly lead to a higher risk of
developing a heart condition.

Risk of sudden cardiac death

also depends on the age and sex of the athlete.13-19
Pathophysiologically, some ethnicities are more prone to
developing heart conditions, which would lead to an
increase of incidences that could potentially be deadly.
Since certain races are prevalent in certain sports, which
leads to a higher number of incidences for certain sports,
than recorded in other sports.20-22

3
Knowing the signs and symptoms of sudden cardiac death
is helpful information when dealing with athletes.

Studies

have been done combining pre-participation screenings with
ECG screenings.

These studies have found that by

screening, athletes with any cardiovascular disease not
currently showing any signs or symptoms were able to be
identified.

Most states in the United States require some

sort of pre-participation exams, even though ECG screenings
are not done unless signs and symptoms are found in the
participant.

Information on sudden cardiac death helps

identify signs and symptoms, which allows for the need of
medical intervention when symptoms occur.1-13
A major part of a history form is identifying the
predisposing factors or risk factors of the participant.
Positive risk factors allow the medical professional to be
alerted of any concerning issues.

Risk factors could

include having a cardiac abnormality like mitral valve
prolapsed, myocarditis, Marfan’s syndrome, aortic
regurgitation, arrhythmogenic right ventricular
cardiomyopathy, and hypertrophic cardiomyopathy.

Consensus

on cardiac issues shows that having hypertrophic
cardiomyopathy is an alarming feature of cardiac issues,
but other cardiac abnormalities are also alarming risk
factors.

Most ECG screenings are done only when

4
participants have family history or other predisposing risk
factors that would warrant a screening.1-12

Different sports

also allot to having a higher risk factor than others,
including marathon running, football, basketball, and
squash.

Other risk factors leading to sudden cardiac death

include gender and ethnicity.

Sudden cardiac death has

been found higher in males than females.

Ethnicity also

plays a role, leading to findings of African Americans
having a higher percentage of cardiac abnormalities,
specifically hypertrophic cardiomyopathy.14-22
Research on sudden cardiac death is hard to find due
to the lack of subjects and valid information.

It is a

prevalent cause to be able to find collegiate athletes’
knowledge of heath care.

Issues dealing with concussion,

cardiac conditions, general illness, and orthopedics are
becoming more and more apparent to the general public
through media sources.

Without teaching and prior to

participation in sports, knowledge levels of athletes vary
depending on their education backgrounds.

Knowledge is the

only thing that can prepare someone to save an athlete from
sudden cardiac death while someone is experiencing it
first-hand.

Without being prepared or having been taught

what to do, people may freeze and in turn may lose the
chance to save the life at risk.23-25

5
This study will provide ample information regarding
sudden cardiac death.

The purpose of this study is to

determine the knowledge collegiate athletes have in regards
to sudden cardiac death.

A secondary purpose of this study

is to determine the reliability for the two dependent
variables: signs & symptoms and risk factors.

The

information found from the survey will potentially help
enlighten the medical field to show the level of knowledge
athletes have on sudden cardiac death.

Based upon

findings, recommendations may show more information needs
to be taught in order to increase knowledge.

6
METHODS

The primary purpose of this study was to examine the
knowledge of collegiate athletes on sudden cardiac death.
This section will include the following subsections:
research design, preliminary research, subjects,
instruments, procedures, hypotheses, and data analysis.

secondary purpose of this study was to determine the
reliability for the two dependent variables: 1) signs and
symptoms and 2) risk factors.

Research Design

The research used a descriptive design for the study.
The independent variables were ethnicity and gender.

The

dependent variables were knowledge on signs and symptoms
along with knowledge of risk factors of sudden cardiac
death as measured by the Collegiate Athletes’ Cardiac
Knowledge Survey.

The design was made to specifically

determine the knowledge of college athletes on sudden
cardiac death along with specific diseases or conditions
that could possibly lead to being at a higher risk for
sudden cardiac death.

The strength of the study was that

content validity was determined after a review by a panel

7
of experts.

A limitation of this study was that only

athletes from one division III college were subjects.

Preliminary Research

There was a panel of four experts (Appendix C1) who
reviewed the survey.

The panel was handpicked from a list

of experts and was asked directly by the researcher.

The

members included certified athletic trainers Shaun Toomey,
Adam Annaconne, and Michele Kabay, along with Dr. Jose
Ramirez-DelToro, who is the team physician at California
University of Pennsylvania.

The researcher was looking for

the expert’s opinion on the survey along with comments and
revisions on questions and overall presentation of the
survey.

Subjects

The subjects (N=80) that were used for this study were
volunteers from the population of male and female athletes
from Westminster College.

All subjects were enrolled in

college and participated in a varsity and/or club sport.
These sports included football, soccer, swimming, diving,
cheerleading, volleyball, tennis, basketball, baseball,

8
softball, track & field, cross-country, golf, or any other
sport offered at the school.
Informed consent was assumed by the subject’s
participation in the survey.

Each participant’s identity

and personal information remained confidential and was not
included in the study.

Instruments

A survey titled Collegiate Athletes’ Cardiac Knowledge
(Appendix C2) was developed by the researcher.

The

information was found in a Starkey et al textbook titled
Examination of Orthopedic and Athletic Injuries.26
survey was distributed using Survey Monkey.
consisted of four sections.

The

The survey

The first section was

comprised of demographic questions including gender, age,
sport, and ethnicity.

The second section asked questions

about a CPR/AED certification and if any previous education
was taught on sudden cardiac arrest/death.

The next

section has one question about their knowledge on the signs
and symptoms of cardiac issues.
would be a 24.

The highest score possible

The fourth section deals with one question

that asks about their knowledge on risk factors of sudden
cardiac death.

The optimal score with this question would

9
be 18.

There are eight questions for the entirety of the

survey.
The athletes’ knowledge was measured by how well they
answer the knowledge questions, which are the last two
questions (signs and symptoms, risk factors).

The survey

was scored by a correct answer of one and an incorrect
answer of zero.

In total, there are a combined 19 correct

answers out of a total of 42 answers for the seven and
eighth questions.
score.

The demographic questions do not have a

They are made strictly to see what sort of

background the athlete is coming from.

Procedures

The researcher obtained approval from the IRB at
California University of Pennsylvania (Appendix C3) before
any research was conducted.

The study was distributed

through an email to varsity athletes (n=80) of all sports
on campus at Westminster College.

To be able to send the

survey out to athletes, the researcher obtained permission
from Westminster College athletic director Jim Dafler.
Prior to the survey being emailed to the athletes, a panel
of experts analyzed the survey and suggested improvements
or changes (Appendix C1).

Instructions for the survey were

10
included in the email along with a link to take the survey.
In addition, accompanying the survey was a cover letter
(Appendix C4) explaining the purpose of the study.

follow-up email was sent after the first week encouraging
participants to complete the survey.

The knowledge survey

took approximately 10 minutes to complete.

Hypotheses

The following hypotheses were based previous research
and the researcher’s intuition based on a review of the
literature.
1. There will be a difference between genders for a)
signs and symptoms score and b) risk factors of
cardiac knowledge score.
2. There will be a difference between ethnicity for a)
signs and symptoms score and b) risk factors of
cardiac knowledge score.

Data Analysis

All data was analyzed by SPSS version 18.0 for Windows
at an alpha level of 0.05.
analyzed using a MANOVA.

The research hypotheses were

11
RESULTS

Demographic Data

Collegiate athletes from Westminster College (N = 80)
voluntarily participated in this study.

Table 1 represents

the gender of these athletes.
Table 1 Gender of Athlete
Gender
Frequency
Male
36
Female
44

Percent
45.0
55.0

Table 2 represents the age of the athlete.
Table 2 Age of Athlete
Age
18-20
21-23
24-26
27-29

Frequency
53
26
0
1

Percent
66.3
32.5
0
1.3

Table 3 represents the athlete’s ethnicity.
Table 3 Ethnicity of Athlete
Ethnicity
Frequency
Caucasian
76
Hispanic / Latino
0
Native American
1
African American
3
Asian / Pacific Islander 0
Other
0

Percent
95.0
0
1.3
3.8
0
0

Table 4 represents the sport(s) that the athlete
participates in at Westminster College.

Other represents

12
club sports played at the school.

The two participants

were involved in the lacrosse and wrestling club.
Table 4 Sports Participated
Sport
Frequency
Football
15
Soccer
18
Swimming
8
Diving
0
Cheerleading
0
Volleyball
7
Tennis
5
Basketball
8
Baseball
1
Softball
0
Track / Field
29
Cross Country
11
Golf
1
Other
2

Percent
18.8
22.5
10.0
0
0
8.8
6.3
10.0
1.3
0
36.3
13.8
1.3
2.6

Table 5 represents if the athlete is CPR/AED certified
or not.
Table 5 CPR/AED Certified
Answer
Frequency
Yes
38
No
42

Percent
47.5
52.5

Table 6 represents if the athlete has had any previous
formal education on sudden cardiac arrest/death.
Table 6 Formal Education on Sudden Cardiac Arrest/Death
Answer
Frequency
Percent
Yes
35
43.8
No
45
56.3

13
Hypothesis Testing
The level of significances for testing all hypotheses
was set at an alpha level of .05.
Hypothesis 1: There will be a difference between genders
for a) signs and symptoms score and b) risk factors of
cardiac knowledge score.
Hypothesis 2: There will be a difference between
ethnicity for a) signs and symptoms score and b) risk
factors of cardiac knowledge score.

Conclusion: A 2 (gender) x 3 (ethnicity) between-subjects
factorial MANOVA was calculated comparing the knowledge
scores for participants on signs and symptoms and risk
factors of sudden cardiac death.
Table 7.

This is presented in

The main effect for gender on signs and symptoms

was not significant, (F(1,73) = 0.198, p > .05), and for gender
on risk factors, (F(1,73) = 0.471, p > .05).

There was no

significant main effect for ethnicity on signs and
symptoms, (F(2,73) = 0.203, p > .05), and for ethnicity on risk
factors, (F(2,73) = 0.048, p > .05).

The interaction between

gender and ethnicity was also insignificant for signs and
symptoms, (F(1,73) = 0.000, p > .05)., and interaction between
gender and ethnicity was also insignificant on risk
factors, (F(1,73) = 0.355, p > .05).

Thus, it appears that

neither the gender nor ethnicity have any significant
effect on signs and symptoms and risk factors.

14
Table 7 A MANOVA for Gender and Ethnicity on Cardiac Signs
and Symptoms and Risk Factors
Source
Dependent
Type III df
MS
F
P
Variable
Sum of
Squares
Gender
SS*
0.670
1
0.670
0.198 .658
RF*
1.658
1
1.658
0.471 .495
Ethnicity
SS*
1.375
2
0.687
0.203 .817
RF*
0.337
2
0.168
0.048 .953
Gender*Ethnicity
SS*
0.000
1
0.000
0.000 .993
RF*
1.250
1
1.250
0.355 .553
Error
SS*
247.208
73
3.386
RF*
256.838
73
3.518
*SS (Signs & Symptoms), RF (Risk Factors)

Additional Findings

The secondary purpose of this study was to determine
the reliability of the survey.

A Kuder Richardson test was

used to determine the reliability of signs and symptoms and
risk factors.

The reliability for the signs and symptoms

section of the study was 0.565.

The reliability for the

risk factors section of the study was 0.624.

Both

variables had moderate reliability.
In addition to the MANOVA test, frequencies for the
athletes’ knowledge on signs and symptoms along with
knowledge on risk factors were also done.

Table 8 reveals

15
the knowledge answers for signs and symptoms of sudden
cardiac death.
Table 8 Sign and Symptoms Knowledge Answers
Sign & Symptoms
Correct
Fatigue*
50
Nausea
55
Headache
56
Fever
72
Night Sweats
77
Chest Pain*
73
Upset Stomach
78
Knee Pain
80
Shoulder Pain*
20
Panic*
31
Trouble Sleeping
72
Sore Throat
80
Sensitivity Light/Sound
70
Dizziness*
45
Exertional Syncope*
1
Dyspnea*
2
Amnesia
78
Heart’s “Racing”*
66
Double Vision
69
Blurry Vision
52
Sensation of Chest Pain*
67
Low Back Pain
78
Coughing
68
Shortness of Breath*
70
*Correct sign and symptoms answers

Incorrect
30
25
24
8
3
7
2
0
60
49
8
0
10
35
79
78
2
14
11
28
13
2
12
10

Table 9 shows knowledge answers for risk factors of
sudden cardiac death.

16
Table 9 Risk Factors Knowledge Answers
Risk Factors
Correct
Sudden Death Family
Before 50*
49
Seizures
59
History of Cancer
75
Sickle Cell Trait
65
Any Heart Conditions*
69
History of Concussion
79
Family History
Of Heart Conditions*
71
Migraines
77
Asthma*
12
Heart Murmur*
64
Shortness of Breath
During Exercise*
49
Weight*
53
Previous Fracture
80
Atherosclerosis*
8
Insomnia
78
Pain with Exercise*
22
Sudden Weight Loss
63
Wears Contacts/Glasses
80
*Correct risk factors answers

Incorrect
31
21
5
15
11
1
9
3
68
16
31
27
0
72
2
68
17
0

17
DISCUSSION

The following section will include discussion of
results, conclusions, and recommendations.

Discussion of Results

This study focused on the knowledge of collegiate
athletes on sudden cardiac death focusing on signs and
symptoms and risk factors.

A secondary purpose of this

study was to determine the reliability for the two
dependent variables: 1) signs and symptoms and 2) risk
factors.

Cardiac issues are something that not every

athlete knows enough about prior to participation.
not know that they have a potential risk for injury.

They do
The

athletes may also not know what to do in the time of
emergency during a cardiac related issue if they are not
sure of the signs and symptoms or risk factors associated
with cardiac problems.
Surveys are not usually done on sudden cardiac death
due to the lack of subjects from passing away; therefore, a
knowledge survey could be potentially very informative.
One survey dealt with students’ perceptions and beliefs
about sudden cardiac death, understanding of using an AED

18
and preparedness level to recognize and respond to an
emergency event, and experiences of responding to handling
an emergency event.

This showed that many of the

participants were confused on the difference between a
myocardial infarction and sudden cardiac death.

Also, the

participants had a lot of uncertainty about what to do if
they had to respond to an unconscious individual along with
the fear about the use of the AED and CPR.23

Although this

survey did not show knowledge but more of a common
perception, it does relate in the fact that people did not
know what to do in certain situations and weren’t sure of
what some medical conditions were.

These perceptions could

be helped if education is increased among the general
public and with the athlete population.
This survey showed there were no significant
differences between gender or ethnicity for knowledge of
signs and symptoms and for knowledge of risk factors of
sudden cardiac death.

Even though the results were not

significant, they were found to be meaningful.

The results

showed how many participants are CPR/AED certified along
with who has had formal training on sudden cardiac
arrest/death.

This is meaningful for the fact that the

results came out to be close to even, which was not
expected.

I did not expect such a high number of athletes

19
to be CPR/AED certified.

This could mean that more

training is happening than previously thought, but the
right kind of training including signs and symptoms along
with risk factors of cardiac issues are not necessarily
being taught.
It was found that 47.5% (n=38) of student athlete
participants are CPR/AED certified.

However, matched up to

the comparative data of correct and incorrect answers of
signs and symptoms along with risk factors, this data does
not match.

With the amount of participants certified, it

would be implied correct knowledge of signs, symptoms, and
risk factors was implied.

It is thought that the student

athletes who are CPR/AED certified assume what to do in
case of emergency, even though they did not correctly
identify all of the signs, symptoms, and risk factors.
Frequencies were run on the amount of correct
knowledge answers found on signs and symptoms along with
risk factors.

The percentage of correct answers found from

the sign and symptoms question on the survey ranged from
25% (n=20) to 100% (n=80), with a few outliers of 1.3%
(n=1) for exertional syncope and 2.5% (n=2) for dyspnea.
Compared to the risk factors correct knowledge answers, the
knowledge of signs and symptoms of sudden cardiac death
were less familiar to the student athletes.

The percentage

20
of correct answers associated with the risk factors
question ranged from 27.5% (n=22) to 100% (n=80), with two
outliers of 10% (n=8) for atherosclerosis and 15% (n=12)
for asthma.
Table 8 and 9 indicate the percentage of correct
answers for signs and symptoms and risk factors.

The top

correct answers for signs and symptoms include sore throat,
low back pain, upset stomach, and amnesia.

This indicated

that the participants knew that these were not a sign and
symptom of sudden cardiac death, hence the high percentage
rate.

For risk factors, the top correct knowledge answers

include history of cancer, previous fracture, and wears
contacts and/or glasses.

From this, it is seen that

participants also did have a good grasp of what is a risk
factor and what is not a risk factor.

The items from both

tables (8 and 9) show that most participants were unsure
about were the items with medical names, like
atherosclerosis, exertional syncope, and dyspnea.

This is

most likely due to the unfamiliarity of terms.

Conclusion

After reviewing the results of this study, it is
concluded that knowledge does not differ between genders

21
and ethnicities on signs, symptoms, and risk factors of
sudden cardiac death.

Regardless of the gender or

ethnicity, there is still a lack of knowledge about sudden
cardiac death.

Even with CPR/AED certifications, student

athletes at Westminster College were not sure of what signs
and symptoms or risk factors were associated with sudden
cardiac death.

Recommendations

Further research recommendations for this study first
and foremost include surveying other colleges and
universities of all divisions in the United States.

This

would give a better picture of what knowledge is known and
what education is available to collegiate athletes from
different demographic settings.
To increase participation, I would recommend
personally handing out surveys to the desired population.
This would ensure a more diverse and complete
participation.

I would also check the demographics of the

school or region I am surveying to see if an appropriate
number of athletes, gender, or ethnicity is available.
It would be beneficial to have more educational
materials on sudden cardiac death available to collegiate

22
athletes country- wide.

This would allow for a better

preparedness during an emergency event or better
recognizing of signs and symptoms if a cardiac issue was
experienced by them or a teammate.

Adding signs, symptoms,

and risk factors to the CPR/AED and first aid curriculum
could also increase knowledge of cardiac issues including
sudden cardiac death.
I would also recommend implications for certified
athletic trainers to help teach educational materials to
athletes prior to participation to play.

Holding an

informative group meeting for each individual sport allows
for information to be taught along with questions to be
asked from athletes.

Having certified athletic trainers

teach the athletes allow for the most knowledge transferred
to the athlete, compared to a basic CPR class that may not
include signs, symptoms, and risk factors of cardiac
issues.
Another important recommendation would be to develop a
regulated pre-participation history form on both the
athlete and the athlete’s family.

A more detailed pre-

participation exam would help eliminate certain cardiac
issues that may be overlooked during a basic history form.
Using information found on the American Heart Association

23
would help regulate pre-participation exams along with
developing more detailed history forms.
The American Heart Association states that there are
eight questions that need to be asked in order to uncover
any potential health issues that could signal a
cardiovascular problem.

These questions pertain to both

personal and family history.

Personal history would

include questions like: 1)chest pain/discomfort upon
exertion, 2)unexplained fainting or near fainting,
3)excessive and unexplained fatigue associated with
exercise, 4)heart murmur, and 5)high blood pressure.
Family history questions include: 6)one or more relatives
who died of heart disease (sudden/unexplained or otherwise)
before age 50, 7)close relative under age 50 with
disability from heart disease, and 8)specific knowledge of
certain cardiac conditions in family members.

The eighth

question has specific conditions including hypertrophic or
dilated cardiomyopathy in which the heart cavity or wall
becomes enlarged, long QT syndrome which affects the
heart’s electrical rhythm, Marfan syndrome in which the
walls of the heart’s major arteries are weakened, and
clinically important arrhythmias or heart rhythms.27

Using

a history form that is detailed like this form would allow
for the participant to correctly identify if any medical

24
issues are present, rather than just saying cardiac
conditions, which the participant may not understand.
A cardiologist on the panel of experts would be a good
recommendation for future study.

This would allow the

survey to be analyzed prior to sending out to participants.
Having a specialists recommendations on a survey dealing
with sudden cardiac death would have increased the
reliability and possibly change the questions being asked
to the participants.
Location of the student athlete would also be
beneficial to find out in order to have a more diverse
population.

If a suburban area has more resources

available than a rural area, then this would be another
consideration to analyze.

It may be true that different

types of area may have more resources.

In addition,

depending on the division of college or university, there
may be a difference in educational material.

25
REFERENCES

1) Corrado D, Basso C, Schiavon M, Pelliccia A, Thiene G.
Pre-participation screening of young competitive
athletes for prevention of sudden cardiac death.
Journal American College Cardiology. 2008;52(24):19811989. Available from http://highwire.stanford.edu/.
Accessed July 3, 2012.
2) Corrado D, Pelliccia A, Bjornstad H, et al.
Cardiovascular pre-participation screening of young
competitive athletes for prevention of sudden death:
proposal for a common European protocol.
European
Heart Journal. 2005;26:516-524. Available from
http://highwire.stanford.edu/. Accessed June 30, 2012.
3) Corrado D, Schmied C, Basso C, et al. Risk of sports:
do we need a pre-participation screening for competitive
and leisure athletes.
European Heart Journal.
2011;32:934-944. Available from
http://highwire.stanford.edu/. Accessed July 3, 2012.
4) Steinvil A, Chundadze T, Zeltser D, et al. Mandatory
electrocardiographic screening of athletes to reduce
their risk for sudden death. Journal of the American
College of Cardiology. 2011;57(11):1292-1296.
Available from http://highwire.stanford.edu/. Accessed
July 12, 2012.
5) Pelliccia A, Paolo F, Corrado D, et al. Evidence for
efficacy of the Italian nation pre-participation
screening programme for identification of hypertrophic
cardiomyopathy in competitive athletes. European Heart
Journal. 2006;27:2196-2200. Available from
http://highwire.stanford.edu/. Accessed July 12, 2012.
6) Pigozzi, Spataro A, Fagnani F, Maffulli. Preparticipation screening for the detection of
cardiovascular abnormalities that may cause sudden death
in competitive athletes. Br J Sports Med. 2003;37:4-5.
Available from http://highwire.stanford.edu/. Accessed
July 3, 2012.

26
7) Crawford M. Screening athletes for heart disease. BMJ
Heart. 2008;93:875-879. Available from
http://highwire.stanford.edu/. Accessed July 3, 2012.
8) O’Connor D, Knoblauch M. Electrocardiogram Testing
During Athletic Pre-participation Physical Examinations.
Journal of Athletic Training. 2010;45(3):265-272.
Available from
http://nata.publisher.ingentaconnect.com/content/nata/ja
t. Accessed July 3, 2012.
9) Drezner J, Pluim B, Engebretsen L. Prevention of sudden
cardiac death in athletes: new data and modern
perspectives confront challenges in the 21st century. Br
J Sports Med. September 2009;43(9):625-626. Available
from http://highwire.stanford.edu/. Accessed July 3,
2012.
10) Wheeler M, Heidenreich P, Froelicher V, Hlatky M,
Ashley E. Cost effectiveness of pre-participation
screening for prevention of sudden cardiac death in
young athletes.
Ann Intern Med.
March
2010;152(5):276-286. Available from
http://highwire.stanford.edu/. Accessed July 3, 2012.
11) Maron B, Thompson P, Puffer J, et al. Cardiovascular
pre-participation screening of competitive athletes:
addendum: an addendum to a statement for health
professionals from the sudden death committee (council
on clinical cardiology) and the congenital cardiac
defects committee (council on cardiovascular disease in
the young). AHA Circulation. 1998;97:2294. Available
from http://www.ncbi.nlm.nih.gov/pmc/. Accessed July 3,
2012.
12) Papadakis M, Sharma S. Electrocardiographic screening
in athletes: the time is now for universal screening.
Br J Sports Med. 2009;43:663-668. Available from
http://highwire.stanford.edu/. Accessed July 3, 2012.
13) McKenna W, Behr E. Hypertrophic cardiomyopathy:
management, risk stratification, and prevention of
sudden death. BMJ Heart. 2002;87:169-176. Available
from http://highwire.stanford.edu/. Accessed July 3,
2012.

27
14) Borjesson M, Pelliccia A. Incidence and aetiology of
sudden cardiac death in young athletes: an international
perspective. Br J Sports Med. 2009;43:644-648.
Available from http://highwire.stanford.edu/. Accessed
June 30, 2012.
15) Maron B, Roberts W, McAllister H, Rosing D, Epstein S.
Sudden death in young athletes. AHA Circulation.
1980;62(2):218-229. Available from
http://www.ncbi.nlm.nih.gov/pmc/. Accessed July 3,
2012.
16) Maron B, Doerer J, Haas T, Tierney D, Mueller F.
Sudden deaths in young competitive athletes: analysis of
1866 deaths in the United States, 1980-2006. AHA
Circulation. 2009;119:1085-1092. Available from
http://highwire.stanford.edu/. Accessed July 3, 2012.
17) Harmon K, Asif I, Klossner D, Drezner J. Incidence of
sudden cardiac death in National Collegiate Athletic
Association Athletes. AHA Circulation. 2011;123:15941600. Available from http://highwire.stanford.edu/.
Accessed June30, 2012.
18) Maron B, Poliac L, Roberts W. Risk for sudden cardiac
death associated with marathon running. JACC. August
1996;28(2):428-431. Available from
http://www.ncbi.nlm.nih.gov/pmc/. Accessed July 3,
2012.
19) Northcote R, Flannigan C, Ballantyne D. Sudden death
and vigorous exercise-a study of 60 deaths associated
with squash. Br Heart Journal. 1986;55:198-203.
Available from http://highwire.stanford.edu/. Accessed
July 3, 2012.
20) Link M. Prevention of sudden cardiac death: return to
sport considerations in athletes with identified
cardiovascular abnormalities. Br J Sports Med.
2009:43;685-689. Available from
http://highwire.stanford.edu/. Accessed June 30, 2012.
21) Maron B, Carney K, Lever H, et al. Relationship of
race to sudden cardiac death in competitive athletes
with hypertrophic cardiomyopathy. JACC.

28
2003;41(6):974-980. Available from
http://highwire.stanford.edu/. Accessed July 3, 2012.
22) Maron B, Shirani J, Poliac L, et al. Sudden death in
young competitive athletes. JAMA. 1996;276:199-204.
Available from http://highwire.stanford.edu/. Accessed
July 3, 2012.
23) McDonough A, Callan K, Egizio K, et al. Student
perceptions of sudden cardiac arrest: a qualitative
inquiry. British Journal of Nursing. 2012;21(9):523527. Available from EBSCOhost. Accessed September 13,
2012.
24) Gourley M, Valovich T, Bay R. Awareness and
recognition of concussion by youth athletes and their
parents. Athletic Training & Sports Health Care.
2010;2(5):208-218. Available from EBSCOhost. Accessed
September 5, 2012.
25) Sullivan S, Bourne L, Choie S, et al. Understanding
of sport concussion by the parents of young rugby
players: a pilot study. CJ Sport Med. May
2009;19(3):228-230. Available from EBSCOhost. Accessed
September 13, 2012.
26) Starkey C, Brown S, Ryan J. Thoracic, Abdominal, and
Cardiopulmonary Pathologies. In: Connors M, Granlund S,
eds. Examination of Orthopedic and Athletic Injuries.
2nd ed. Philadelphia, PA: F.A. Davis Company; 2010:570605.
27) 12-step screening may help reduce sudden cardiac death in
young athletes: American Heart Association scientific
statement. American Heart Association Web site.
http://newsroom.heart.org/news/12-step-screening-may-helpreduce-217875/. March 12, 2007. Accessed May 7, 2013.

APPENDICES

APPENDIX A
Review of Literature

31
REVIEW OF LITERATURE

Sudden cardiac death among young athletes is seen in
the news regularly.

Even though the occurrence of this

issue is actually rare in comparison to the amount of
publicity it receives, the knowledge among the public on
this topic may not adequate.

The purpose of this study is

to find out, through a survey, the amount of knowledge
collegiate athletes of have in regards to the issue of
sudden cardiac death.

A secondary purpose of this study is

to determine the reliability for the survey, which contains
two dependent variables: signs & symptoms and risk factors.
This literature review will report on previous
information, which has been found on the prevention of
sudden cardiac death dealing with screening and history,
background of sudden cardiac death in sport dealing with
incidence and pathophysiology, and collegiate athletes’
knowledge of healthcare.

Prevention of Sudden Cardiac Death

Screening
For all sports, screening of some kind is done in
order to allow an athlete to participate.

Screenings can

32
vary and may include a medical history form or specialized
testing such as stress tests.

In order to evaluate

different conditions, different screenings are done.

Most

health care offices require medical history forms to be
filled out prior to treatment.

By doing this, the doctor

is alerted of any conditions.

Some conditions have become

more relevant in the current day including sudden cardiac
death.
Current research has been performed on screenings
associated with sudden cardiac death.

A major study done

on a nationwide program of pre-participation screenings in
Italy was started in 1982.

As the study progressed, the

screening technique was deemed adequate in both sensitivity
and specificity for detection of potentially deadly
conditions.

It also identified a reduced risk of death in

young competitive athletes by almost 90%.

The study showed

that this approach to pre-participation screenings, with
the help of a 12-lead ECG screening, athletes with
cardiovascular diseases not currently showing any other or
outward signs or symptoms could be identified.

The study

also stated the fact that this program restricted lifethreatening competitions.1 More research relating to this
European study emphasizes the need for pre-participation
exams of all young athletes involved in organized sports.

33
Even though this research occurred in Europe, the American
Heart Association recommendations come from this study,
which includes the recommendation of using of a 12-lead ECG
with a common screening protocol.2

There is huge debate

over whether screenings are needed, even though reducing
the chance of sudden cardiac death from this study was
found.3
More international research done comes from Israel and
Italy.

Research was done to determine if pre-participation

screening of athletes help reduce their risk for sudden
death.

The subjects were found by searching two main

newspapers in Israel to determine the number of yearly
cases of cardiac death in competitive athletes.

The

information collected came from the Israel Sport Authority
from the years of 1985 through 2009.

The study wanted to

find the impact of the National Sport Law which began in
1997 in Israel.

There was a need to see if more deaths

occurred before or after the law was mandated.

This law

mandates screening of all athletes with resting ECG and
exercise testing.

The search found 24 documented events of

sudden death or cardiac arrest in competitive athletes over
the allotted time period.

Of the 24 deaths, 11 occurred

before the 1997 law and 13 occurred after it.

The average

yearly incidence the decade before was 2.54 per 100,000

34
athletes and 2.66 per 100,000 athletes the decade after.
These results show the incidence is within the range
reported by others that have done a similar study.
However, it was found from the data that ECG screening had
no effect on their risk for sudden death or cardiac arrest.4
Another study looked at how effective preparticipation exams with a 12-lead ECG along with history
and physical examination were in identification of
hypertrophic cardiomyopathy.

This study was done with the

Italian national teams and consisted of 4,450 subjects.
Subjects were chosen initially due to pre-participation
screening where alarming conditions were found.
Participants then underwent a clinical and ECG examination
to access the presence of hypertrophic cardiomyopathy,
which was previously undetected.

These results showed that

none of the 4,450 subjects having any evidence of
hypertrophic cardiomyopathy.

There were subjects whom were

found to have other cardiac abnormalities including
myocarditis, mitral valve prolapsed, Marfan’s syndrome,
aortic regurgitation, and arrhythmogenic right ventricular
cardiomyopathy.

The total amount of subjects having these

conditions only came to 12.

This was beneficial because

hypertrophic cardiomyopathy was not the only reason for

35
sudden cardiac death.

Other types of cardiac abnormalities

also lead to a chance of sudden cardiac death.5
Much of the research on sudden cardiac death deals
with the screenings including ECG readings.

Most of the

research shows the background on sudden cardiac death and
the efficacy of screening programs.

It has been found more

than 70% of cardiac disease is the reason for athletes not
being cleared by physicians in order to participate in
sports.

Most screenings include a 12-lead ECG, which has

increased the diagnostic efficacy of screening.

Even with

the time involved, a large amount of research shows
screening is worth doing because of the positive results
found.6

In the United States, most states require some sort

of pre-participation screening, even though ECGs are not
usually done unless signs and symptoms are found.

Sudden

cardiac death is a relatively rare event, and therefore,
some feel no screening would be much more cost effective.7
Because screenings do cost a lot of money, some
research has been done with projected studies about what
would happen in a situation.

One study in particular

examined ECG testing during physical examines for athletes.
The subjects included public high school athletes, grades 9
through 12.

The students were drawn from the National

Federation of High School Association during the years of

36
2006 to 2007.

Four groups were made, consisting of black

males, white males, black females, and white females.

The

groups had pre-participation exams whereby the athletes
were given ECG tests.

The results came out as a predicted

16% of athletes would be expected to have a positive ECG,
but only 2% would have a finding that leads to potential
cardiovascular abnormality.

Also, the study found males

seemed to have a higher potential risk factor than females.
The study showed screenings do cost too much due to the
amount of false-positive tests.

There would also be the

need for personnel for interpretation and administering the
tests.

The study, along with others, suggested screening

only high-risk athletes.8
A main part of the debate over sudden cardiac death is
whether a 12-lead ECG should be used in addition to a
medical history and a physical examination before
competition for athletes.

The debate in the medical field

also talks about whether the purpose of screenings are to
find problems or to help identify problems in order to
reduce their chance of sudden cardiac death during sports.
The problem that comes up most often with ECG screenings is
that the staff, money, and education are all parts of the
screening process, which not all facilities are able to
accommodate.9

There is some previous research done to

37
determine the cost-effectiveness of electrocardiography
along with cardiac history and physicals for preparticipation screening.

The subjects of this study

included high school and college athletes ranging from age
14 to 22.

The data was found by using published

epidemiologic and pre-participation screening data, vital
statistics, and other publicly available data.

The results

show that adding electrocardiography to pre-participation
screenings saved 2.06 lives per 1,000 a year.

This cost

approximately $89 per athlete.
The costs of just cardiac history and physical alone
were $199 per athlete and saved 2.6 lives per 1,000.

Even

though financial restrictions may limit the use of ECG in
pre-participation screenings, these screenings have found
using ECG along with history and physicals may result in
fewer deaths but also may be cost effective.10

History
Medical history is needed in order to establish a good
background on the patient.

History forms also allow

medical professionals to determine when a patient may be at
risk for different conditions or injuries.

Pre-

participation exams include medical history forms, which

38
usually allow the medical professional to have all relevant
information in one complete packet.
Research shows how pre-participation screenings are
needed for athletes, but some groups of medical
professionals believe only athletes whom have both a
history and physical exam should be screened every two
years in collegiate sports.

Over 300,000 athletes would

need to be screened and most universities and colleges find
the budgetary constraints and the availability of personnel
not ideal.

If the athlete does have medical history of

cardiovascular abnormalities then screenings would then be
done more often depending on the severity of the
abnormality found.

Each year in colleges, there is paper

work done on history and a physical exam is completed for
each athlete before competition.

High school, on the other

hand, requires less of a screening than in colleges.
Athletes are required to get a screening before
competition, but this is done at a family doctor office and
is not usually sport specific or thorough.11

Other

information on the subject of screenings discusses the
urgency of screenings to be done to help prevent sudden
cardiac death.
death cases.

Urgency reflects wide coverage of cardiac
As of now, only recommendations were advised

to athletes to get screenings based on family history and

39
other predisposing factors.

Most of the current evidence

comes from a 25 year study done in Italy and does suggest
that screening has led to a reductions in sudden cardiac
death.12
Medical research has given the world a general
background of hypertrophic cardiomyopathy.

Some

information found identifies the natural history of the
disease and relates it to the need for medical intervention
to help with symptoms, which could potentially lead to
death.

Overall, the management of hypertrophic

cardiomyopathy remains a clinical challenge.

Despite the

high risk of sudden death, data on younger age groups are
limited.13

Background of Sudden Cardiac Death in Sport

Incidence
Different predisposing factors lead to the incidence
level of sudden cardiac death.
ethnicity, age, sex, and sport.

Some of these include
Each of these factors

could potentially lead to a chance of developing cardiac
issues, which could potentially lead to sudden cardiac
death.

Due to the prevalence of sudden cardiac death in

40
athletes, different sports also have a higher risk factor
than others.
Sudden cardiac death has been found to be higher in
athletes due to several factors that increase the risk of
death, including having an unknown disease worsened by
exercise.

The incidence of sudden cardiac death has been

found to be much higher in males than in females, about
nine times higher.

Geographical differences have also been

reported, but this is due more to how pre-participation
screening is done, which can vary by location.

Even with

the evidence of deaths among young athletes, there still
has to be more studies done in order to clarify what role
ethnicity has in the prevalence of diseases that may
possibly lead to sudden cardiac death.14
A study done pertaining to athletes tested 29
competitive, in shape, and conditioned athletes ranging in
age from 13 to 30 years old.

The results show that out of

the 29 subjects, the most common cause of death was
hypertrophic cardiomyopathy.

Only seven of the 29 subjects

were suspected to have cardiac disease during their life.
These results showed that even when heart disease was
relatively uncommon, hypertrophic cardiomyopathy was a
frequent cause of death in athletes.15

41
Other research done on athletes was based in the
United States.

This study was done throughout the country

from 1980 to 2006 and obtained information from 38
different sports.

The subject total came to 1866 athletes

who died suddenly with ages ranging from 13 to 25.

Of the

1866 athletes, 1049 were due to cardiovascular disease, 416
to blunt trauma, 65 to commotio cordis, and 46 to heat
stroke.

The most common causes were hypertrophic

cardiomyopathy and congenital coronary artery
abnormalities.

Research shows the number of cardiovascular

sudden deaths in the United States was higher than
previously estimated, but still relatively low, which would
further suggest the need for systematic and mandatory
reporting of deaths to a national registry to better
estimate the deaths per year.

Also, the need for pre-

participation screening with ECG is relative to this
research.16
Most athletes in the United States compete in the NCAA
or National College Athletic Association.

There was

research done to better estimate the incidence of sudden
cardiac death in the NCAA student-athletes.
done from 2004 to 2008.

The study was

All cases of sudden cardiac death

in the NCAA were identified with a NCAA database, weekly
search of public media reports, and catastrophic insurance

42
claims.

The results came to show during the time period,

there were 273 deaths to 1,969,663 athletes that
participated.

The causes of death included 68% nonmedical

or traumatic causes, 29% medical causes, and 6% to unknown
causes.

In the 29% of medical deaths, cardiovascular

related sudden death was the leading cause in 45 athletes,
which represented 75% of sudden deaths during exertion.
The results showed sudden cardiac death is the leading
medical cause of death during participation in the NCAA.
Research also shows that an accurate assessment of sudden
cardiac death is underestimated and needs better ways to
find data in order to help develop effective strategies to
help prevent sudden death.17
Pertaining to athletes, individual sports have been
examined to gain more knowledge of sudden cardiac death
risk factors.

One sport that has an increase in incidence

with cardiac problems has been marathon running.
is very intense and could go on for hours.

The sport

Even though it

is a non-contact sport, it is an intensive cardiovascular
sport, therefore making the risk for sudden death still
relevant.

Research shows the risk of sudden cardiac death

during marathon running.

One study included subjects from

two groups of endurance runners held over a time period of
30 years, from 1976 to 1994, during the Marine Corps and

43
Twin Cities marathons.

The subjects were mostly men with

an average age of 37 years old.
runners was 215,413.

The total number of

The results showed only four deaths

occurred, each due to underlying cardiovascular diseases.
Three deaths happened during the race and one after.
made up three of the deaths, while one woman died.

Men
The

ages ranged from 19 to 58 years old.18
Another sport that researched was squash.
was done from October 1976 to February 1984.
included one female and 59 men.

Research

The subjects

Reports on the deaths

showed that out of the 60 deaths, 51 were coronary artery
disease, four were valvar heart disease, two were cardiac
arrhythmia, and one was hypertrophic cardiomyopathy.
two deaths were not cardiac related.

Only

Of the subjects, 22

had a previous medical condition at one point during their
life.

The players never received the screenings that they

should have, therefore resulting in death.

The subjects

that had the previous medical conditions could have been
saved if screening was done.19

Pathophysiology
Abnormalities along with defects found in the heart
could be based on ethnicity.

It has been found the sex of

a person also matters when it comes to determining the

44
chance of having a cardiac related issue.

Even though the

type of sport is important, if a person has a predisposing
factor there is a chance that a cardiovascular injury can
still occur.
Genetic heart disease accounts for a majority of
sudden cardiac deaths in athletes under age 30.

These

include hypertrophic cardiomyopathy, right ventricular
cardiomyopathy, and ion channel disorders.20

Ethnicity and

race also play a role in the number of cardiovascular
abnormalities found.

Research was done to determine the

impact of race on identification of hypertrophic
cardiomyopathy, one of the leading cardiac conditions
leading to sudden cardiac death.

The national athlete

registry was utilized to find the relationship of race to
the prevalence of cardiovascular diseases.

This

information was then compared with a hospital-based cohort
of patients with hypertrophic cardiomyopathy.

The subjects

included 584 athlete deaths, 286 being cardiovascular
deaths.

The results from the study show that of the total

number of athletes that died, 42% were African American and
most were male, approximately 90%.

Of the 286

cardiovascular deaths, 55% were African American and died
of hypertrophic cardiomyopathy.

Out of the hospital group

of 1986 hypertrophic cardiomyopathy patients, only 8% were

45
African American.

From this research, it is found that

many African American male athletes go undiagnosed with
hypertrophic cardiomyopathy.21 Another study addressed
subjects who participated in organized sports.
period of the study was from 1985 to 1995.

The time

A total of 158

sudden deaths that occurred in trained athletes throughout
the United States comprised the subjects.
were younger than 35.

These subjects

The results showed that out of the

158 subjects, 15% were noncardiovascular causes.

Of the

athletes with cardiovascular causes, 90% were male and 52%
were white.

The most deaths occurred in basketball and

football, accounting for 68% of deaths.

The most common

cause of death was hypertrophic cardiomyopathy.

Of the

total subjects, 115 had a standard pre-participation exam
with only 3% being suspected of having a cardiovascular
disease and one athlete having an abnormality.22

Collegiate Athletes’ Knowledge of Healthcare

Athletes usually focus on one thing, their sport.
Most do not consider what else could happen while playing
that sport.

The amount of education that is taught before

participating has increased over the years due to increases
in certain problems including concussion.

A major issue at

46
this current time deals with cardiac issues.

Most athletes

have not heard much about these situations besides what is
being told on news reports.

They do not know that they

have a potential risk for injury.

The athletes may also

not know what to do in the time of emergency during a
cardiac related issue.
Most athletes in college have not been taught about
sudden cardiac death among other major health issues like
concussion.

Knowledge surveys are done in order to gain a

populations’ knowledge on a specific item.

Research was

done in order to describe university students’ perceptions
and beliefs about sudden cardiac death, describe university
students’ understanding of using an AED and their level of
preparedness to recognize and respond to an emergency
event, and to identify university students’ experiences of
responding to handling an emergency event.

This particular

survey was done with qualitative descriptive methodology
using written narrative responses on perceptions and
beliefs about sudden cardiac death.

Participants included

30 college students between age 18 and 48 years old from
two campuses of a northeast American university, with 23
participants being female and seven being male.

The

participants were recruited using the university’s daily
electronic newsletter.

The participants had to be enrolled

47
in college as a student, have access to a computer, and
agree to take the survey.

The results of the survey showed

that many of the participants were confused on the
difference between a myocardial infarction and sudden
cardiac death.

In addition, the participants had a lot of

uncertainty about what to do if they had to respond to an
unconscious individual along with the fear about the use of
the AED and CPR.

Making sure that more education is done

in a collegiate setting on the warning signs of cardiac
issues, what exactly sudden cardiac death is, and being
able to use an AED or be trained in CPR is absolutely
neccessary.23

Surveys done on sudden cardiac death are very

sparse due to the lack of subjects from passing away,
therefore researching surveys that have been done relating
to knowledge on a specific condition are sometimes used in
order to gain a better perspective on the knowledge of the
general population.
Concussion seems to be a big topic of debate lately.
Since sudden cardiac death has not received the same type
of hype just yet, surveys on concussion lead to very good
assistance with knowledge surveys on sudden cardiac death.
One specific study doing research on concussion includes a
knowledge survey.

The participants included 44 boys and 29

girls who were athletes and 39 men and 61 women who were

48
parents.

The athletes were between ages 10 and 14.

Most

of the survey included questions about signs and symptoms
along with any history that they have had with concussions,
either personally or in a general setting.

Out of the

parents, 57 had first aid certification, 53 CPR
certification, 57 general medical training, and 13 in
concussion assessment.
never stated.

The careers of the parents were

The results of this survey showed that there

was not a significant difference between athletes and
parents for the number of concussion symptoms correctly
identified.

Only three out of five true-or-false questions

were answered right by 70% of the participants.

However,

parents who had a background in medical training or
certification in first aid or CPR did score higher than
other parents who had no previous knowledge or training.
There was a retrospective survey done with collegiate
athletes.

This research found that 56% of athletes had no

knowledge of concussion consequences, 28% continued to play
while dizzy, and 30% continued to play while experiencing a
headache.

These results show that education is very

beneficial when done, but it needs to be done in school
settings in order to build a good foundation for concussion
awareness.24

49
More research has been done pertaining to concussion.
One survey wanted to establish the knowledge and beliefs of
parents of high school rugby players about concussion with
a descriptive cross-sectional intercept pilot study.
Participants included 200 parents of male high school rugby
players.

The surveys were handed out while attending their

children’s games.

Results showed that most parents, 165

out of 198, reported they were able to recognize a
concussion in their children and able to provide a list of
well-accepted signs and symptoms.

Nearly all, 188 out of

196, were aware of risks while concussed and continued to
allow their children to play.

Roughly half, 99 of 196,

were aware of return-to-play guidelines after a concussion
but still allowed their children to participate.

The

results of this information show that parents have a good
basic knowledge of concussion symptoms and signs, but are
still neglecting the fact that their child may sit out a
game due to a concussion.25

Summary

From the information in the literature review, sudden
cardiac death is important in the current news on
healthcare.

It is shown from recent research that

50
screenings following pre-participation medical exams are a
good way to eliminate the chance of participation with a
heart condition.

However, due to cost and time, screenings

are not always available to be done.

As stated in a study

done in Italy, screenings reduced the risk of death in
young competitive athletes by almost 90%.1

Screenings have

become such a big deal due to the fact that more than 70%
of cardiac disease makes up the majority of athletes not
being able to participate in sports.6
History also strongly relates to decreasing the risk
of sudden cardiac death.

In order to establish a good

background of the patient, a complete medical history is
needed.

Medical history also shows which athletes are in

need of screenings due to family history of cardiac issues
or their own personal issues.

Only recommendations can be

made to athletes to get screenings based on predisposing
factors since screenings cost significant amounts of
money.12
Sudden cardiac death has many reasons why it may
occur.

This would be referred to as the background aspect

of sudden cardiac death.

Incidence and pathophysiology

make up this background.

It was found that sudden cardiac

death represents 75% of all sudden deaths during exertion,
which in turn makes up the leading cause of death in the

51
NCAA.17

Ethnicity and race plays a role in the

pathophysiology of sudden cardiac death.

A study found

that of 286 cardiovascular deaths, 42% were African
American and 90% were male.21
Knowledge out in the public setting about sudden
cardiac death is very limited due to the limited resources
available to determine causes.

One study done in the

United States deals with the comfort level of students with
people who experience a cardiac issue and how they respond
to the situation.

Most of the students were unsure of what

to do if they had to respond using an AED or CPR.23

Even

though this is not specifically about sudden cardiac death
knowledge, it gives a good perspective about the fears of
the public about emergency situations.

APPENDIX B
The Problem

53
PROBLEM

Statement of the Problem
The purpose of this study is to examine the knowledge
of college athletes on sudden cardiac death.

A secondary

purpose of this study is to determine the reliability for
the two dependent variables: signs and symptoms and risk
factors.

It is important to examine knowledge due to the

severity of an emergency that could occur during a practice
or a game.

If we can assess the knowledge of an athlete

then we are able to know what is going to happen in an
emergency.

Additionally it would be beneficial for

athletic trainers and others in the medical field to see
how much knowledge is out there, along with how much
teaching on current medical conditions have been taught
prior to playing.

Definition of Terms
The following definitions of terms will be defined for
this study:
1) Hypertrophic Cardiomyopathy – part of the heart
becomes thicker than the other parts which makes blood
flow difficult26

54
2) Medical History Form – filled out prior to
participation in order to tell in detail conditions or
problems a person may have had or currently has27
3) Sudden Cardiac Death – the heart suddenly and
unexpectedly stops beating which results in death
within an hour or less28

Basic Assumptions
The following are basic assumptions of this study:
1)

The survey will have content validity after a review
by a panel of experts.

The subjects will answer the survey questions to the
best of their ability during survey completion
sessions.

Limitations of the Study
The following are possible limitations of the study:
1)

Only college athletes from one college will serve as
subjects.

Participants may not take the survey seriously.

Number of returned surveys may not be ideal.

Results may not be generalizable due to a small
sampling size, especially with regards to ethnicity.

55
5)

A cardiologist was not part of the Panel of Experts
review.

Significance of the Study
The results of this study will show the knowledge of
different levels of college athletes about sudden cardiac
death.

It is very important to get this information due to

the fact that it could potentially save lives.
If athletes are knowledgeable about cardiac issues,
an emergency situation could be handled in a better and
more efficient manner.

If an athlete has more knowledge

about cardiac issues prior to participation, then when they
are feeling abnormal sensations, they can recognize the
signs and symptoms during playing and can alert the medical
personnel.

Once the results are in, if it is found that

knowledge is very low on sudden cardiac death then it shows
the medical field more educational materials are needed to
be discussed before sport participation of an athlete.
The research done in this study will allow the current
medical field to see the true knowledge of a college-aged
athlete about sudden cardiac death.

Due to the lack of

research previously done, this will lead to a good
background on what teaching instructions need to be taught
in order to educate athletes on what to do in emergency

56
situations.

APPENDIX C
Additional Methods

APPENDIX C1
Letter to Experts

59
Dear________________:

I am a graduate student at California University of Pennsylvania pursuing a Master of
Science degree in Athletic Training. To fulfill the thesis requirement for this program, I
am conducting a knowledge study. The objective of this study is to determine what
college athletes know about sudden cardiac death in terms of history along with signs and
symptoms. A secondary purpose of this study is to determine the reliability for the two
dependent variables: signs and symptoms and risk factors.
In order to increase the content validity of the instrument, a panel of experts has been
chosen to review the survey. You have been selected as one of the three professionals to
be on this panel. Due to your position and experience, your feedback is very important to
the success of this study. The information obtained by this panel of experts review will
be used to make revisions and create the final survey to be distributed to the population
sample. Your responses are voluntary and will be confidential.
Please answer the following questions based on the attached survey and make any other
additional comments you deem appropriate. Please return your comments and revisions
via email no later than December 30, 2012. If you have any questions or concerns, please
do not hesitate to contact me.

Are the questions appropriate, valid, and understandable?

Comment on the overall presentation of the survey.

Which questions, if any, should be restated from the survey? Why?

Which questions, if any, should be added to the survey? Why?

Thank you in advance for your time and efforts.

Sincerely,
Brittney Brown, ATC
California University of Pennsylvania
412-860-0567
bro6175@calu.edu

APPENDIX C2
Collegiate Athletes’ Cardiac Knowledge Survey

’
Please complete the following sections to the best of your abilities
Gender: M ____

F____

Age: 18-20____

21-23____

24-26____

27-29____

Ethnicity: Caucasian ____
Hispanic / Latino ____
Native American ____
African American ____
Asian / Pacific Islander ____
Other ____
Sport (check more than one if applicable):
Football ____

Soccer ____

Swimming ____

Diving ____

Cheerleading ____

Volleyball ____

Tennis ____

Basketball ____

Baseball ____

Softball ____

Track / Field ____

Cross Country ____

Golf ____

Other ____

Are you CPR / AED certified?
Yes____

No____

Have you had any previous formal education on sudden cardiac arrest / death?
Yes____

No____

62
Which signs and symptoms, from the list below, do you believe are associated with
an individual who is experiencing cardiac issues? Select all that apply.
Fatigue____

Nausea ____

Headache ____

Fever ____

Night Sweats ____

Chest pain ____

Upset Stomach ____

Knee Pain ____

Shoulder Pain ____

Panic ____

Trouble Sleeping ____

Sore Throat ____

Sensitivity to Light / Sound ____

Dizziness ____

Exertional syncope ____

Dyspnea ____

Amnesia ____

Heart’s “Racing” ____

Double Vision ____

Blurry Vision ____

Sensation of chest pain and arrhythmias ____

Low Back Pain ____

Coughing ____

Shortness of breath ____

Which of the following items do you believe place an individual at risk of
experiencing a cardiac issue?
Sudden Death Before Age 50 in Family ____

Seizures ____

History of Cancer ____

Sickle Cell Trait ____

Any Heart Conditions ____

History of Concussion ____

Family History of Heart Conditions ____

Migraines ____

Asthma ____

Heart Murmur ____

Shortness of Breath with Exercise ____

Weight ____

Previous Fracture History ____

Atherosclerosis ____

Insomnia ____

Pain with Exercise ____

Sudden Weight Loss ____

Contacts / Glasses ____

Approved by the California University of Pennsylvania IRB

APPENDIX C3
Institutional Review Board –
California University of Pennsylvania

69
Institutional Review Board
California University of Pennsylvania
Morgan Hall, Room 310
250 University Avenue
California, PA 15419
instreviewboard@calu.edu
Robert Skwarecki, Ph.D., CCC-SLP,Chair

Dear Ms. Brown:
Please consider this email as official notification that your proposal
titled "Collegiate Athlete’s Knowledge of Sudden Cardiac Deathon Signs &
Symptoms and Risk Factors” (Proposal #12-057) has been approved by the
California University of Pennsylvania Institutional Review Board , with the
following stipulations:
--:-In the second paragraph of the consent form, text equivalent to the phrase
“without penalty” must be added to the section concerning participant withdrawal
from participation.

Once you have amended your consent form, you may immediately begin data
collection. You do not need to wait for further IRB approval. At your earliest
convenience, you must forward a copy of the consent form for the Board’s
records].

(1)
(2)
(3)
(4)

The effective date of the approval is 3-1-13 and the expiration date is 2-28-14.
These dates must appear on the consent form .
Please note that Federal Policy requires that you notify the IRB promptly
regarding any of the following:
Any additions or changes in procedures you might wish for your study (additions
or changes must be approved by the IRB before they are implemented)
Any events that affect the safety or well-being of subjects
Any modifications of your study or other responses that are necessitated by any
events reported in (2).
To continue your research beyond the approval expiration date of 2-28-14 you
must file additional information to be considered for continuing review. Please
contact instreviewboard@cup.edu
Please notify the Board when data collection is complete.
Regards,
Robert Skwarecki, Ph.D., CCC-SLP
Chair, Institutional Review Board

APPENDIX C4
Survey Cover Letter

Date:
Dear:
My name is Brittney Brown and I am currently a graduate student at California University of
Pennsylvania pursing a Master of Science in Athletic Training. Part of the graduate study
curriculum is to complete a research thesis through conducting research. I am conducting survey
research to examine the amount of knowledge that a collegiate athlete has on sudden cardiac
death, pertaining to the signs and symptoms along with risks. A secondary purpose of this study
is to determine the reliability for the two dependent variables: signs and symptoms and risk
factors. The data will be used to formulate an idea of what athletes are being taught prior to
participation along with allowing athletes to the most up to date information on sudden cardiac
death as possible.
Athletes from Westminster College will be surveyed; however, your participation is voluntary
and you do have the right to choose not to participate. You also have the right to discontinue
participation at any time during the survey completion process, without penalty, at which time
your data will be discarded. The California University of Pennsylvania Institutional Review
Board has reviewed and approved this project. The approval is effective March 1, 2013 and
expires February 28, 2014 (IRB).
All survey responses are anonymous and will be kept confidential, and informed consent to use
the data collected will be assumed upon return of the survey. Aggregate survey responses will be
housed in a password protected file on the CalU campus. Minimal risk is posed by participating
as a subject in this study. I ask that you please take this survey at your earliest convenience as it
is 8 questions long and will take approximately 10 minutes to complete. If you have any
questions regarding this project, please feel free to contact the primary researcher, Brittney
Brown, ATC (bro6175@calu.edu). You can also contact the faculty advisor for this research:
Carol Biddington, EdD (biddington@calu.edu). Thanks in advance for your participation.
Please click the following link to access the survey:
https://www.surveymonkey.com/s/KDSZVQ3.

Thank you for taking the time to take part in my thesis research. I greatly appreciate your time
and effort put into this task.

Sincerely,
Brittney Brown, ATC
Primary Researcher
California University of Pennsylvania
250 University Ave
California, PA 15419
bro6175@calu.edu

72
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ABSTRACT
TITLE:

COLLEGIATE ATHLETES’ KNOWLEDGE OF SUDDEN
CARDIAC DEATH ON SIGNS & SYMPTOMS AND RISK
FACTORS

RESEARCHER:

Brittney Brown, ATC, PES

ADVISOR:

Dr. Carol Biddington

PURPOSE:

To examine the knowledge collegiate athletes
have on sudden cardiac death pertaining to
signs and symptoms along with risk factors.
To determine the reliability for the two
dependent variables of signs and symptoms
and risk factors.

METHODS:

Westminster College athletes (n=80) were
surveyed using Survey Monkey. The survey
consisted of eight questions regarding
knowledge of signs and symptoms along with
knowledge of risk factors of sudden cardiac
death.

FINDINGS:

There were no significant differences
between gender and ethnicity for knowledge
of signs and symptoms and risk factors of
sudden cardiac death. It was found that
almost half (n=38, 47.5%) were CPR/AED
certified. The reliability of the two
dependent variables was moderate.

CONCLUSION:

After reviewing the results of this study,
it is concluded that gender and ethnicity do
not have any impact on the amount of
knowledge a collegiate athlete has on signs
and symptoms along with risk factors of
sudden cardiac death. The reliability of
this survey was found to be moderately
reliable. More research needs done in order
to assess what information on sudden cardiac
death is available to athletes prior to
competition.