Sudden Cardiac Death In Athletes Research Articles

Sudden Cardiac Death in Athletes: Facts and Fallacies

The benefits of exercise for cardiovascular and general health are many. However, sudden cardiac death (SCD) may occur in apparently healthy athletes who perform at the highest levels. A diverse spectrum of diseases is implicated in SCD in athletes, and while atherosclerotic coronary artery disease predominates in individuals of >35 years of age, primary cardiomyopathies and ion channelopathies are prevalent in young individuals. Prevention of SCD in athletes relies on the implementation of health policies aimed at the early identification of arrhythmogenic diseases (such as cardiac screening) and successful resuscitation (such as widespread utilization of automatic external defibrillators and training members of the public on cardiopulmonary resuscitation). This review will focus on the epidemiology and aetiologies of SCD in athletes, and examine fallacies in the approach to this controversial field. Furthermore, potential strategies to prevent these tragic events will be discussed, analysing current practice, gaps in knowledge and future directions.

807 MATERNAL ANTI-RO/SSA AUTOANTIBODIES AND PROLONGED PR INTERVAL IN A COMPETITIVE ATHLETE

Abstract Background Prolongation of the PR interval is a common finding among competitive athletes. However, further investigations should be performed when the PR interval is markedly prolonged. We report the case of a young male athlete with a late progressive congenital form of autoimmune-mediated atrioventricular block. Case presentation A 26-year-old male athlete was referred to our center because of a significant prolongation of the PR interval (PR=400 ms), firstly found at the age of 7 years in a preparticipation screening and then confirmed when he was 10 years old. He has been playing soccer for 6 hours/week without symptoms or limitations. His personal remote medical history was unremarkable, he did not have a family history of sudden cardiac death, channelopathies, or cardiomyopathies. Vital parameters and physical examination were normal. Blood test results were within the limits, with negative inflammation indexes and normal thyroid function. Ambulatory 12-lead ECG monitoring, including a training session to assess the chronotropic response to exercise, showed a 1st and 2nd type 1 AV block with narrow QRS without pauses and a shortening of the PR interval during the training session, also confirmed by exercise testing. After three months of detraining, no variation in the PR interval was observed. Echocardiography and cardiac magnetic resonance were normal, as well as genetic testing. Finally, we assessed the autoimmunity status of the patient and his mother, given the potential association between damage induced by anti-Ro/SSA antibodies and AV block and we found maternal seropositivity only, compatible with a late progressive congenital form of autoimmune AV bock. Accordingly, no circulating anti-Ro/SSA-autoantibodies were found in the athlete and we did not recommend immuno-modulating therapy. Considering the absence of symptoms and of cardiac, laboratory and genetic abnormalities, no circulating autoantibodies in the patient and the stability of the PR interval, the athlete was deemed eligible for sports competition. We advised him yearly follow-up visits to exclude the possibility of conduction disturbance progression. During the follow-up period he has continued to practice competitive sports without events. Discussion According to current recommendations, 1st degree AV block (up to 399 ms) and 2nd degree type 1 AV block can be considered physiological adaptations to exercise, especially if they disappear during exercise and detraining. Otherwise, further investigations are recommended to exclude abnormalities associated with sudden cardiac death in athletes, such as structural heart diseases, primary electrical diseases and autoimmunity. The most recognized form of autoimmune AV block is congenital (neonatal lupus). Growing evidence supports the existence of a late progressive congenital form, in which the conduction system injury is mediated by transplacental passage of antibodies produced by the mother and cross-reacting with calcium channels in the fetus, with a subclinical presentation in utero/at birth/in the neonatal phase and a manifest conduction disease later in life. Finally, autoimmune AV block can be acquired, in this case autoantibodies are found in the patient only and immuno-modulating therapy can be considered. In our case, maternal only seropositivity supported the hypothesis of a late progressive congenital form.

QT interval variability and athlete's heart remodeling

At present, the prevention of sudden cardiac death in athletes is of great interest. A large amount of literature data concerning the correlation between the length of the QT interval and the proarrhythmic potential of the myocardium has been accumulated. However, new potential predictors of the fatal arrhythmias occurrence in athletes have emerged in recent years — an increase in the dispersion of the QT interval, as well as short-term variability in repolarization. This review provides detailed data on the diagnosis, prevalence, classifi cation, etiology of long QT as one of the manifestations of QT variance. The variety of causes leading to long QT syndrome (LQTS) causes diffi culties in the diff erential diagnosis of this condition and, and as a result, LQTS often remains outside the attention of practitioners. The data of recent studies of the athlete’s heart remodelling are presented as well.

ASSOCIATION OF DURATION AND INTENSITY OF EXERCISE WITH SEVERITY OF PHENOTYPIC EXPRESSION IN HYPERTROPHIC CARDIOMYOPATHY

ASSOCIATION OF DURATION AND INTENSITY OF EXERCISE WITH SEVERITY OF PHENOTYPIC EXPRESSION IN HYPERTROPHIC CARDIOMYOPATHY

Risk Factors for Sudden Death in Athletes, Is There a Role for Screening?

Purpose of ReviewSudden cardiac death (SCD) in a young athlete is an infrequent yet devastating event often associated with substantial media attention. Screening athletes for conditions associated with SCD is a controversial topic with debate surrounding virtually each component including the ideal subject, method, and performer/interpreter of such screens. In fact, major medical societies such as the American College of Cardiology/American Heart Association and the European Society of Cardiology have discrepant recommendations on the matter, and major sporting associations have enacted a wide range of screening policies, highlighting the confusion on this subject. This review seeks to summarize the literature in this area to address the complex and disputed subject of screening young athletes for SCD.Recent FindingsThe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause myocarditis, which is one acquired cardiac disease associated with SCD. The coronavirus 2019 (COVID-19) pandemic has therefore resulted in an increased incidence of an otherwise less common condition, providing an expanded dataset for further study of this condition. Recent findings indicate that cardiac complications of athletes with myocardial involvement of SARS-CoV-2 infection are rare. Other contemporary work in SCD screening has been focused on the implementation of various screening protocols and measuring their effectiveness.SummaryNo universal consensus exists for athlete screening for conditions associated with SCD with varying guidelines and protocols across cardiology and sport-specific organizations. No screening program will prevent all SCD; however, small programs managed by physicians familiar with the examination of an athlete that carefully personalize screening to the individual may maximize detection of dangerous cardiac conditions while minimizing false positives.

A Morte Súbita Cardíaca em Atletas e a Avaliação Médico-Desportiva Cardiovascular em Portugal

Introduction: Sudden cardiac death in athletes is an event that everyone wants to prevent, and it is necessary to know what principal causes are and the best way to diagnose them. Methods: Research on Pubmed using articles published between 2011 and 2021 and the creation of a questionnaire answered by Portuguese clubs. Results: The data acquired was accordant to the recommendations in Portugal. The echocardiogram is not regularly used. Conclusion: The use of the echocardiogram in athletes should be studied. There should also be a note on the necessity of better supervision of federated athletes to make sure they carry-out the pre-participation evaluation required by law.

Pre-participation cardiovascular screening in athletes with a focus on Asia

Pre-participation screening (PPS) in young competitive athletes aims to identify conditions associated with sudden cardiac death (SCD) in this population, with a view to appropriate management and potential mitigation of risk. A medical history questionnaire and physical examination are standard components of a PPS programme, whereas controversy still exists regarding mandatory utilisation of resting 12-lead electrocardiogram as a screening tool. Apart from a landmark study from Italy attributing the reduction of SCD rates in athletes to the implementation of a mandatory PPS programme, there remains no additional compelling evidence for similar outcomes to date. Nonetheless, comprehensive PPS programmes when carried out systematically, are efficacious in detection of cardiac pathology and cost-effective. While the incidence rate of SCD in athletes from Western countries is estimated to be around 1:50,000, comparable data in Asian athletes remain lacking. Prospective registries are much needed to accurately determine the magnitude of this issue in Asia and recent recommendations on PPS in young Asian athletes have been published to increase awareness and encourage collaboration. To further reduce SCD events, prompt recognition of sudden cardiac arrests and early defibrillation are vital components in the spectrum of SCD prevention. This review aims to outline the rationale, current status and efficacy of PPS in athletes, with a focus on Asia.

Risk of sudden cardiac death and preventive measures in athletes

Arrhythmias, which are fatal in some patients, can be triggered by sports in vulnerable people. It is estimated that 1:40,000–1:250,000 athletes will suffer a sudden cardiac death (SCD). However, female athletes appear to have some level of cardiac protection, since suffering from SCD considerably less than male athletes during sports. Athletes with underlying coronary, valvular or myocardial disease, as well as channelopathies, may be particularly prone to SCD from exercise- and sports-related physical activity. There are three main causes of SCD in young athletes: Sudden Arrhythmic Death Syndrome (56%), congenital anomalous coronary arteries (7%–14%), and hypertrophic cardiomyopathy (36%–48%). In the context of exercise, acute ischemia, myocardial infarction, and stroke risk are increased by catecholamine surge and exercise-induced stress. In middle-aged athletes, excessive cardiovascular activity is associated with a higher risk of mortality related to cardiovascular disease. It is possible to detect at-risk athletes by conducting cardiac screening, which involves a family history, physical examination, and a resting electrocardiogram. Consequently, efforts have been made to better understand the causes of SCD in athletes and to develop appropriate prevention methods.

Prevention and Management of Sudden Cardiac Death in Athletes

Sudden cardiac death (SCD) is the biggest challenge of all sports emergencies, as it is the leading cause of preventable deaths in both professional and recreational athletes. There is also an ongoing concern about COVID-19-associated cardiac pathology among athletes because myocarditis is an important cause of SCD during exercise. Hypertrophic cardiomyopathy represents 24% of SCD and Sudden Unexplained Death (normal heart at autopsy) represents 34% of SCD. To make sports participation safer, it is important to synergistically combine primary prevention of SCD by pre-participation identification of athletes affected by at-risk cardiomyopathies and secondary prevention with backup defibrillation of unpredictable sudden cardiac arrest on the field. The prompt application of an automated external defibrillator itself is associated with a greater likelihood of survival. With the advancement in the field of sports cardiology, the implantation of implantable cardioverter defibrillator has been promising in getting the athlete back on the field including in contact sports. Hence, knowledge of primary and secondary prevention is of great importance in reducing the incidence of SCD as well as improvising existing strategies.

217 Why it is important to recognize Brugada syndrome in athletes: a case report

Abstract Aims The Brugada syndrome (Brs) is an inherited disorder associated with risk of ventricular fibrillation and sudden cardiac death in a structurally normal heart. The purpose of this case presentation was to spread awareness about this condition, highlight the importance of timely diagnosis and effective treatment of this channelopathy especially in asymptomatic young athletes at high risk of sudden cardiac death. Methods and results In this report, we discuss the case of a 47-year-old male. He was a tennis player who performed a visit to the sports doctor to have issued a certificate for competitive fitness. He had no familiar history of sudden death or syncope. The patient’s electrocardiogram (ECG) revealed J-point elevation and ST-segment elevation in the right precordial leads V1 and V2 positioned in the second, third, or fourth intercostal space, showing classic type II ‘saddleback’ morphology in V2 and BrS was suspected. Hence, the patient underwent Holter ECG monitoring with evidence of spontaneous type 1 Brugada pattern (‘coved’ morphology), as well as frequent ventricular ectopic beats with left branch block morphology. Indeed, a diagnosis of BrS was made. Antiarrhythmic prophylaxis therapy with hydroquinidine was initiated and the patient was suspended from competitive activity with a 3-month follow-up. Conclusions The BrS is a hereditary disease characterized by a typical ECG pattern potentially predisposing active individuals with no patent structural heart disease to ventricular arrhythmias (VA) and sudden cardiac death (SCD). Nowadays, it is difficult to discern the true burden of BrS due to the unknown real prevalence of asymptomatic patients and the dynamic variability of the ECG pattern in individuals. The purpose of this case presentation was to spread awareness about this condition, highlight the importance of timely diagnosis, and effective treatment of this channelopathy especially in asymptomatic young athletes at high risk of SCD. Indeed, exercise may potentially worsen the ECG abnormalities in BrS patients, resulting in higher peak J-point amplitudes during the vasovagal reaction of the recovery period, possibly leading to an increased risk of cardiac events. Moreover, the enhanced vagal tone in athletes could be both a BrS risk factor and an exercise effect. For this reason, athletic pre-participation screening is essential for minimizing the risk for SCD in athletes participating in either competitive or leisure sporting activities.

Direct Reimplantation Procedure in Anomalous Aortic Origin of the Right Coronary Artery: Long-Term Single Center Outcomes.

Anomalous aortic origin of the right coronary artery is known to be a cause of sudden cardiac death in athletes. There are no specific guidelines concerning treatment strategy in the literature. The aim of this study is to describe and report our experience of direct reimplantation technique in the treatment of this anomaly. This was a retrospective single center study of 30 patients who underwent surgery in the congenital heart disease unit of Louis Pradel Heart and Lung Hospital between January 2003 and December 2016. The mean follow-up was seven years (3 months-17 years). Thirty patients underwent surgery. The median age was 17 years (0.2-52 years). There were 24 males. The median weight was 58 kg (3.6-118 kg). Fourteen patients were actively engaged in sports. Twenty-six patients had exertional chest pain or syncope. The median time lapse between diagnosis and intervention was 4.5 months (0.5-179 months). Twenty-seven (90%) patients underwent reimplantation of the anomalous coronary artery without transverse aortotomy, while in 3 (10%) patients transverse aortotomy was used to facilitate reimplantation to avoid tension at the anastomosis. There was no early death; one late death occurred in the third postoperative month. At the last follow-up, all patients had returned to normal physical activity without evidence of ischemia. Direct reimplantation allows for a complete restoration of the coronary anatomy and enables patients to return to normal physical activity. Our study shows encouraging results using a direct reimplantation technique without aortotomy.

COVID-19: the Risk to Athletes.

Purpose of ReviewThe COVID-19 pandemic has had a profound impact on athletics, and the question of safely resuming competitive sports at all levels has been a source of significant debate. Concerns regarding myocarditis and the risk of arrhythmias and sudden death in athletes have prompted heightened attention to the role of cardiovascular screening. In this review, we aim to comprehensively outline the cardiovascular manifestations associated with COVID-19 infection, to discuss screening, diagnosis, and treatment strategies, and to evaluate the current literature on the risk to athletes and recommendations regarding return-to-play.Recent FindingsCOVID-19 is known to cause myocarditis, with presentations ranging from subclinical current or prior infection detected on cardiac MRI imaging, to fulminant heart failure and shock. While initial data early in the pandemic suggested that the risk of myocarditis could be significant even in patients with nonsevere COVID-19 infection, recent studies suggest a very low prevalence of clinically significant disease in young athletes.SummaryWhile COVID-19 can have significant cardiovascular manifestations, recent data demonstrate that a screening approach guided by severity of COVID-19 infection and cardiovascular symptoms allows the majority of athletes to safely return to play in a timely manner. We must continue to tailor our approach to screening athletes as knowledge grows, and further research on the longitudinal cardiovascular effects of COVID-19 is needed.

Sudden Cardiac Death in Athletes.

Sudden Cardiac Death in Athletes.

Comparison of the Limb-lead Electrocardiogram to the 12-Lead Electrocardiogram for Identifying Conditions Associated with Sudden Cardiac Death in Youth Athletes

The optimal screening strategy to prevent sudden cardiac death (SCD) in athletes remains unknown. Pre-participation screening with electrocardiogram (ECG) remains controversial. The utility and accuracy of limb-lead (LL) ECG alone in identifying cardiac abnormalities associated with SCD has not been studied.This study was a comparative secondary data analysis, comparing the interpretation accuracy of 4 physicians evaluating publicly available ECGs of the most common cardiac conditions associated with SCD in athletes. Each physician interpreted a total of 100 ECGs: 50 normal ECGs (25 LL and 25 standard 12L) and 50 abnormal ECGs (25 LL and 25 standard 12L). The agreement between LL ECGs and 12L ECGs was assessed by Cohen's kappa coefficient and the accuracy of identifying an abnormal ECG was compared across LL and 12L ECGs using a chi-squared test. Inter-rater reliability was assessed by estimating the Fleiss's kappa coefficient.The sensitivity of LL ECG and 12L ECG was identical at 86%. The specificity of LL ECG was 75% (95% CI=65% to 83%) and 12L ECG was 82% (95% CI=73% to 89%). Substantial agreement was seen between LL ECG and 12L ECG interpretation across all readers (k=0.63; 95% CI=0.49 to 0.77). Interpretation accuracy was 81% (95% CI=74% to 86%) and 84% (95% CI 78% to 89%) using LL ECG and 12L ECG, respectively (p=0.43). In conclusion, the accuracy, sensitivity, and specificity were high and comparable for both LL ECG and 12L ECG in identifying cardiovascular conditions associated with SCD. Agreement between LL ECG and 12L ECG was substantial.

Young athletes: Preventing sudden death by adopting a modern screening approach? A critical review and the opening of a debate.

Preventing sudden cardiac death (SCD) in athletes is a primary duty of sports cardiologists. Current recommendations for detecting high-risk cardiovascular conditions (hr-CVCs) are history and physical examination (H&P)-based. We discuss the effectiveness of H&P-based screening versus more-modern and accurate methods. In this position paper, we review current authoritative statements and suggest a novel alternative: screening MRI (s-MRI), supported by evidence from a preliminary population-based study (completed in 2018), and a prospective, controlled study in military recruits (in development). We present: 1. Literature-Based Comparisons (for diagnosing hr-CVCs): Two recent studies using traditional methods to identify hr-CVCs in >3,000 young athletes are compared with our s-MRI-based study of 5,169 adolescents. 2. Critical Review of Previous Results: The reported incidence of SCD in athletes is presently based on retrospective, observational, and incomplete studies. H&P's screening value seems minimal for structural heart disease, versus echocardiography (which improves diagnosis for high-risk cardiomyopathies) and s-MRI (which also identifies high-risk coronary artery anomalies). Electrocardiography is valuable in screening for potentially high-risk electrophysiological anomalies. 3. Proposed Project : We propose a prospective, controlled study (2 comparable large cohorts: one historical, one prospective) to compare: (1) diagnostic accuracy and resulting mortality-prevention performance of traditional screening methods versus questionnaire/electrocardiography/s-MRI, during 2-month periods of intense, structured exercise (in military recruits, in advanced state of preparation); (2) global costs and cost/efficiency between these two methods. This study should contribute significantly toward a comprehensive understanding of the incidence and causes of exercise-related mortality (including establishing a definition of hr-CVCs) while aiming to reduce mortality.

Causes of sudden cardiac death in young athletes and nonathletes: systematic review and meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction. The etiology of sudden cardiac death (SCD) in young people is still debated. The aim of this meta-analysis was to identify the most frequent causes of SCD in individuals aged ≤35 years, the differences between athletes and nonathletes and among geographic areas. Methods. Studies published between 01/01/1990 and 01/31/2020 and evaluating post-mortem the etiology of SCD in young individuals (≤35 years) were included. Individuals were divided in athletes and nonathletes. Studies that did not report separately data between athletes and nonathletes were excluded. Results. Thirty-four studies met the inclusion criteria and a total population of 5,060 victims of SCD were analysed (2,890 athletes, 2,170 nonathletes). Structurally normal heart, hypertrophic cardiomyopathy (HCM), idiopathic left ventricular hypertrophy, and anomalous origin of coronary arteries (AOCA) were the most frequent causes of SCD in athletes while coronary artery disease (CAD), arrhythmogenic cardiomyopathy (ACM), and channelopathies were frequent causes of SCD in nonathletes. The number of SCDs due to ischemic heart disease (19.6% vs. 9.1%, p = 0.009), ACM (11.5% vs. 4.7%, p = 0.03) and channelopathies (8.4% vs. 1.9%, p = 0.02) was higher in nonathletes comparing with athletes. SCD due to non-ischemic left ventricular scar (5.1% vs. 1.1%, p = 0.01) was more frequent in athletes. HCM (p = 0.01) and AOCA (p = 0.004) were more frequently cause of SCD in US while ACM (p = 0.001), structurally normal heart (p = 0.02), and channelopathies (p = 0.02) in Europe. Conclusions. Structurally normal heart, HCM, AOCA were frequent causes of SCD in athletes while CAD, ACM and channelopathies in nonathletes. The causes of SCD differ between US and Europe.

Contribution of American Football Uniforms to the Development of Exercise-Induced Hyperthermia: A Critically Appraised Topic

Clinical Scenario: Many American football players have died from exertional heatstroke, one of the leading causes of sudden death in athletes. These athletes are predisposed to exertional heatstroke, in part, because of their protective equipment. Few authors have systematically appraised the research to determine how much faster rectal temperature (Trec) increases when full American football uniforms generally consisting of a helmet, shoulder pads, jersey, pants with padding, socks, shoes, and underwear/compressions (PADS) are worn compared with no uniform so that clinicians can better plan and modify exercise sessions to prevent dangerous Trec (i.e., ≥40.5 °C). Clinical Question: How much faster does Trec increase when men wear a full American football uniform compared with workout clothing during exercise in the heat? Summary of Key Findings: The authors searched the literature for randomized controlled studies with PEDro scores >6 that compared Trec of males wearing PADS to a control uniform during exercise under controlled laboratory conditions. In all four studies, Trec increased faster when PADS were worn during exercise (PADS = 0.052 ± 0.007 °C/min and control = 0.039 ± 0.009 °C/min). The average effect size across studies was 1.4 ± 0.5. Clinical Bottom Line: PADS increase Trec significantly faster than lesser uniform ensembles. Clinicians should factor in equipment and alterations in exercise duration and rest break frequency to help prevent dangerous Trec in American football players. Strength of Recommendation: Given the large effect size and controlled experimental study designs, there is strong evidence that wearing PADS during exercise results in faster increases in body core temperature.

Myocardial Inflammation, Sports Practice, and Sudden Cardiac Death: 2021 Update.

Myocardial inflammation is an important cause of cardiovascular morbidity and sudden cardiac death in athletes. The relationship between sports practice and myocardial inflammation is complex, and recent data from studies concerning cardiac magnetic resonance imaging and endomyocardial biopsy have substantially added to our understanding of the challenges encountered in the comprehensive care of athletes with myocarditis or inflammatory cardiomyopathy (ICM). In this review, we provide an overview of the current knowledge on the epidemiology, pathophysiology, diagnosis, and treatment of myocarditis, ICM, and myopericarditis/perimyocarditis in athletes, with a special emphasis on arrhythmias, patient-tailored therapies, and sports eligibility issues.

Sudden Cardiac Death in Athletes: From the Basics to the Practical Work-Up.

Sudden cardiac death in athletes is a relatively rare event, but due to the increasing number of individuals practicing high-performance sports, in absolute terms, it has become an important issue to be addressed. Since etiologies are many and the occurrence is rare, tracing the ideal preparticipation screening program is challenging. So far, as screening tools, a comprehensive clinical evaluation and a simple 12-lead electrocardiogram (ECG) seem to be the most cost-effective strategy. Recent technological advances came to significantly help as second-line investigation tools, especially the cardiac magnetic resonance, which allows for a more detailed ventricular evaluation, cardiac tissue characterization, and eliminates the poor acoustic window problem. This article aims to review all aspects related to sudden cardiac death in athletes, beginning with definitions and epidemiology, passing through etiology and clinical characteristics, then finishing with a discussion about the best ambulatory investigational approach.

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

Sickle cell trait (SCT) is a risk factor of collapse and sudden death in athletes. We conducted a longitudinal study to determine the hematological responses and hydration status in NCAA Division I American football players with SCT. The study took place over 2 years with 6 SCT and 6 position-matched controls (CON) in year 1; and 4 SCT and 4 CON in year 2. In year 2, three of the four SCT players were recruited and re-enrolled with new position-matched controls (total sample data = 10 SCT and 10 CON). Blood samples were taken at three visits: pre-camp, post-camp, and post-season to examine hemoglobin variants, complete blood counts, and chemistry panel 26. Hydration status was assessed by measuring body weight change, urine specific gravity, and urine and sweat electrolyte concentrations during the pre-season training camp. All SCT players were confirmed to have SCT (HbS = 37.9 ± 2.4%) and had greater red cell distribution width (RDW) compared to CON across all visits. Serum uric acid was higher in SCT (7.3 ± 1.0 mg/dL) compared to CON (6.1 ± 0.6 mg/dL; p = 0.001). Furthermore, serum creatine kinase levels were greater in SCT (1617.0 ± 1034.8 IU/L) at pre-camp compared to CON (1037.4 ± 602.8 IU/L; p = 0.03). SCT players exhibited lower pre- and post-practice urine electrolytes and urine specific gravity (SCT pre: 1.019 ± 0.005 vs. CON pre: 1.026 ± 0.008 p < 0.001; SCT post: 1.020 ± 0.005 vs. CON post: 1.030 ± 0.008 p < 0.01), whereas sweat sodium concentrations were higher in SCT players (55.4 ± 13.6 mmol/L) compared to CON (45.5 ± 10.6 mmol/L; p < 0.001). Given the evidence, greater uric acid and CPK levels in SCT players compared to CON may be an early indicator of altered kidney function and muscle damage, which could be added into NCAA guidelines for surveillance among SCT players. Consistent education and reinforcement of the importance of adequate fluid balance during exercise are critical for both SCT and CON players.