Sudden death resulting from cardiac arrest in athletes occurs once per 86,000 athletes per sport per year.
Emergency action plans (EAPs) can prevent death from sudden cardiac arrest in athletes.
Twelve states, including MO, require high schools to have formal EAPs, cardiopulmonary resuscitation (CPR) training for staff and students, and access to automated external defibrillators (AEDs).
Sudden death (SCD) in athletes is an unexpected fatality due to a heart problem during or within one hour of practice or competition (Michelland et al. 2023). Sudden cardiac arrest (SCA) occurs when the heart stops unexpectedly and is the leading cause of SCD in athletes (Kim et al. 2024, Casa 2012).
The rate of SCA and SCD is standardized using the athlete-year metric (one athlete in one sport for one year) to accurately compare risk particularly among multi-sport athletes (Petek et al. 2024). The reported incidence of SCD in National Collegiate Athletic Association (NCAA) athletes between 2014 and 2023 was about one in 86,000 athlete-years (Wainwright 2025, Petek et al. 2024). Black male Division I basketball players face the highest risk, with a reported incidence of one in 21,000 athlete-years (Petek et al. 2024). While high school students account for the largest population of all competitive youth athletes, calculating SCD and SCA in this group is difficult due to the lack of mandated case reporting (Dineen et al. 2024, Kim et al. 2024).
Before participating in any sport, athletes are evaluated for SCD risk using the American Heart Association’s 14-point screening, which consists of a medical history report and physical exam (Maron 2014). While adding an electrocardiogram (ECG) improves the detection of underlying heart disorders, it is not widely used (Williams et al. 2019). An ECG screening requires a specialist to interpret the results, creating access and cost barriers (Azorzi et al. 2018).
A rapid and immediate response to SCA is the most effective way to prevent SCD (Kim et al. 2024). Survival rates for SCA drop by 10% every minute the heart is not regularly beating (Michelland et al. 2023). Immediate cardiopulmonary resuscitation (CPR) or the use of an automated external defibrillator (AED) are each associated with higher survival rates, and survival rates are as high as 89% when both these measures are used (Michelland et al. 2023, Vetter et al. 2022, Drezner et al. 2018, Naim et al. 2017). Studies examining policy effects show state laws mandating AED placement in schools increases SCA survival (Tamirisa 2023). However, funding for these devices is often inadequate, leading to a shortage of AEDs in lower socioeconomic (Williams et al. 2019).
States can require SCD prevention strategies in high schools (Dineen et al. 2024, Vetter et al. 2022). This includes primary prevention (screening) and secondary prevention (emergency response). Some states require primary prevention, however the cost can be a barrier for some families (Maron et al. 2015). In addition, false-positive screening results can disqualify healthy athletes (Maron et al. 2015).
Legislative efforts have focused on mandating four core components for effective emergency response (Dineen et al. 2024, Kim et al. 2024, Tamirisa 2023):
Forty-four states require CPR training as a graduation requirement (School CPR 2023). AK, NE, NH, and WY have no training requirements. CO and ME, encourage but do not mandate training, and MA introduced requirement legislation in 2025. In MO, public high school students are required to receive 30 minutes of CPR instruction to graduate (RSMO 170.310, Vetter et al. 2022).
State policies mandating EAPs, AED proximity, and training for coaches vary (Figure 1). NJ’s “Janet’s Law” mandates all four components, while OK requires AED access but not EAPs or CPR/AED training (Janet’s Law 2012). MO requires public schools to develop and implement an EAP that includes EMS coordination, yearly practice drills, and CPR and AED training for coaches and school nurses, and AED (RSMo 160.482).
Figure 1. Emergency response components. The core policy components for SCA emergency response: (1) Emergency action plans (EAPs), (2) Defined automated external defibrillator (AED) access, (3) Cardiopulmonary resuscitation (CPR) and AED training for coaches and school personnel, (4) CPR training as a high school graduation requirement. Adapted from Dineen et al. 2024 with updates for AZ, DE, ME, MO, NH. Map created with mapchart.net.
References
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