to the editor: I would like to commend Dr. O'Connor and colleagues on an excellent review of sudden death in athletes.¹ The authors point out the importance of preparticipation cardiovascular screening in young athletes. However, the association between sudden death and sickle cell trait² is not addressed in this article.

The prevalence of sickle cell trait is 8 percent in blacks.³ In one study,³ a 50 percent prevalence of sickle cell trait was found among black military basic trainees with exertional sudden death. Risk factors for sudden death associated with sickle cell trait include heavy exercise with poor physical conditioning, dehydration, increased ambient temperature and training at high altitudes.³

No specific recommendations exist for screening of the general population or for limitation of activities in athletes. The American College of Sports Medicine and the National Collegiate Athletic Association have published guidelines on the screening and counseling of individuals who may have sickle cell trait.⁴ They recommend that team physicians and athletic trainers familiarize themselves with the literature on sickle cell trait, as well as counsel patients with sickle cell trait on dehydration, acclimatization, physical conditioning, training at high altitudes and exercise during acute illness.⁴ Screening for sickle cell trait has additional relevance in family planning and genetic counseling. The association between sickle cell trait and sudden death might also be considered by physicians performing preparticipation physical examinations and managing athletes with exertional collapse.

in reply: We would like to thank Drs. Holmes, Kerle and Seto for their kind comments, as well as for addressing an important omission in our article.

We are currently working with Dr. Kark to review 20 years of nontraumatic sudden deaths in military basic training. Our preliminary review, which is unpublished, demonstrates that heat stroke, not hypertrophic cardiomyopathy, appears to be the principal cause of death in this population.

The issue of screening for sickle cell trait, as was pointed out by Drs. Holmes, Kerle and Seto, is controversial. The ramifications of screening on participation in athletics or military service raise even more questions.

We feel that “universal precautions” should be applied to all soldiers and athletes, regardless of their sickle cell trait status. We agree with Drs. Holmes, Kerle and Seto that these precautions should include careful attention to acclimatization, proper hydration and modification of exercise with altitude and illness.