Risk and Causes of Death among Former National Football League Players (1986-2012).

PURPOSE: Previous research identified decreased overall and cardiovascular mortality for National Football League (NFL) players from the 1959-1988 era. The present study explored the mortality risk among recent NFL players who played in an era of heavier linemen and nearly year-round physical conditioning. METHODS: This cohort study included 9778 former NFL players with at least 1 yr in the NFL whose last season was between 1986 and 2012. Players' pension fund records were matched to the National Death Index to determine vital status, date of death, and cause of death. Standardized mortality ratios (SMR) compared player mortality through 2014 with US men of the same age, race, and calendar year. Cox proportional hazards models assessed the effect of player characteristics on overall and cardiovascular mortality. RESULTS: Two percent (n = 227) of players were deceased, with a median age at death of 38 yr (range, 23-61 yr). The most common major causes of death were diseases of the heart (n = 47; 21%), violence (n = 39; 17%), and transportation injuries (n = 34; 15%). Risk of death was significantly lower than the general population for overall mortality (SMR, 0.46, 95% confidence interval (CI), 0.40-0.52), cardiovascular disease (SMR, 0.65; 95% CI, 0.50-0.84), and other major causes. Players with playing-time body mass index (BMI) of >35 kg·m had significantly higher cardiovascular disease mortality (SMR, 2.20; 95% CI, 1.32-3.44) than did the general population and higher overall mortality risk (standardized rate ratio, 3.84; 95% CI, 2.66-5.54) than did players with a BMI of <30 kg·m. CONCLUSIONS: Consistent with an earlier NFL cohort and other elite athlete populations, the overall and cardiovascular mortality risk of this NFL cohort was significantly lower than that of the general US male population, likely attributable to a healthy worker effect and less smoking.However, players with the highest playing-time BMI exhibited elevated cardiovascular mortality risk.

Sleep-apnea risk and subclinical atherosclerosis in early-middle-aged retired National Football League players.

PURPOSE: Limited data from former National Football League (NFL) players suggest that obstructive sleep apnea (OSA) may be highly prevalent after retirement. It remains unclear whether the high prevalence of OSA in retired players is comparable to nonathletes. This retrospective analysis compared sleep apnea (SA) risk in retired NFL players to a community cohort (CARDIA Sleep study), and examined associations between SA risk and cardiovascular risk factors, including subclinical atherosclerosis. MATERIALS AND METHODS: Retired NFL players (n=122) were matched to CARDIA Sleep participants by age ±2 years (range 37-55 years), body mass index ±2 kg/m2, race, and male sex. Participants underwent electron-beam computed tomography to measure coronary artery calcium (CAC) and completed the Berlin Questionnaire to determine SA risk. The presence of CAC was defined as an Agatston score >0. RESULTS: Retired NFL players had a greater prevalence of high SA risk than the matched CARDIA Sleep participants (27% vs 11.5%, P=0.002). Compared to the CARDIA Sleep participants, retired players were less likely to smoke, and had higher blood pressure, lower fasting glucose levels, and higher cholesterol levels. However, there was no difference in the prevalence of detectable CAC (30% vs 30%, P=1). In both players and the community cohort, SA risk was not significantly associated with CAC after controlling for age, race, and body mass index. CONCLUSION: Retired NFL players have a greater prevalence of high SA risk but similar prevalence of CAC compared with a well-matched community cohort.

Lack of blood pressure difference by race in professional American football players.

Previous findings suggest that professional American football players have higher blood pressures (BP) and a higher prevalence of pre-hypertension and hypertension than the general population. We sought to determine whether race is associated with differences in BP and prevalence of pre-hypertension and hypertension among a large sample of professional football players. BP was measured at 2009 team mini-camps for 1484 black (n = 1007) and white (n = 477) players from 27 National Football League (NFL) teams. Players were categorized into three position groups based on body mass index (BMI). There was no racial difference in mean systolic or diastolic BP in any of the three position groups. There were no racial differences in prevalence of hypertension (99 [9.8%] black players vs. 39 [8.2%] white players; P = .353) or pre-hypertension (557 [55.3%] black players vs. 264 [55.3%] white players; P = 1.0). Contrary to findings in the general population, BP and prevalence of pre-hypertension/hypertension did not vary with race in a large population of active NFL players.

Relation between playing position and coronary artery calcium scores in retired National Football League players.

Retired National Football League (NFL) linemen have an increased prevalence of risk factors for atherosclerosis and have an increased risk of cardiovascular death compared with nonlinemen and the general population. We evaluated whether playing in lineman position is independently associated with an increased risk of the presence and severity of subclinical atherosclerosis. Players were categorized as linemen if they reported playing on the offensive or defensive line during their careers. Subclinical atherosclerosis was assessed using coronary artery calcium (CAC) scores in 931 retired NFL players (310 linemen, 621 nonlinemen). CAC scores were evaluated for absence of subclinical atherosclerosis (CAC = 0), presence of mild subclinical atherosclerosis (CAC 1 to 100), and moderate to severe subclinical atherosclerosis (CAC ≥100). We performed multivariate logistic regression to determine whether the lineman position is independently associated with the presence and severity of subclinical atherosclerosis. Linemen were noted to have a lesser likelihood of absence of subclinical atherosclerosis (CAC = 0, 33.8% vs 41.7%, p = 0.02), a similar likelihood of mild subclinical atherosclerosis (CAC 1 to 100, 33.2% vs 31.8%, p = 0.7), and a greater likelihood of moderate to severe subclinical atherosclerosis (CAC >100, 32.9% vs 26.4%, p = 0.04) compared with nonlinemen. Adjusting for demographic and metabolic covariates, lineman status remained independently associated with mild subclinical atherosclerosis (CAC 1 to 100, odds ratio [OR] 1.41, 95% confidence interval [CI] 1.05 to 2.2, p = 0.04) and moderate to severe subclinical atherosclerosis (CAC ≥100, OR 1.67, 95% CI 1.05 to 2.2). The association was attenuated after adjustment for race (CAC 1 to 100, OR 1.24, 95% CI 0.82 to 1.8; CAC >100, OR 1.59, 95% CI 1.01 to 2.49). In conclusion, lineman status in retired NFL players is associated with presence and severity of subclinical atherosclerosis, which is partly explained by race.

Association of body mass index and waist circumference with subclinical atherosclerosis in retired NFL players.

OBJECTIVES: It is unknown which measure of adiposity (body mass index [BMI] or waist circumference [WC]) is associated with subclinical atherosclerosis in retired National Football League (NFL) players and whether this relation is attenuated after adjusting for components of the metabolic syndrome (elevated triglycerides, fasting glucose, and low levels of high-density lipoprotein-cholesterol [HDL-C]) that frequently coexist with obesity. METHODS: Coronary artery calcium (CAC) was measured in 926 retired NFL players. BMI was calculated as weight (in kilograms)/height (in meters)(2) and WC was measured in inches. Logistic regression analyses adjusting for age, race, systolic blood pressure, high sensitivity C-reactive protein, triglycerides, HDL-C, and fasting blood glucose were performed to evaluate whether BMI or WC was independently associated with the presence of CAC (CAC score >0). RESULTS: The median age, BMI and WC were 54 years, 31 kg/m(2), and 40 inches, respectively. CAC was present in 61% (n = 562) of retired players. Adjusting for age, race, systolic blood pressure, high sensitivity C-reactive protein, triglycerides, HDL-C, and fasting blood glucose, each standard deviation increase in BMI (4.85 kg/m(2)) was significantly associated with CAC (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.03-1.50), but each standard deviation increase in WC (10.53 inches) was not significantly associated with CAC (OR 1.18, 95% CI 0.96-1.45). There was a significant association for the presence of CAC for highest versus lowest quartiles of both BMI (OR 1.93, 95% CI 1.13-3.28) and WC (OR 1.75, 95% CI 1.05-2.92), although the trend for the presence of CAC was significant only across increasing BMI quartiles, even in models that included WC. CONCLUSIONS: In retired NFL players both BMI and WC were associated with CAC. Higher BMI may be associated with an increasing trend for the presence of CAC independent of WC.

PCSK9 Inhibitors: potential in cardiovascular therapeutics.

Despite the efficacy of statin therapy, patients treated with these agents face substantial residual risk that is associated with achieved levels of LDL cholesterol (LDL-C). These observations suggest a potential benefit of additional strategies to promote further LDL-C reduction. Proprotein convertase subtilisin/kexin type 9 (PCSK9) has emerged as an attractive target in this regard. Abrogation of PCSK9 function prevents PCSK9-mediated catabolism of LDL receptors, increases cell surface LDL receptor density, and promotes clearance of LDL and other atherogenic lipoproteins from the circulation. Thus far, the most advanced approaches to block PCSK9 action are monoclonal antibodies and anti-sense oligonucleotides. Among statin-treated patients, these agents may produce additional LDL-C lowering exceeding 50 %. In rare genetic experiments of nature, individuals with dominant negative or dual loss of function mutations of PCSK9 appear to have no adverse health effects resulting from lifelong, very low levels of LDL-C. In short-term trials, PCSK9 antibodies have been generally well-tolerated. However, evidence to support long-term safety and efficacy of PCSK9 therapy to reduce cardiovascular risk awaits the results of large cardiovascular outcome trials.

Cardiovascular damage resulting from chronic excessive endurance exercise.

A daily routine of physical activity is highly beneficial in the prevention and treatment of many prevalent chronic diseases, especially of the cardiovascular (CV) system. However, chronic, excessive sustained endurance exercise may cause adverse structural remodeling of the heart and large arteries. An evolving body of data indicates that chronically training for and participating in extreme endurance competitions such as marathons, ultra-marathons, Iron-man distance triathlons, very long distance bicycle racing, etc., can cause transient acute volume overload of the atria and right ventricle, with transient reductions in right ventricular ejection fraction and elevations of cardiac biomarkers, all of which generally return to normal within seven to ten days. In veteran extreme endurance athletes, this recurrent myocardial injury and repair may eventually result in patchy myocardial fibrosis, particularly in the atria, interventricular septum and right ventricle, potentially creating a substrate for atrial and ventricular arrhythmias. Furthermore, chronic, excessive, sustained, high-intensity endurance exercise may be associated with diastolic dysfunction, large-artery wall stiffening and coronary artery calcification. Not all veteran extreme endurance athletes develop pathological remodeling, and indeed lifelong exercisers generally have low mortality rates and excellent functional capacity. The aim of this review is to discuss the emerging understanding of the cardiac pathophysiology of extreme endurance exercise, and make suggestions about healthier fitness patterns for promoting optimal CV health and longevity.

Potential adverse cardiovascular effects from excessive endurance exercise.

A routine of regular exercise is highly effective for prevention and treatment of many common chronic diseases and improves cardiovascular (CV) health and longevity. However, long-term excessive endurance exercise may induce pathologic structural remodeling of the heart and large arteries. Emerging data suggest that chronic training for and competing in extreme endurance events such as marathons, ultramarathons, ironman distance triathlons, and very long distance bicycle races, can cause transient acute volume overload of the atria and right ventricle, with transient reductions in right ventricular ejection fraction and elevations of cardiac biomarkers, all of which return to normal within 1 week. Over months to years of repetitive injury, this process, in some individuals, may lead to patchy myocardial fibrosis, particularly in the atria, interventricular septum, and right ventricle, creating a substrate for atrial and ventricular arrhythmias. Additionally, long-term excessive sustained exercise may be associated with coronary artery calcification, diastolic dysfunction, and large-artery wall stiffening. However, this concept is still hypothetical and there is some inconsistency in the reported findings. Furthermore, lifelong vigorous exercisers generally have low mortality rates and excellent functional capacity. Notwithstanding, the hypothesis that long-term excessive endurance exercise may induce adverse CV remodeling warrants further investigation to identify at-risk individuals and formulate physical fitness regimens for conferring optimal CV health and longevity.

Association between traditional cholesterol parameters, lipoprotein particle concentration, novel biomarkers and carotid plaques in retired National Football League players.

OBJECTIVES: We assessed whether low-density lipoprotein particle concentration (LDL-P) and high-sensitivity C-reactive protein [hs-CRP] can identify subclinical atherosclerosis better than traditional cholesterol parameters in retired National Football League (NFL) players. BACKGROUND: It is not known whether LDL-P and the biomarker hs-CRP can identify subclinical atherosclerosis better than low-density lipoprotein cholesterol (LDL-C) or non-high-density-lipoprotein cholesterol (non-HDL-C) in retired NFL players, given high prevalence of metabolic syndrome in these players. METHODS: Carotid artery plaque screening was performed with traditional lipids, LDL-P, and hs-CRP in 996 retired players. Logistic regression analyses comparing highest with the lowest quartile were performed. RESULTS: Carotid artery plaques were seen in 41%. LDL-C (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.06-2.59), non-HDL-C (OR 1.67, 95% CI 1.04-2.67), and LDL-P (OR 2.21, 95% CI 1.35-3.62) were associated with plaques in adjusted models. Among 187 retired players with metabolic syndrome, LDL-C (OR 1.40, 95% CI 0.53-3.72) was not associated with carotid plaques, whereas LDL-P (OR 3.71, 95% CI 1.16-11.84) and non-HDL-C (OR 2.63, 95% CI 0.91-7.63, p=0.07; borderline significant) were associated with carotid plaques. hs-CRP (OR 1.13, 95% CI 0.71-1.79) was not associated with carotid plaques. CONCLUSION: Carotid artery plaques were common in retired NFL players and were strongly associated with LDL-P, especially among those with metabolic syndrome. hs-CRP was not associated with carotid plaques in this cohort.

Sleep-disordered breathing in the National Football League.

STUDY OBJECTIVES: Prior studies have suggested that the prevalence of sleep disordered breathing (SDB) among players in the National Football League (NFL) is disproportionately high. SDB can increase cardiovascular disease risk and is correlated with hypertension. NFL players have a higher prevalence of hypertension, and we sought to determine the prevalence of SDB among players the NFL and the associations of SDB with anthropometric measures and cardiovascular risk factors. DESIGN: Cross-sectional cohort study. SETTING: NFL athletic training facilities from April to July 2007. PARTICIPANTS: A total of 137 active veteran players from 6 NFL teams. MEASUREMENTS: This evaluation of SDB among players in the NFL used a single-channel, home-based, unattended, portable, sleep apnea monitor. Multiple domains of self-reported sleep were assessed. Weight, body mass index, body fat percentage, neck circumference, waist circumference, and waist-to-hip ratio, as well as blood pressure, cholesterol, and fasting glucose concentrations were measured. RESULTS: The mean respiratory disturbance index was 4.7 (+/- 12), with a median (interquartile range) of 2 (1,4). The prevalence of at least mild SDB (RDI > or = 5) was 19% (95% confidence interval, 12.8%-26.6%). Only 4.4% (95% confidence interval, 1.6%-9.2%) of participants had respiratory disturbance index of 15 or greater. Linemen and non-linemen were not different in their prevalence or severity of SDB. No single anthropometric measure was highly associated with SDB, and SDB was not well correlated with cardiovascular risk factors. CONCLUSIONS: The prevalence of SDB in active NFL players was modest, predominately mild, and positively associated with several measures of adiposity. SDB did not account for excess cardiovascular risk factors.

Body size, body composition, and cardiovascular disease risk factors in NFL players.

AIMS: We characterized the size of active National Football League (NFL) players by multiple criteria and analyzed their relation to traditional cardiovascular disease (CVD) risk factors with the objective of further clarifying the occurrence of cardiovascular risk factors in different player positions. METHODS: This cross-sectional study was conducted in professional athletic training facilities. The participants were 504 active veteran players from a convenience sample of 12 NFL teams, grouped as interior linemen (IL) or all others (AO). Comparisons were made between the NFL groups and an age-equivalent general population database. RESULTS: The IL group was significantly larger than AO by all size measures. Both groups were significantly larger than the Coronary Artery Risk Development in Young Adults (CARDIA) group. Mean percent body fat measurements in AO (mean, 13.4%; 95% confidence interval [CI], 12.9%-14%) and IL (mean, 25.2%; 95% CI, 24.4%-26%) groups were lower than estimates for the general population. Systolic blood pressure (BP) was higher in IL (mean, 131 mm Hg; 95% CI, 129-133 mm Hg) than AO (mean, 126 mm Hg; 95% CI, 125-127 mm Hg) and greater in both groups compared with the CARDIA group (mean, 112 mm Hg; 95% CI, 111-112 mm Hg). Mean low-density lipoprotein cholesterol and high-density lipoprotein cholesterol (HDL-C), total cholesterol, triglycerides, and glucose were within the normal range for both IL and AO. Interior linemen had significantly lower HDL-C than AO and the CARDIA group. Both NFL groups had significantly lower fasting glucose than CARDIA. CONCLUSION: Body fat in active NFL players was lower than predicted by standard measures of obesity. Although the players were large, they were in the normal range for most CVD risk factors. Mean BP in the prehypertensive range was found in both NFL position groups, but was significantly higher in IL than in AO. Prehypertension in these athletes warrants vigilance.