HUDDLE Up! High BP and Cardiac Changes Prevalent in Retired NFL Players

ATLANTA, GA—There’s a flag on the play when it comes to the cardiovascular health of retired professional football players, a new study suggests.

Among a group of athletes who retired from the National Football League (NFL), nearly 90% had hypertension and the vast majority weren’t unaware of it, reported investigators last week at the American College of Cardiology 2024 Scientific Session. Structural cardiac abnormalities detected by transthoracic echocardiography (TTE) also were highly prevalent.

Alexis K. Okoh, MD (Emory University, Atlanta, GA), who led the HUDDLE study, said the findings were a “huge shock” to researchers.

“To find that nine out of 10 people, completely asymptomatic, walk into a room at random and have high blood pressure, that’s scary,” he told TCTMD. “About 37% of them reportedly had a history of hypertension, so there is also a large knowledge gap. Five or six out of every 10 of these people had no idea they had this problem.”

The structural abnormalities on TTE, he added, also suggest that these retired NFL players are suffering some end-organ damage as a result of hypertension.

Michael Amponsah, MD (Banner Boswell Medical Center, Sun City, AZ), who presented the results from HUDDLE this week, said that early screening for cardiovascular risk relies largely on risk scores “but may not provide a complete picture, especially when dealing with specific, special populations.” Professional athletes are “perceived” to be pinnacles of health, but that may not be the case as they age.

“These guys are quite physically active, at least in their formative years,” Amponsah told TCTMD. “What is assumed is that carries on when they are retired. What is also assumed is that these guys are made of Teflon. We think of them as gladiators, running up and down the field, and associate them the epitome of health. We figured we’d take a look to see what it will show—our results were quite surprising.”

We think of them as gladiators, running up and down the field, and associate them the epitome of health. Michael Amponsah

Past studies in professional American football players have shown a high prevalence of sleep apnea and prehypertension/hypertension, as well as a higher risk of cardiovascular mortality and cardiometabolic syndrome among linemen or those with a body mass index (BMI) ≥ 30 during their playing years. More recent studies have been done in collegiate football players, but even here there is high prevalence of prehypertension/hypertension.

Highly Prevalent Structural Changes

HUDDLE, which was published simultaneously in the Journal of the American College of Cardiology, was designed to assess cardiovascular disease and risk factor prevalence in a representative sample of retired NFL players (50 years or older), their family, and coaches. Nine screening events were held across the US between 2021 and 2022 where participants had their blood pressure measured as well as a 12-lead ECG and TTE. Follow-up phone visits were done by physicians 30 days after screening to provide recommendations on further care if necessary.

Hypertension was defined as ≥ 130/80 mm Hg as per the 2017 clinical guidelines for the assessment of blood pressure. Abnormal ECGs were defined as the presence of one or more prognostic findings based on the clinical expertise of primary investigators. For structural changes, these were defined using sex-specific cutoffs from the American Society of Echocardiography guidelines, such as elevated LV mass index (LVMI) and changes in valve gradients.  

In total, 498 participants were screened, including 285 former NFL players (mean age 63.1 years; 67.6% African American/Black). The mean BMI in these former athletes was 31.2. At screening, 37.5% reported having high blood pressure, 32.6% high cholesterol, and 12.6% diabetes.

Overall, the prevalence of hypertension was 89.3% in the entire cohort and 89.8% in the NFL players. For NFL players with known hypertension, 36.5% still had elevated blood-pressure levels, with just 6.7% of hypertensive former players having their blood pressure controlled.

Regarding the ECG testing, 37.5% had an abnormal finding. In NFL players, nearly half (46.1%) had an abnormal prognostic finding. On TTE, 55.0% of the entire cohort and 61.8% of retired players had a structural change deemed abnormal by ASE guidelines. There was a strong association between elevated systolic blood pressure and structural abnormalities, say investigators. For example, elevated blood pressure was prevalent in 93.6% of players with an elevated LVMI. This measure, said Okoh, is an important prognostic predictor of mortality adjusted for the patient’s size. Additionally, a known history of CVD, CVD medication use, and an abnormal ECG were also associated with structural changes on TTE.

At 30 days, investigators recommended that 76.7% of the former NFL players seek additional follow-up, the most common reason being for high blood pressure or abnormal TTE findings.

“Being an American-style football athlete doesn't absolve you of risk,” said Amponsah. “All of this working out doesn't necessarily absolve you of this risk. It's probably time to change our thinking and our assumptions about these gentlemen. Not that American style football is necessarily a bad thing, but the risk is there, and they also need to take good care of themselves.”

Former Athletes Not Bulletproof

Matthew Martinez, MD (Morristown Medical Center/Atlantic Health System, NJ), the cardiologist for the New York Jets, as well as for the National Basketball Players Association and Major League Soccer, emphasized that this isn’t just a sports problem, noting that the prevalence of untreated and uncontrolled hypertension is extremely high across the world. Primary prevention is the best tool in everybody, including retired professional athletes.

“Just because you are a current or a former athlete, just like all of us, it does not make you bulletproof,” he said during the ACC panel discussion. “If you are a former exerciser or someone who's actively exercising, you can still have heart disease. Just by being a former NFL player, they are not out of the woods just yet. Those maladaptive changes—because they are viewed as being bulletproof—are often missed.”

With screening, he cautioned that the standard criteria for an abnormal ECG or echocardiogram differs in athletes, particularly in African-American men. Left and right ventricles, including LVMI, wall thickness, and ejection fractions are often “abnormal” in as many as 10% of active athletes, said Martinez, and the worry is that standard cutoffs might lead to false-positive diagnoses.

Just because you are a current or a former athlete, just like all of us, it does not make you bulletproof. Matthew Martinez

Okoh noted that retired athletes are 25 years or more beyond their playing days, adding that many are just “regular people” now. “I don’t know if it’s appropriate to apply criteria of an athlete to them or apply the criteria of the general population,” he said. “That’s a question the scientific community has to look into.”

Nonetheless, Okoh said that all retired athletes should have their blood pressure checked and that their findings suggest that screening ECG and TTE also have a role in risk stratification, especially among those who are hypertensive. “I believe it will give us the opportunity to intervene if necessary and, most importantly, follow them up very closely to mitigate future cardiovascular events,” he said.

Amponsah pointed out that even among the few former athletes with normal blood pressure, there was a high prevalence of structural abnormalities on TTE. “Primary prevention is everything,” he said. “It starts with their blood pressure, but I think there might be a role for transthoracic echocardiograms in individuals who are age 50 and older.”

Okoh said the initial screening included an information session and physician-led panel about CVD, risk factors, symptoms, and prevention. He also noted that 30-day follow-up with the players, family members, and coaches was 100%.

“When you educate people, they begin to participate effectively,” he said. “All the participants followed us appropriately. We've never conducted a study that had 100% follow-up and that actually taught us something pretty new. If you really want to get this going, you've got to bridge that knowledge gap, then you can implement something and you’re more likely to succeed.”