Exercise collapse associated with sickle cell trait: from consensus to confusion

Sickle cell trait (SCT) and its association with exertional rhabdomyolysis (ER) and exercise-related death (ERD) in warfighters and athletes (WA) are significant and controversial issues confronting sports medicine communities and the US Department of Defense (DoD). Although SCT carrier status is largely considered a benign condition, potential risks, in particular with intense repetitive or continuous exertion, are increasingly recognised. The deaths of two soldiers in 2010 prompted the convening of a summit by the Consortium for Health and Military Performance at the Uniformed Services University in Bethesda, Maryland.1 In collaboration with the American College of Sports Medicine, interested DoD entities, the American Medical Society for Sports Medicine, the American Society of Hematology and selected members of the haematology and sports medicine community met to discuss SCT with particular emphasis on mitigating risk in WA. During that summit, the term ‘exercise collapse associated with sickle cell trait’ (ECAST) was adopted, recognising the increased relative risk of both ER and ERD in WA, in the absence of a clearly recognised pathophysiology. A subsequent series of ECAST events in military personnel in 2019 prompted a reevaluation of current efforts and called for a second consensus conference. As a result of that conference, the US Army adopted a policy for SCT screening and education to align with all other DoD services. Consensus management strategies included identification of the struggling warfighter or athlete, with urgent medical assessment to include the provision of oxygen, the availability of an automated external defibrillator …