Association between basic life support and survival in sports-related sudden cardiac arrest: a meta-analysis

Characteristics and Causes of Sports-Related Sudden Death in the General Population during the COVID-19 Pandemic

PURPOSE

COVID-19 is an independent risk factor for cardiovascular disease. The aim of this study is to determine the burden, characteristics, and causes of sudden death in sport (SrSD) before and after the COVID-19 pandemic in the general population.

METHODS

Retrospective observational study. Autopsied SrSD studied in Catalonia was consecutively included. Two periods were considered: before lockdown (January 2019-March 2020) and after lockdown (March 2020-December 2021). Initial care variables and causes of death were collected. Periods were compared, and logistic regression analyses were performed.

RESULTS

A total of 156 SrSD were collected, with no differences in the incidence between the study periods. Of the cases, 98.7% were male, with a mean age of 55.8 yr (SD, 12.1). Cycling was practiced by 40.0%. Coronary artery disease was the leading cause of death, with no difference before and after lockdown. No cases of myocarditis were described. Of the total number of SrSD, 98 (62.8%) received a cardiopulmonary resuscitation (CPR) attempt. After lockdown, the SrSD that occurred in country areas decreased (40.6% vs 24.4%, P = 0.032), and the rate of CPR attempts (54.3% vs 69.8%, P = 0.034) and hands-only CPR increased (76.6% vs 57.9%, P = 0.048).

CONCLUSIONS

There were no changes in the burden and causes of SrSD before and after the COVID-19 lockdown. Differences were found in the SrSD initial care received due to the change of basic life support recommendations and the sport activity habits.

Survival Outcomes After Sudden Cardiac Arrest in Young Competitive Athletes From the United States

BACKGROUND

Sudden cardiac arrest (SCA) is the leading cause of death among young competitive athletes during sports and exercise. A detailed analysis of survival outcomes should inform prevention strategies.

OBJECTIVES

The purpose of this study was to determine survival outcomes and trends following SCA among young competitive athletes in the United States and to explore outcomes based on race and exertional status.

METHODS

This observational study identified cases of SCA among young competitive athletes through longitudinal surveillance by the National Center for Catastrophic Sports Injury Research from July 1, 2014, to June 30, 2023. Young athletes ≥11 years of age competing in middle school, high school, club, college, or semiprofessional/professional sports, and former athletes (within 1 year of participation) with SCA during exercise, rest, or sleep were included. The primary outcome was survival from SCA. Multivariable log binomial regression estimated survival proportion ratios by race and exertional status.

RESULTS

A total of 641 athletes with SCA were identified during the 9-year study period (mean age 17 ± 3 years; 85% male). Overall survival was 49% (315 of 641). Survival from SCA occurring during exercise was 57% (275 of 481). The majority of cases were in high school athletes (61%), followed by college (15%) and middle school (12%) athletes. Overall survival (range 30%-66% per academic year; P = 0.007) and survival from exertional SCA (range 38%-72% per academic year; P = 0.03) both increased throughout the study period. Among exertional SCA events, survival was higher among athletes who experienced SCA during a game/competition vs practice/training (70% vs 53%; P = 0.001). Black race (RR: 0.63; 95% CI: 0.53-0.76), Other race (RR: 0.69; 95% CI: 0.50-0.94), and nonexertional SCA (RR: 0.43; 95% CI: 0.32-0.59) were associated with lower survival from SCA after adjusting for sex and level of competition.

CONCLUSIONS

Although survival from SCA among young competitive athletes in the United States has improved in the last decade, important racial disparities in outcomes were observed warranting additional research and prevention strategies.

Out-of-Hospital Cardiac Arrest in Apparently Healthy, Young Adults

Importance

Out-of-hospital cardiac arrest incidence in apparently healthy adults younger than 40 years ranges from 4 to 14 per 100 000 person-years worldwide. Of an estimated 350 000 to 450 000 total annual out-of-hospital cardiac arrests in the US, approximately 10% survive.

Observations

Among young adults who have had cardiac arrest outside of a hospital, approximately 60% die before reaching a hospital (presumed sudden cardiac death), approximately 40% survive to hospitalization (resuscitated sudden cardiac arrest), and 9% to 16% survive to hospital discharge (sudden cardiac arrest survivor), of whom approximately 90% have a good neurological status (Cerebral Performance Category 1 or 2). Autopsy-based studies demonstrate that 55% to 69% of young adults with presumed sudden cardiac death have underlying cardiac causes, including sudden arrhythmic death syndrome (normal heart by autopsy, most common in athletes) and structural heart disease such as coronary artery disease. Among young adults, noncardiac causes of cardiac arrest outside of a hospital may include drug overdose, pulmonary embolism, subarachnoid hemorrhage, seizure, anaphylaxis, and infection. More than half of young adults with presumed sudden cardiac death had identifiable cardiovascular risk factors such as hypertension and diabetes. Genetic cardiac disease such as long QT syndrome or dilated cardiomyopathy may be found in 2% to 22% of young adult survivors of cardiac arrest outside of the hospital, which is a lower yield than for nonsurvivors (13%-34%) with autopsy-confirmed sudden cardiac death. Persons resuscitated from sudden cardiac arrest should undergo evaluation with a basic metabolic profile and serum troponin; urine toxicology test; electrocardiogram; chest x-ray; head-to-pelvis computed tomography; and bedside ultrasound to assess for pericardial tamponade, aortic dissection, or hemorrhage. Underlying reversible causes, such as ST elevation myocardial infarction, coronary anomaly, and illicit drug or medication overdose (including QT-prolonging medicines) should be treated. If an initial evaluation does not reveal the cause of an out-of-hospital cardiac arrest, transthoracic echocardiography should be performed to screen for structural heart disease (eg, unsuspected cardiomyopathy) or valvular disease (eg, mitral valve prolapse) that can precipitate sudden cardiac death. Defibrillator implant is indicated for young adult sudden cardiac arrest survivors with nonreversible cardiac causes including structural heart disease and arrhythmia syndromes.

Conclusions and Relevance

Cardiac arrest in apparently healthy adults younger than 40 years may be due to inherited or acquired cardiac disease or noncardiac causes. Among young adults who have had cardiac arrest outside of a hospital, only 9% to 16% survive to hospital discharge. Sudden cardiac arrest survivors require comprehensive evaluation for underlying causes of cardiac arrest and cardiac defibrillator should be implanted in those with nonreversible cardiac causes of out-of-hospital cardiac arrest.

Preparticipation Cardiovascular Screening of Athletes: Current Controversies and Challenges for the Future

Sports cardiology is an evolving field in cardiology, with several topics remaining controversial. Beyond the several well-known benefits of regular exercise practice, the occurrence of adverse clinical events during sports in apparently healthy individuals, especially sudden cardiac death, and the described long-term adverse cardiac adaptations associated to high volume of exercise, remain challenging. The early identification of athletes with increased risk is critical, but the most appropriate preparticipation screening protocols are also debatable and a more personalized evaluation, considering individual and sports-related characteristics, will potentially optimize this evaluation. As the risk of major clinical events during sports is not zero, independently of previous evaluation, ensuring the capacity for cardiopulmonary resuscitation, especially with availability of automated external defibrillators, in sports arenas, is crucial for its prevention and to improve outcomes. As in other areas of medicine, application of new digital technologies, including artificial intelligence, is promising and could improve in near future several aspects of sports cardiology. This paper aims to review the methodology of athletes' preparticipation screening, emphasizing current controversies and future challenges, in order to improve early diagnosis of conditions associated with sudden cardiac death.

Basic life support for non-traumatic out-of-hospital cardiac arrests during school-supervised sports activities in children: A nationwide observational study in Japan

Objective

To investigate the prognostic impact of bystander-initiated cardiopulmonary resuscitation (CPR) and public-access automated external defibrillator (AED) use on non-traumatic out-of-hospital cardiac arrest (OHCA) occurring during school-supervised sports activities in children.

Methods

From a nationwide database of pediatric OHCAs occurring under school supervision in Japan, data between April 2008 and December 2020 were obtained. We analyzed non-traumatic OHCAs that occurred during school-supervised sports activities among schoolchildren from elementary, junior high, high, and technical colleges. A multivariable logistic regression model was used to evaluate the effect of basic life support (BLS) on 1-month survival with favorable neurological outcomes after OHCA.

Results

In total, 318 OHCA cases were analyzed. The 1-month survival with favorable neurological outcomes was 64.8% (164/253) in cases receiving both bystander-CPR and AED application, 40.7% (11/27) in cases receiving CPR only, 38.5% (5/13) in patients receiving AED application only, and 28.0% (7/25) in cases receiving no bystander intervention. Compared with cases receiving no BLS, cases receiving both CPR and AED had a significantly higher proportion of 1-month survival with favorable neurological outcomes (adjusted odds ratio [AOR]: 3.97, 95% confidence interval [CI]: 1.32-11.90, p = 0.014). However, compared to cases receiving no BLS, there was no significant difference in the outcome in the cases receiving CPR only (AOR: 1.35, 95% CI: 0.34-5.29, p = 0.671) and the cases receiving AED application only (AOR: 1.26, 95% CI: 0.25-6.38, p = 0.778).

Conclusion

The combination of CPR and AED as BLS performed by bystanders for non-traumatic OHCA during school-supervised sports activities improved the outcomes.

Sudden Cardiac Death in Young Athletes: JACC State-of-the-Art Review

Athletes epitomize the healthiest segment of society. Despite this premise, sudden cardiac death may occur in apparently healthy athletes, attracting significant attention not only in the medical community but also in laypersons and media. The incidence of sudden cardiac death is variably reported, and epidemiological burden differs among cohorts. Athletes appear to be at risk of developing fatal arrhythmias when harboring a quiescent cardiac disorder. Primary cardiomyopathies, ion channelopathies, and coronary artery anomalies are prevalent causes in young individuals. Cardiac assessment of athletes can be challenging because these individuals exhibit a plethora of electrical, structural, and functional physiological changes that overlap with cardiac pathology. A diagnosis of cardiac disease in a young athlete is not necessarily an indication to terminate competition and sports participation. International guidelines, traditionally focused on disqualification of individuals with cardiac disease, have recently adopted a more liberal attitude, based on a careful assessment of the risk and on a shared-decision making approach.