All-cause mortality risks among participants in mass-participation sporting events

OBJECTIVES

Exercise transiently increases the risk for sudden death, whereas long-term exercise promotes longevity. This study assessed acute and intermediate-term mortality risks of participants in mass-participation sporting events.

METHODS

Data of participants in Dutch running, cycling and walking events were collected between 1995 and 2017. Survival status was obtained from the Dutch Population Register. A time-stratified, case-crossover design examined if deceased participants more frequently participated in mass-participation sporting events 0-7 days before death compared with the reference period (14-21 days before death). Mortality risks during follow-up were compared between participants and non-participants from the general population using Cox regression.

RESULTS

546 876 participants (median (IQR) age 41 (31-50) years, 56% male, 72% runners) and 211 592 non-participants (41 (31-50) years, 67% male) were included. In total, 4625 participants died of which more participants had partaken in a sporting event 0-7 days before death (n=23) compared with the reference period (n=12), and the mortality risk associated with acute exercise was greater but did not reach statistical significance (OR 1.92; 95% CI 0.95 to 3.85). During 3.3 (1.1-7.4) years of follow-up, participants had a 30% lower risk of death (HR 0.70; 95% CI 0.67 to 0.74) compared with non-participants after adjustment for age and sex. Runners (HR 0.65; 95% CI 0.62 to 0.69) and cyclists (HR 0.70; 95% CI 0.64 to 0.77) had the best survival during follow-up followed by walkers (HR 0.88; 95% CI 0.80 to 0.94).

CONCLUSION

Participating in mass-participation sporting events was associated with a non-significant increased odds (1.92) of mortality and a low absolute event rate (4.2/100 000 participants) within 7 days post-event, whereas a 30% lower risk of death was observed compared with non-participants during 3.3 years of follow-up. These results suggest that the health benefits of mass sporting event participation outweigh potential risks.

Exercise-induced cardiac troponin release in athletes with versus without coronary atherosclerosis

The magnitude of exercise-induced cardiac troponin (cTn) elevations is dependent on cardiovascular health status, and previous studies have shown that occult coronary atherosclerosis is highly prevalent among amateur athletes. We tested the hypothesis that middle-aged and older athletes with coronary atherosclerosis demonstrate greater cTn elevations following a controlled endurance exercise test compared with healthy peers. We included 59 male athletes from the Measuring Athletes' Risk of Cardiovascular events 2 (MARC-2) study and stratified them as controls [coronary artery calcium score (CACS) = 0, n = 20], high CACS [≥300 Agatston units or ≥75th Multi-Ethnic Study of Atherosclerosis (MESA) percentile, n = 20] or significant stenosis (≥50% in any coronary artery, n = 19). Participants performed a cycling test with incremental workload until volitional exhaustion. Serial high-sensitivity cTn (hs-cTn) T and I concentrations were measured (baseline, after 30-min warm-up, and 0, 30, 60, 120, and 180 min postexercise). There were 58 participants (61 [58-69] yr) who completed the exercise test (76 ± 14 min) with a peak heart rate of 97.7 [94.8-101.8]% of their estimated maximum. Exercise duration and workload did not differ across groups. High-sensitivity cardiac troponin T (Hs-cTnT) and high-sensitivity cardiac troponin I (hs-cTnI) concentrations significantly increased (1.55 [1.33-2.14]-fold and 2.76 [1.89-3.86]-fold, respectively) over time, but patterns of cTn changes and the incidence of concentrations >99th percentile did not differ across groups. Serial sampling of hs-cTnT and hs-cTnI concentrations during and following an exhaustive endurance exercise test did not reveal differences in exercise-induced cTn release between athletes with versus without coronary atherosclerosis. These findings suggest that a high CACS or a >50% stenosis in any coronary artery does not aggravate exercise-induced cTn release in middle-aged and older athletes.NEW & NOTEWORTHY Exercise-induced cardiac troponin (cTn) release is considered to be dependent on cardiovascular health status. We tested whether athletes with coronary atherosclerosis demonstrate greater exercise-induced cTn release compared with healthy peers. Athletes with coronary atherosclerosis did not differ in cTn release following exercise compared with healthy peers. Our findings suggest that a high CACS or a >50% stenosis in any coronary artery does not aggravate exercise-induced cTn release in middle-aged and older athletes.

Outcomes of medical students training schoolchildren of ages 13-18 in cardiopulmonary resuscitation: A systematic review

Background

Training schoolchildren in cardiopulmonary resuscitation (CPR) can increase the number of qualified people in the community, which in turn can improve survival rates of out-of-hospital cardiac arrests (OHCA). Medical students could be a valuable resource for providing the training. This systematic review aims to determine the outcomes of medical students providing CPR training to schoolchildren, aged 13-18 (who are thought to have the strength for effective chest compression), specifically CPR skills for both and non-technical skills such as communication and leadership for medical students.

Methods

A literature search of academic databases was conducted on 5 July 2023 using the following keywords: cardiopulmonary resuscitation, basic life support, medical students and high/middle/secondary school students. For the purpose of this review, "schoolchildren" refer to those aged 13-18. Studies were included where the primary focus was medical students teaching CPR to schoolchildren. The studies were critically appraised using the Medical Education Research Study Quality Instrument (MERSQI) tool and outcomes categorised by Kirkpatrick's Levels.

Results

Eleven studies were included, six randomised controlled trials and five cohort studies, with 1670 schoolchildren and 355 medical students as participants. Eight studies examined outcomes targeting schoolchildren, two examined outcomes for medical students and one examined both. Four of the eleven studies used validated outcome measures. Only outcomes at Kirkpatrick Level 1 and 2 were found, and all outcomes for both schoolchildren and medical students were positive. Schoolchildren showed improvements in theoretical and practical elements of CPR post-training, while medical students demonstrated improved professional practice skills such as leadership and mentorship as well as improvements in their own CPR skills post-teaching.

Conclusions

Schoolchildren can effectively acquire CPR skills through being trained by medical students, who themselves also benefit from improved CPR and professional practice skills after teaching. Further studies with robust methodology such as multi-site randomised controlled trials, the use of consistent and validated outcome measures, and the measurement of outcomes at higher Kirkpatrick levels to determine the impact on bystander CPR rates and community OHCA survival rates, are needed.

BEAT-IT: A de-novo cardiac screening programme in Maltese adolescents

AIMS

Sudden cardiac death (SCD) in young individuals is often unexpected, provoking substantial emotional stress for family and friends of the deceased. Cardiac screening may identify individuals who harbour disorders linked to SCD. The feasibility and diagnostic yield of a nationwide cardiac screening programme in adolescents has never been explored.

METHODS

All individuals eligible for cardiac screening (students aged 15 years) were systematically invited to enrol. Students were provided with a health questionnaire. ECGs were acquired at school. A physician led consultation was carried out on site. Participants with an abnormal screen were then referred for secondary evaluation to the nation's tertiary centre. Feasibility criteria included a) participation rate >60%, b) adherence to secondary evaluation >80%, and c) cost per individual screened equating to <€100. The diagnostic yield was also evaluated.

RESULTS

At the end of enrolment, 2708 students gave consent (mean 15 years, 50.4% male), equating to 67.9% of the eligible cohort. Overall, 109 participants (4.0%) were referred for further evaluation. An abnormal electrocardiogram (ECG) was the most common reason for referral (3.7%). Fifteen individuals (0.6%) were diagnosed with a cardiac condition. Nine (0.3%) had a condition linked to SCD (n = 1 Long-QT syndrome, n = 1 Hypertrophic Cardiomyopathy, n = 5 Wolff-Parkinson White, n = 2 coronary anomalies). The yield was similar in athletes and non-athletes (p = 0.324). The cost per cardiac individual screened equated to €51.15.

CONCLUSION

A nationwide systematic cardiac screening programme for adolescent athletes and non-athletes is feasible and cost-efficient, provided that responsible centres have the appropriate infrastructure.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Out-of-Hospital Cardiac Arrest during the COVID-19 Pandemic: A Systematic Review

Objective: Out-of-hospital cardiac arrest (OHCA) is a prominent cause of death worldwide. As indicated by the high proportion of COVID-19 suspicion or diagnosis among patients who had OHCA, this issue could have resulted in multiple fatalities from coronavirus disease 2019 (COVID-19) occurring at home and being counted as OHCA. Methods: We used the MeSH term "heart arrest" as well as non-MeSH terms "out-of-hospital cardiac arrest, sudden cardiac death, OHCA, cardiac arrest, coronavirus pandemic, COVID-19, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)." We conducted a literature search using these search keywords in the Science Direct and PubMed databases and Google Scholar until 25 April 2022. Results: A systematic review of observational studies revealed OHCA and mortality rates increased considerably during the COVID-19 pandemic compared to the same period of the previous year. A temporary two-fold rise in OHCA incidence was detected along with a drop in survival. During the pandemic, the community's response to OHCA changed, with fewer bystander cardiopulmonary resuscitations (CPRs), longer emergency medical service (EMS) response times, and worse OHCA survival rates. Conclusions: This study's limitations include a lack of a centralised data-gathering method and OHCA registry system. If the chain of survival is maintained and effective emergency ambulance services with a qualified emergency medical team are given, the outcome for OHCA survivors can be improved even more.

The aftermath of surviving a sudden cardiac arrest for young exercisers - a qualitative study in Norway

BACKGROUND

When surviving a sudden cardiac arrest (SCA), physical, cognitive, and emotional effects of surviving may be present for months or years. The survivors' family and colleagues are also highly affected by the incident. There is little knowledge about experiences of surviving SCA in individuals who prior to the incident were young and reported to exercise regularly. Consequently, the aim of this study was to explore the aftermath of surviving a SCA in young, regular exercisers.

METHODS

The study had a qualitative design, conducting in-depth individual interviews with SCA survivors < 50 years of age reporting to exercise ≥ 5 h/week and/or who suffered SCA during or less than 60 min after exercise. The data were analysed using systematic text condensation in-line with recommendations from Malterud.

RESULTS

18 of 31 eligible participants were included in the study. Through analysis we identified 'Establishing a new everyday life' as superordinate category, with subordinate categories a) being part of my surroundings, b) expecting normality but facing a new reality and c) lucky to be alive!

CONCLUSION

This study adds knowledge about young and regular exercisers' experiences after surviving a SCA. The obligations of everyday life in young survivors of SCA often imply a high work load and complex tasks, e.g. due to being in the beginning of their career or even still studying. Healthcare personnel, as well as the society, need to acknowledge that although lucky to be alive and apparently well-functioning, young survivors of SCA may have persistent challenges that cause frustration and reduced quality of life.

Sudden Cardiac Arrest During Sports Activity in Older Adults

BACKGROUND

Sports activity among older adults is rising, but there is a lack of community-based data on sports-related sudden cardiac arrest (SrSCA) in the elderly.

OBJECTIVES

In this study, the authors investigated the prevalence and characteristics of SrSCA among subjects ≥65 years of age in a large U.S.

POPULATION

METHODS

All out-of-hospital sudden cardiac arrests (SCAs) were prospectively ascertained in the Portland, Oregon, USA, metro area (2002-2017), and Ventura County, California, USA (2015-2021) (catchment population ∼1.85 million). Detailed information was obtained for SCA warning symptoms, circumstances, and lifetime clinical history. Subjects with SCA during or within 1 hour of cessation of sports activity were categorized as SrSCA.

RESULTS

Of 4,078 SCAs among subjects ≥65 years of age, 77 were SrSCA (1.9%; 91% men). The crude annual SrSCA incidence among age ≥65 years was 3.29/100,000 in Portland and 2.10/100,000 in Ventura. The most common associated activities were cycling, gym activity, and running. SrSCA cases had lower burden of cardiovascular risk factors (P = 0.03) as well as comorbidities (P < 0.005) compared with non-SrSCA. Based on conservative estimates of community residents ≥65 years of age who participate in sports activity, the SrSCA incidence was 28.9/100,000 sport participation years and 18.4/100,000 sport participation years in Portland and Ventura, respectively. Crude survival to hospital discharge rate was higher in SrSCA, but the difference was nonsignificant after adjustment for confounding factors.

CONCLUSIONS

Among free-living community residents age ≥65 years, SrSCA is uncommon, predominantly occurs in men, and is associated with lower disease burden than non-SrSCA. These results suggest that the risk of SrSCA is low, and probably outweighed by the high benefit of exercise.

Sport Related Sudden Death: The Importance of Primary and Secondary Prevention

Sports are a double-edged sword. On the one hand, cardiovascular benefits from sports activity are well-known, and on the other hand, sports may increase the risk of sudden cardiac death (SCD) in subjects with known or unknown cardiovascular diseases. SCD is rare but has a very strong emotional issue. There are many examples involving famous professional athletes, but this is only scratching the surface of a widespread phenomenon that also involves amateur athletes. The importance of safely performing physical activity appears clear in both professional and amateur athletes. In particular, the former undergo a pre-participation screening for SCD primary prevention with different recommendations in each country. On the other hand, a medical examination is not mandatory for non-professional athletes and, therefore, for people who practice sports as an amateur. Widespread distribution of automatic external defibrillators and people trained for cardiopulmonary resuscitation are necessary to promote secondary prevention of SCD. We briefly report a case series of athletes with aborted SCD during sports activity in order to underline and discuss in this review the previously highlighted issues.

Exercise-related major adverse cardiovascular events in asymptomatic recreational master athletes: a case series

Background

In master athletes, atherosclerotic coronary artery disease (CAD) is the primary condition leading to major adverse cardiovascular events during sports. We report two cases of asymptomatic recreational athletes who suffered from an exercise-induced cardiovascular event.

Case summary

The first athlete is a 70-year-old male speed skater without known history of cardiovascular disease. He has no typical risk factors for CAD and denied preceding symptoms. During training at the speed skating rink, he suddenly experienced severe chest pain. Electrocardiogram (ECG) showed ST-segment elevation in the precordial leads. In the ambulance, an episode of ventricular fibrillation was converted to atrial fibrillation. Coronary angiography showed a thrombus in the left anterior descending (LAD) coronary artery, treated with a glycoprotein IIb/IIIa inhibitor intravenously.

The second athlete is a 59-year-old male endurance athlete who presented with chest pain during cycling. He had a history of cavotricuspid isthmus ablation and pulmonary vein isolation for paroxysmal atrial fibrillation and flutter but experienced no symptoms in the weeks prior to the event. He also had no risk factors for CAD. ECG showed ST-segment elevation in the inferior leads and reciprocal depression in V2–V4. Successful primary percutaneous intervention of the circumflex artery was performed.

Discussion

Limited data are available to guide recommendations for cardiovascular screening in master athletes. Since master athletes with CAD are often asymptomatic, more knowledge on the optimal pre-participation screening algorithm for identifying individuals at risk of adverse cardiac events is required.

Could Repeated Cardio-Renal Injury Trigger Late Cardiovascular Sequelae in Extreme Endurance Athletes?

Regular exercise confers multifaceted and well-established health benefits. Yet, transient and asymptomatic increases in markers of cardio-renal injury are commonly observed in ultra-endurance athletes during and after competition. This has raised concerns that chronic recurring insults could cause long-term cardiac and/or renal damage. Indeed, extreme endurance exercise (EEE) over decades has sometimes been linked with untoward cardiac effects, but a causal relation with acute injury markers has not yet been established. Here, we summarize the current knowledge on markers of cardiac and/or renal injury in EEE athletes, outline the possible interplay between cardiac and kidney damage, and explore the roles of various factors in the development of potential exercise-related cardiac damage, including underlying diseases, medication, sex, training, competition, regeneration, mitochondrial dysfunction, oxidative stress, and inflammation. In conclusion, despite the undisputed health benefits of regular exercise, we speculate, based on the intimate link between heart and kidney diseases, that in rare cases excessive endurance sport may induce adverse cardio-renal interactions that under specific, hitherto undefined conditions could result in persistent cardiac damage. We highlight future research priorities and provide decision support for athletes and clinical consultants who are seeking safe strategies for participation in EEE training and competition.

Better outcomes from exercise-related out-of-hospital cardiac arrest in males and in the young: findings from the Swedish Registry of Cardiopulmonary Resuscitation

BACKGROUND

Survival from out-of-hospital cardiac arrest (OHCA) is higher if the arrest is witnessed and occurs during exercise, however, there is contradicting data on prognosis with regards to sex and age. The purpose of this study was to compare the outcomes and circumstances of exercise-related OHCA in different age groups and between sexes in a large unselected population.

METHODS

Data from exercise-related OHCAs reported to the Swedish Registry of Cardiopulmonary Resuscitation from 2011 to 2014 and from 2016 to 2018 were analysed. All cases of exercise-related OHCA in which emergency medical services attempted resuscitation were included. The primary outcome was survival to 30 days.

RESULTS

In total, 635 cases of exercise-related OHCA outside of the home were identified. The overall 30-day survival rate was 44.5% with highest survival rate in the age group 0-35 years, compared with 36-65 years and >65 years (59.6% vs 46.0% and 40.4%, p=0.01). A subgroup analysis of 0-25 years showed a survival rate of 68.8%. Exercise-related OHCA in females (9.1% of total) were witnessed to a lower extent (66.7% vs 79.6%, p=0.03) and median time to cardiopulmonary resuscitation (CPR) was longer (2.0 vs 1.0 min, p=0.001) than in males. Females also had lower rates of ventricular fibrillation (43.4% vs 64.7%, p=0.003) and a lower 30-day survival rate (29.3% vs 46.0%, p=0.02).

CONCLUSION

In exercise-related OHCA, younger victims have a higher survival rate. Exercise-related OHCA in females was rare, however, survival rates were lower compared with males and partly explained by a lower proportion of witnessed events, longer time to CPR and lower frequency of a shockable rhythm.

Bystander interventions and survival after exercise-related sudden cardiac arrest: a systematic review

OBJECTIVE

To evaluate the provision of bystander interventions and rates of survival after exercise-related sudden cardiac arrest (SCA).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, PubMed, CINAHL, SPORTDiscus, Cochrane Library and grey literature sources were searched from inception to November/December 2020.

STUDY ELIGIBILITY CRITERIA

Observational studies assessing a population of exercise-related SCA (out-of-hospital cardiac arrests that occurred during exercise or within 1 hour of cessation of activity), where bystander cardiopulmonary resuscitation (CPR) and/or automated external defibrillator (AED) use were reported, and survival outcomes were ascertained.

METHODS

Among all included studies, the median (IQR) proportions of bystander CPR and bystander AED use, as well as median (IQR) rate of survival to hospital discharge, were calculated.

RESULTS

A total of 29 studies were included in this review, with a median study duration of 78.7 months and a median sample size of 91. Most exercise-related SCA patients were male (median: 92%, IQR: 86%-96%), middle-aged (median: 51, IQR: 39-56 years), and presented with a shockable arrest rhythm (median: 78%, IQR: 62%-86%). Bystander CPR was initiated in a median of 71% (IQR: 59%-87%) of arrests, whereas bystander AED use occurred in a median of 31% (IQR: 19%-42%) of arrests. Among the 19 studies that reported survival to hospital discharge, the median rate of survival was 32% (IQR: 24%-49%). Studies which evaluated the relationship between bystander interventions and survival outcomes reported that both bystander CPR and AED use were associated with survival after exercise-related SCA.

CONCLUSION

Exercise-related SCA occurs predominantly in males and presents with a shockable ventricular arrhythmia in most cases, emphasising the importance of rapid access to defibrillation. Further efforts are needed to promote early recognition and a rapid bystander response to exercise-related SCA.

Immediate Bystander Cardiopulmonary Resuscitation to Sudden Cardiac Arrest During Sports is Associated with Improved Survival-a Video Analysis

Background

Sudden cardiac arrest (SCA) during sports can be the first symptom of yet undetected cardiovascular conditions. Immediate chest compressions and early defibrillation offer SCA victims the best chance of survival, which requires prompt bystander cardiopulmonary resuscitation (CPR).

Aims

To determine the effect of rapid bystander CPR to SCA during sports by searching for and analyzing videos of these SCA/SCD events from the internet.

Methods

We searched images.google.com, video.google.com, and YouTube.com, and included any camera-witnessed non-traumatic SCA during sports. The rapidity of starting bystander chest compressions and defibrillation was classified as < 3, 3–5, or > 5 min.

Results

We identified and included 29 victims of average age 27.6 ± 8.5 years. Twenty-eight were males, 23 performed at an elite level, and 18 participated in soccer. Bystander CPR < 3 min (7/29) or 3–5 min (1/29) and defibrillation < 3 min was associated with 100% survival. Not performing chest compressions and defibrillation was associated with death (14/29), and > 5 min delay of intervention with worse outcome (death 4/29, severe neurologic dysfunction 1/29).

Conclusions

Analysis of internet videos showed that immediate bystander CPR to non-traumatic SCA during sports was associated with improved survival. This suggests that immediate chest compressions and early defibrillation are crucially important in SCA during sport, as they are in other settings. Optimal use of both will most likely result in survival. Most videos showing recent events did not show an improvement in the proportion of athletes who received early resuscitation, suggesting that the problem of cardiac arrest during sports activity is poorly recognized.

[Cardiac arrest under special circumstances]

These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).

European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances

These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).

The Hidden Fragility in the Heart of the Athletes: A Review of Genetic Biomarkers

Sudden cardiac death (SCD) is a devastating event which can also affect people in apparent good health, such as young athletes. It is known that intense and continuous exercise along with a genetic background that predisposes a person to the risk of fatal arrhythmias is a trigger for SCD. Therefore, knowledge of the athlete’s genetic conditions underlying the onset of SCD must be extended, in order to develop new effective prevention and/or therapeutic strategies. Arrhythmic features occur across a broad spectrum of cardiac diseases, sometimes presenting with overlapping phenotypes. The genetic basis of arrhythmogenic disorders has been greatly highlighted in the last 30 years, and has shown marked heterogeneity. The advent of next-generation sequencing has constantly updated our understanding of the genetic basis of arrhythmogenic diseases and is laying the foundation for precision medicine. With the exception of a few clinical cases involving a single athlete showing a highly suspected phenotype for the presence of a heart disease, there are few studies to date that analysed the applicability of genetic testing on cohorts of athletes. This evidence shows that genetic testing can contribute to the diagnosis of up to 13% of athletes; however, the presence of clinical markers is essential. This review aims to provide a reference collection on current knowledge of the genetic basis of sudden cardiac death in athletes and to review updated evidence on the effectiveness of genetic testing in early identification of athletes at risk for SCD.

Laboratory medicine: health evaluation in elite athletes

The need to evaluate the health status of an athlete represents a crucial aim in preventive and protective sports science in order to identify the best diagnostic strategy to improve performance and reduce risks related to physical exercise. In the present review we aim to define the main biochemical and haematological markers that vary significantly during and after sports training to identify risk factors, at competitive and professional levels and to highlight the set up of a specific parameter's panel for elite athletes. Moreover, we also intend to consider additional biomarkers, still under investigation, which could further contribute to laboratory sports medicine and provide reliable data that can be used by athlete's competent staff in order to establish personal attitudes and prevent sports injuries.

Differences in coronary vasodilatory capacity and atherosclerosis in endurance athletes using coronary CTA and computational fluid dynamics (CFD): Comparison with a sedentary lifestyle

BACKGROUND

The aim was to assess the effect of endurance exercise on coronary vasodilatory capacity and atherosclerosis by coronary computed tomography angiography (CTA) and computational fluid dynamic (CFD) modelling.

METHODS

100 subjects (age 56.2y±11, 29 females) who underwent coronary CTA were included into this retrospectively matched cohort study. Endurance athletes (≥1 h per unit and ≥3 times per week training) were compared to controls with a sedentary lifestyle, and within subgroups with and without sublingual nitroglycerin preparation. CTA image analysis included coronary stenosis severity (CADRADS), total (segment involvement score = SIS) and mixed plaque burden (G-score), high-risk plaque criteria, the coronary artery calcium score (CACS) and CFD analysis including Fractional Flow Reserve (FFR_CT), myocardial mass (M), total vessel lumen volume (V) and volume-to-mass (V/M) ratio.

RESULTS

The prevalence of atherosclerosis by CTA was 65.4 % and >50 % coronary stenosis was found in 17.3 % of athletes. Coronary stenosis severity (CADRADS), total and mixed non-calcified plaque burden (SIS and G-score) were lower in athletes (p = 0.003 and p < 0.001) but not CACS (p = 0.055) and less high-risk plaques were found (p < 0.001). The G-score was correlated with distal FFR_CT (p = 0.025). V/M-ratio was different between athletes who received nitroglycerin compared with those who did not (V/M: 21.1 vs. 14.8; p < 0.001), but these differences were not observed in the control subjects.

CONCLUSION

Endurance training improves coronary vasodilatory capacity and reduces high-risk plaque and mixed non-calcifed plaque burden as assessed by coronary CTA angiography. Our study may advocate coronary CTA with FFR_CT for evaluation of coronary artery disease in endurance athletes.

Overview of Physical Activity Counseling in Primary Care

Physical inactivity is a global health burden. Promoting physical activity in primary care through physical activity counseling is an effective intervention. This article provides an overview of and perspectives on physical activity counseling in primary care. The identification of physical inactivity as a health problem may increase the awareness of physical inactivity among patients and primary care providers, which will lead to an action plan. The contents of physical activity counseling should be based on evidence-based recommendations. Safety issues should be evaluated appropriately to optimize the utilization of primary care services. Physical activity counseling methods should be "tailored" for an individual using appropriate counseling methods and setting-specific resources. Multilevel barriers to physical activity counseling in primary care (i.e., healthcare providers, patients, and systems) must be addressed. Setting-specific strategies to overcome these barriers should be implemented to maximize the effectiveness of physical activity counseling in primary care.

Special Article - Exercise-induced right ventricular injury or arrhythmogenic cardiomyopathy (ACM): The bright side and the dark side of the moon

There is still debate on the range of normal physiologic changes of the right ventricle or ventricular (RV) function in athletes. Genetic links to arrhythmogenic cardiomyopathy (ACM) are well-established. There is no current consensus on the importance of extensive exercise and exercise-induced injury to the RV. During the intensive exercise of endurance sports, the cardiac structures adapt to athletic load over time. Some athletes develop RV cardiomyopathy possibly caused by genetic predisposition, whilst others develop arrhythmias from the RV. Endurance sports lead to increased volume and pressure load in both ventricles and increased myocardial mass. The extent of volume increase and changes in myocardial structure contribute to impairment of RV function and pose a challenge in cardiovascular sports medicine. Genetic predisposition to ACM may play an important role in the risk of sudden cardiac death of athletes. In this review, we discuss and evaluate existing results and opinions. Intensive training in competitive dynamic/power and endurance sports leads to specific RV adaptation, but physiological adaptation without genetic predisposition does not necessarily lead to severe complications in endurance sports. Discriminating between physiological adaptation and pathological form of ACM or RV impairment provoked by reinforced exercise presents a challenge to clinical sports cardiologists.

Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training: Placing the Risks Into Perspective-An Update: A Scientific Statement From the American Heart Association

Epidemiological and biological plausibility studies support a cause-and-effect relationship between increased levels of physical activity or cardiorespiratory fitness and reduced coronary heart disease events. These data, plus the well-documented anti-aging effects of exercise, have likely contributed to the escalating numbers of adults who have embraced the notion that "more exercise is better." As a result, worldwide participation in endurance training, competitive long distance endurance events, and high-intensity interval training has increased markedly since the previous American Heart Association statement on exercise risk. On the other hand, vigorous physical activity, particularly when performed by unfit individuals, can acutely increase the risk of sudden cardiac death and acute myocardial infarction in susceptible people. Recent studies have also shown that large exercise volumes and vigorous intensities are both associated with potential cardiac maladaptations, including accelerated coronary artery calcification, exercise-induced cardiac biomarker release, myocardial fibrosis, and atrial fibrillation. The relationship between these maladaptive responses and physical activity often forms a U- or reverse J-shaped dose-response curve. This scientific statement discusses the cardiovascular and health implications for moderate to vigorous physical activity, as well as high-volume, high-intensity exercise regimens, based on current understanding of the associated risks and benefits. The goal is to provide healthcare professionals with updated information to advise patients on appropriate preparticipation screening and the benefits and risks of physical activity or physical exertion in varied environments and during competitive events.

Coronary atherosclerosis in middle-aged athletes: Current insights, burning questions, and future perspectives

Regular exercise training is considered healthy as it reduces the risk of cardiovascular events and mortality. Nevertheless, athletes are not immune to the development of cardiovascular diseases and recent studies reported a higher prevalence of coronary artery calcifications and atherosclerotic plaques in athletes compared to less active controls. These observations have raised many questions among sport scientists, sports cardiologists, amateur athletes, and the general population. For example, Are athletes (not) immune for coronary atherosclerosis? How to assess coronary atherosclerosis in athletes? What about chalk (calcified plaque) and cheese (mixed plaque)? Does exercise intensity play a role? Are there sport‐related differences? Are there sex differences? Can sports medical evaluation detect coronary atherosclerosis? Do athletes get worried? Should athletes get worried? How should athletes with coronary atherosclerosis be managed? The goal of this review is to discuss the latest scientific insights and to answer these important questions. Furthermore, we will explore potential clinical implications and point out directions for further research.

Does occurrence during sports affect sudden cardiac arrest survival?

OBJECTIVES

A higher survival rate was observed in Sudden Cardiac Arrest (SCA) occurring during sports activities, although the underlying mechanisms remain unclear. We tested the hypothesis that better initial management, rather than sports per se, may account for the observed better outcomes during sports activities.

METHODS

Data was taken between May 2011 and March 2016 from a prospective ongoing registry that includes all SCA in Paris and suburbs (6.7 million inhabitants). Sports-related SCA (i.e. SCA occurring during sport activities or within one hour of cessation of the activity) were identified.

RESULTS

Over the study period, 13,400 SCA occurred, of which 154 were sports-related (median age: 51.2 years, 96.1% males). At discharge, sports activity was associated with an 8-times higher survival rate (39.7% vs. 5.1%, P < 0.001). Logistic regression showed that after considering potential confounders, including age, gender, SCA location, witness presence, time to response, and initial shockable rhythm, occurrence of SCA during sports was associated with a higher survival rate (OR 1.77, 95% CI 1.14-2.74, P = 0.01). However, after further adjustment for initial basic life support, i.e. bystander CPR and AED use, there was no association between sports setting and survival at hospital discharge (OR 1.43, 95% CI 0.91-2.23, P = 0.12).

CONCLUSION

Sports-related SCA is a rare event, with an 8-times higher survival rate compared to non-sports-related SCA. Better initial management, including bystander CPR and AED use, rather than sports per se, mainly accounts this difference. This highlights the major importance of population education to basic life support in improving SCA outcome.

Exercise-related out-of-hospital cardiac arrest in Victoria, Australia

BACKGROUND

Characteristics and outcomes of exercise-related out-of-hospital cardiac arrests (OHCA) are not well described in Australia.

METHODS

This was a retrospective observational study of non-exercise-related aetiology and exercise-related OHCAs from the Victorian Ambulance Cardiac Arrest Registry between 2008 and 2016, including 12-month quality of life data from 2010 to 2016. Exercise-related OHCA was defined as taking place during or within 1 h of at least moderate intensity exercise. Descriptive statistics and adjusted logistic regression analyses were performed.

RESULTS

During the study period there were 482 exercise-related and 33,358 non-exercise-related OHCAs. Jogging/running were the most frequent precipitating sports. The incidence rate of exercise-related OHCA was low (<1 per 100,000 person-years). Compared to non-exercise-related aetiology, exercise-related OHCAs were younger (mean 54 versus 70 years, p < 0.001) and more likely to present in an initial shockable rhythm (85% versus 18%, p < 0.001). Bystander CPR, and bystander or EMS defibrillation at any time, were more common among exercise-related arrests (93% versus 38%, p < 0.001 and 91% versus 24%, p < 0.001, respectively). A public access defibrillator was used in 24% of shockable exercise-related OHCAs compared with 4% of non-exercise-related OHCAs (p < 0.001). After adjustment for arrest characteristics, exercise-related OHCAs were more likely to survive to hospital discharge (50% versus 14%, p < 0.001; adjusted odds ratio [AOR] = 1.56, 95% confidence interval [CI] 1.25-1.96, p < 0.001) and survive to 12-months with good functional recovery (72% versus 62%, p = 0.012; AOR = 1.57, 95% CI 1.08-2.28, p = 0.018).

CONCLUSIONS

Exercise-related OHCAs were associated with better short- and long-term prognoses compared to non-exercise-related OHCAs. The underlying factors associated with this survival benefit warrant further investigation.

Sports activity and paediatric out-of-hospital cardiac arrest at schools in Japan

BACKGROUND

Sudden cardiac death during exercise or sports is an important problem among young athletes and non-athletes. An understanding of the epidemiological features of sports-related out-of-hospital cardiac arrest (OHCA) among children is crucial for planning approaches for prevention and better outcomes of paediatric OHCAs. We assessed the characteristics and outcomes of sports-related OHCA among children at schools in Japan to prevent sports-related paediatric OHCA at schools.

METHODS

The Stop and Prevent cardIac aRrest, Injury, and Trauma in Schools (SPIRITS) is a nationwide, prospective, observational study linking databases of two nationally representative registries. Data on the characteristics and outcomes of sports-related paediatric OHCA at schools in Japan were obtained from these databases.

RESULTS

Between 2008 and 2015, 188 sports-related paediatric OHCAs due to presumed cardiac origin occurred. The greatest proportion of OHCA during or after sports was due to long-distance running (21.8%), followed by soccer/futsal (13.3%), basketball (12.2%), and baseball/rubber-ball baseball (11.2%). We also assessed the association between prehospital factors and one-month survival with favourable neurological outcome after sports-related OHCA. The proportions of ventricular fibrillation as the first documented rhythm, bystander cardiopulmonary resuscitation (CPR), and public-access defibrillation (PAD) were 87.8%, 87.2%, and 63.3%, respectively. Compared with the non-PAD group, the adjusted odds ratio (95% confidence interval) of the PAD group was 3.64 (1.78-7.45).

CONCLUSIONS

In Japan, 188 schoolchildren experienced OHCAs of cardiac origin occurring during or after sports activity at schools during the 8-year period. Increasing PAD is essential to enhance better neurological outcome after sports-related OHCA among students.

Outcome of exercise-related out-of-hospital cardiac arrest is dependent on location: Sports arenas vs outside of arenas

Background

The chance of surviving an out-of-hospital cardiac arrest (OHCA) seems to be increased if the cardiac arrests occurs in relation to exercise. Hypothetically, an exercise-related OHCA at a sports arena would have an even better prognosis, because of an increased likelihood of bystander cardiopulmonary resuscitation (CPR) and higher availability of automated external defibrillators (AEDs). The purpose of the study was to compare survival rates between exercise-related OHCA at sports arenas versus outside of sports arenas.

Methods

Data from all treated exercise-related OHCA outside home reported to the Swedish Register of Cardiopulmonary Resuscitation (SRCR) from 2011 to 2014 in 10 counties of Sweden was analyzed (population 6 million). The registry has in those counties a coverage of almost 100% of all OHCAs.

Results

3714 cases of OHCA outside of home were found. Amongst them, 268(7%) were exercise-related and 164 (61.2%) of those occurred at sports arenas. The 30-day survival rate was higher for exercise-related OHCA at sports arenas compared to outside (55.7% vs 30.0%, p<0.0001). OHCA-victims at sports arenas were younger (mean age±SD 57.6±16.3 years compared to 60.9±17.0 years, p = 0.05), less likely female (4.3% vs 12.2%, p = 0.02) and had a higher frequency of shockable rhythm (73.0% vs 54.3%, p = 0.004). OHCAs at arenas were more often witnessed (83.9% vs 68.9%, p = 0.007), received bystander CPR to a higher extent (90.0% vs 56.8%, p<0.0001) and the AED-use before EMS-arrival was also higher in this group (29.8% vs 11.1%, p = 0.009).

Conclusion

The prognosis is markedly better for exercise-related OHCA occurring at sports arenas compared to outside. Victims of exercise-related OHCA at sports arenas are more likely to receive bystander CPR and to be connected to a public AED. These findings support an increased use of public AEDs and implementation of Medical Action Plans (MAP), to possibly increase survival of exercise-related OHCA even further.

Cardiovascular incidents in male professional football players with negative preparticipation cardiac screening results: an 8-year follow-up

BACKGROUND

Preparticipation cardiac screening of athletes aims to detect cardiovascular disease at an early stage to prevent sudden cardiac arrests and deaths. Few studies have described the cardiovascular outcomes in athletes classified as negative on screening.

OBJECTIVE

To identify cardiovascular incidents in a cohort of male professional football players who were cleared to play after a negative screening result.

METHODS

This is a retrospective 8-year follow-up study of 595 professional male football players in Norway who underwent preparticipation cardiac screening by experienced cardiologists, including electrocardiography (ECG) and echocardiography, in 2008. We performed a media search to identify sudden cardiovascular incidents between January 2008 and February 2016. Incidents were cross-checked with medical records.

RESULTS

Six of the 595 players (1%), all classified as negative on cardiac screening, experienced severe cardiovascular incidents during follow-up. Retrospective review revealed abnormal ECG findings in one case, not recognised at the time of screening. Three players suffered a sudden cardiac arrest (all resuscitated successfully), one a myocardial infarction, one a transient ischaemic attack and one atrial flutter. Three of the players ignored chest pain, paresis, dyspnoea or near-syncope, two completed a match with symptoms before seeking medical assistance, one player's symptoms were misinterpreted and received inappropriate treatment initially, and two players were discharged from hospital without proper follow-up, despite having serious cardiovascular symptoms.

CONCLUSIONS

A comprehensive preparticipation cardiac screening did not identify a subset of 6 of 595 players who experienced subsequent cardiovascular incidents as being at risk. It is important to remind athletes that a normal cardiac screening exam does not protect against all cardiac diseases. Timely reporting of symptoms is essential.

Sudden cardiac arrest in sports: a video analysis

Objectives

Information about sudden cardiac arrest (SCA) in sports arises from registries, insurance claims and various reports. Analysing video footage of SCA during sports for scientific purposes has scarcely been done. The objective of this study was to examine videotaped SCA in athletes to better understand the mechanisms of SCA.

Methods

Publicly available online video databases were searched for videos displaying SCA in athletes.

Results

Thirty-five online videos (26 from professional and 9 from amateur sport; 34 male victims) were obtained. Twenty-one events resulted in survival and 14 in sudden cardiac death. Level of physical activity prior to SCA was assessable in 28 videos; 19 events occurred during low-intensity, 6 during moderate-intensity and 3 during high-intensity activity. SCA predominately occurred during low-intensity compared with both moderate-intensity and high-intensity activities (p<0.01). In 26/35 videos, it was possible to observe if resuscitation was provided. Resuscitation was carried out in 20 cases; cardiopulmonary resuscitation (CPR) alone (8 cases), CPR+defibrillation (10), cardiac thump (1) or shock from an implantable cardioverter defibrillator (1). Thirteen of the 20 cases with resuscitation received an intervention within 1 min after collapse. Survival was high when intervention occurred within 1 min (12/13) compared with those who received delayed (3/5) or no intervention (1/6). Associated signs of SCA such as agonal respirations and seizure-like movements were observed in 66% of the cases.

Conclusions

SCA during sport most often occurred during low-intensity activity. Prompt intervention within 1 min demonstrated a high survival rate and should be the standard expectation for witnessed SCA in athletes.

[Place of the exercise stress test at the sportsman]

Is the stress test still part of the useful examinations in the detection of risk heart disease in sports subjects? Should we continue to use it as a surveillance examination in coronary sports patients? Meta-analysis, considering a ST subshift of more than 1mm as a criterion for positivity, underline the low prevalence of abnormal examinations and a significant rate of false-positives. But for the diagnosis of coronary artery disease, it is mainly the evolution of the ST segment to effort or recovery and the occurrence of stress arrhythmias that detect true positivity. When coronary risk is more important (presence of risk factors, resumption of sport, intense and prolonged efforts), it seems lawful to recommend such a review on a regular basis among men over 40 years of age with two risk factors but Also among veterans taking up sport after a period of prolonged inactivity. For the asymptomatic coronary athlete the stress test remains at the centre of the final decision for the resumption of a sport in competition irrespective of the method of revascularization. Of course the stress test, even inevitable, remains flawed in the detection of coronary artery disease in the asymptomatic athlete. However, it provides additional information on the condition of being maximal, and attaching importance to arrhythmias, the tensional profile and the maximum power developed in addition to the ST segment's only study.

Exercise-related resuscitated out-of-hospital cardiac arrest due to presumed myocardial ischemia: Result from coronary angiography and intravascular ultrasound

AIM

Possible causes of exercise-related out-of-hospital cardiac arrest (OHCA) in people with coronary artery disease (CAD) include atherosclerotic plaque rupture (PR) and intra-coronary thrombosis, exercise-induced myocardial ischaemia and other triggers. We investigated whether there are differences in the incidence of PR and/or intra-coronary thrombus and in clinical outcome between 'exercise-related' and 'non-exercise-related' OHCA.

METHODS

219 consecutive resuscitated patients with CAD diagnosed by emergency coronary angiography (CAG) were enrolled. They were divided into the exercise group (≥6 METs; n = 35) and non-exercise group (<6 METs; n = 184), according to estimated METs immediately before OHCA using 2011 Compendium of Physical Activities. We investigated whether culprit lesions had PR and/or thrombus using CAG and intravascular ultrasound. The clinical outcome was 30-day survival with minimal neurologic impairment.

RESULTS

Acute PR and/or thrombus occurred in fewer of the exercise group than the non-exercise group (11% vs. 90%; P < 0.001). The exercise group had a higher incidence of favorable neurological outcome (94% vs. 47%; P < 0.001) than the non-exercise group. Multivariable Cox proportional hazards models revealed that exercise immediately before OHCA was one of the predictors of a good neurological outcome (HR, 0.19; P = 0.025).

CONCLUSION

The incidence of PR and/or thrombosis was lower in the group taking higher levels of exercise, than in the group taking less or no exercise. "Exercise-related" OHCA with CAD has better clinical outcomes than "non-exercise-related" with a greater proportion of witnessed arrests and early return of spontaneous circulation.

Burden of ventricular arrhythmias at 12-lead 24-hour ambulatory ECG monitoring in middle-aged endurance athletes versus sedentary controls

Background

Whether prolonged and intense exercise increases the incidence of ventricular arrhythmias in middle-aged athletes remains to be established.

Design

Prospective, case-control.

Methods

We studied 134 healthy competitive athletes >30 years old (median age 45 (39–51) years, 83% males) who had been engaged in 9 ± 2 h per week of endurance sports activity (running, cycling, triathlon) for 13 ± 4 consecutive years. One hundred and thirty-four age- and gender-matched individuals served as controls. Both groups underwent 12-lead 24-h ambulatory electrocardiogram monitoring, which included a training session in athletes. Ventricular arrhythmias were evaluated in terms of number, complexity (i.e. couplet, triplet or non-sustained ventricular tachycardia), exercise-inducibility and morphology.

Results

Thirty-five (26%) athletes and 31 (23%) controls showed >10 isolated premature ventricular beats or ≥1 complex ventricular arrhythmia ( p = 0.53). Athletes with ventricular arrhythmias were older (median 48 versus 43 years old, p = 0.03) but did not differ with regard to hours of training and years of activity compared with athletes without ventricular arrhythmias. Ten (7%) athletes and six (5%) controls showed >500 premature ventricular beats/24 h ( p = 0.30): the most common ventricular arrhythmia morphologies were infundibular (six athletes and five controls) and fascicular (two athletes and one control).

Conclusions

The prevalence of ventricular arrhythmias at 24-hour ambulatory electrocardiogram monitoring did not differ between middle-aged athletes and sedentary controls and was unrelated to the amount and duration of exercise. These findings do not support the hypothesis that endurance sports activity increases the burden of ventricular arrhythmias. Among individuals with frequent premature ventricular beats, the predominant ectopic QRS morphologies were consistent with the idiopathic and benign nature of the arrhythmia.

Cardiac Screening of Young Athletes: a Practical Approach to Sudden Cardiac Death Prevention

PURPOSE OF REVIEW

We aim to report on the current status of cardiovascular screening of athletes worldwide and review the up-to-date evidence for its efficacy in reducing sudden cardiac death in young athletes.

RECENT FINDINGS

A large proportion of sudden cardiac death in young individuals and athletes occurs during rest with sudden arrhythmic death syndrome being recognised as the leading cause. The international recommendations for ECG interpretation have reduced the false-positive ECG rate to 3% and reduced the cost of screening by 25% without compromising the sensitivity to identify serious disease. There are some quality control issues that have been recently identified including the necessity for further training to guide physicians involved in screening young athletes. Improvements in our understanding of young sudden cardiac death and ECG interpretation guideline modification to further differentiate physiological ECG patterns from those that may represent underlying disease have significantly improved the efficacy of screening to levels that may make screening more attractive and feasible to sporting organisations as a complementary strategy to increased availability of automated external defibrillators to reduce the overall burden of young sudden cardiac death.

Characteristics and Prognosis of Exercise-Related Sudden Cardiac Arrest

Introduction: The previous studies about exercise-related sudden cardiac arrest (SCA) have mainly focused on sports activity, but information related to SCA in other forms of physical exercise is lacking. Our aim was to identify characteristics and prognosis of SCA victims in the general population who suffered SCA during physical activity. Methods and results: We collected retrospectively all cases of attempted resuscitation in Oulu University Hospital Area between 2007 and 2012. A total of 300 cases were of cardiac origin. We only included witnessed cases with Emergency Medical System arrival time ≤15 min. Cases of low-intensity physical activity were excluded. A total of 47 SCAs occurred during moderate-to-vigorous physical activity (exercise-group) and 43 cases took place at rest (rest-group). The subjects in exercise-group were younger compared to the rest-group (60 ± 14 years vs. 67 ± 14 years, p = 0.016). The initial rhythm recorded was more often ventricular fibrillation (VF) in exercise-group compared to the rest-group (77 vs. 50%, p = 0.010). Pulseless electrical activity (PEA) was rare in exercise-group compared to the rest -group (2.1 vs. 14%, p = 0.033, respectively). Bystander cardiopulmonary resuscitation (CPR) was more often performed when SCA took place during physical exercise (47 vs. 23 %, p = 0.020). Survival rates to hospital discharge were higher in the exercise-group compared to the rest -group (49 vs. 9.3%, p < 0.0001). Conclusions: SCA occurring during physical activity is more frequently a result of VF and bystander CPR is more often performed. There is also a notably better survival rate to hospital discharge.

A 10-year review of sudden death during sporting activities

BACKGROUND

Sudden death during sport is a rare but devastating event. Previous research has mostly focused on sudden deaths in young competitive athletes.

OBJECTIVE

The purpose of this study was to characterize the demographics and etiologies of sudden cardiac death during sport in Australia.

METHODS

All autopsies conducted at our forensic medicine facility between 2006 and 2015 inclusive were reviewed. Sporting-related deaths among those 7-65 years of age were identified. Data collected included subject height, weight, gender, circumstances of death, and pathologic findings at autopsy.

RESULTS

A total of 19,740 autopsies were completed in the study period: 12,395 in subjects age 18-65 years (adults) and 385 in subjects age 7-17 years (children). There were 201 sports-related adult deaths at an incidence rate of 0.76-1.49 per 100,000 participant-years. Of the deaths, 74% were witnessed. Of the adult cases, 68% (n = 136) were due to cardiac causes, with coronary artery disease the most frequent cause (n = 90 [45%]). Structural abnormalities were common in adult cardiac deaths; 51 (38%) had cardiac weight ≥500 g, and 75 (55%) had left ventricular wall thickness >15 mm. Of the 15 child deaths, 5 (33%) were arrhythmogenic or presumed arrhythmic, and 5 (33%) were inherited cardiomyopathies (2 hypertrophic cardiomyopathy, 3 arrhythmogenic right ventricular cardiomyopathy).

CONCLUSION

Sudden cardiac death during sport is rare. Deaths are mostly due to coronary artery disease in adults and cardiomyopathy or arrhythmia in children. Because the majority of sports deaths are witnessed, they present an opportunity to enhance outcomes by cardiopulmonary resuscitation training and increased availability of automated external defibrillators at sports venues.

Effect of a first responder on survival outcomes after out-of-hospital cardiac arrest occurs during a period of exercise in a public place

INTRODUCTION

The deployment of first responders in a public place is one of the interventions that is used for increasing bystander cardiopulmonary resuscitation (CPR) of out-of-hospital cardiac arrests (OHCA). We studied the association between the presence of a first responder and the survival of OHCA that occurred during a period of exercise in a public place.

METHODS

All of the adult OHCAs of a presumed cardiac etiology that occurred during a period of exercise in a public place and that were witnessed by a bystander between 2013 and 2015 were analyzed. The main exposure of interest was the characteristics of the bystander (first responder vs. layperson). The endpoints were the provision of bystander CPR and good neurological recovery. Multivariable logistic regression analysis, adjusting for patient-environment and prehospital factors, was performed.

RESULTS

A total of 870 patients had a cardiac arrest during a period of exercise in a public place, and 58 (6.7%) patients were witnessed by the first responder. The OHCAs witnessed by first responders were more likely to result in bystander CPR than those witnessed by laypersons (89.7% vs. 75.4%, p = 0.01, adjusted OR (95% CI): 3.51 (1.44-8.55)). In terms of good neurological recovery, the OHCAs witnessed by first responders had a higher likelihood than the patients witnessed by laypersons (37.9% vs, 24.0%, p = 0.02, adjusted OR (95% CI): 2.92 (1.33-6.40)).

CONCLUSION

The OHCAs occurred during a period of exercise in a public place and whom first responders witnessed were more likely to receive bystander CPR and to have a neurologically intact survival.

Pre-participation screening of asymptomatic athletes : "Don't do stupid stuff"

Catastrophic events, be it traffic accidents, natural disasters or homicides, always lead to scrutiny. Could we have seen the event coming and could it have been prevented? In the case of a sudden cardiac arrest of a seemingly healthy athlete the public outcry is not any different. Despite an intrinsic appeal for screening to prevent similar events, there is no evidence that justifies routine cardiovascular pre-participation screening of athletes. On balance, cardiovascular screening in athletes will most likely do more harm than good. Fatal exercise-related cardiac arrests do not occur very often. The true diagnostic yield of the pre-participation evaluation is not known and once a cardiac condition has been identified, the most appropriate intervention is often unclear. It follows that pre-participation screening of large groups of athletes without known cardiac disease will inevitably result in many false positive findings, while at the same time providing a false sense of security to those screened negative. Except for compelling reasons (e. g. cascade screening, research settings, professional athletes), physicians should not engage in routine examination of asymptomatic athletes to prevent cardiac events.

Cardiac arrest while exercising on mountains in national or provincial parks: A national observational study from 2012 to 2015

BACKGROUND

Previous studies on cardiac arrest in mountainous areas were focused on environmental features such as altitude and temperature. However, those are limited to factors affecting the prognosis of patients after cardiac arrest. We analyzed the cardiac arrests in national or provincial parks located in the mountains and determined the factors affecting the prognosis of patients after cardiac arrest.

METHODS

This study included all emergency medical service (EMS) treated patients over the age of 40 experiencing out-of-hospital cardiac arrests (OHCAs) of presumed cardiac etiology during exercise, between January 2012 and December 2015. The main focus of interest was the location of cardiac arrest occurrence (national mountain parks and provincial parks vs. other sites). The main outcome was survival to discharge and multivariable logistic regression was performed to adjust for possible confounding effects.

RESULTS

A total 1835 patients who suffered a cardiac arrest while exercising were included. From these, 68 patients experienced cardiac arrest in national or provincial parks, and 1767 occurred in other locations. The unadjusted and adjusted ORs (95% CI) for a good cerebral performance scale (CPC) were 0.09 (0.01-0.63) and 0.08(0.01-0.56), survival discharges were 0.13(0.03-0.53) and 0.11 (0.03-0.48).

CONCLUSIONS

Cardiac arrests occurring while exercising in the mountainous areas have worse prognosis compared to alternative locations.

Prevention of sudden cardiac death in athletes, sportspersons and marathoners in India

The annual incidence of sudden cardiac death (SCD) in athletes is significantly lower than the general population. However, when SCD occurs in an athlete during sporting event or training, it sends shockwaves in the society and raises questions about cardiovascular effects of sports and exercise. This document reviews the causes and mechanism of SCD in sports and exercise in young and older athletes. In the Indian context, we suggest a ‘pre-participation screening’ of young and older athletes and consider a ‘supervised, graded exercise regime’ for the uninitiated, older sports participant. Finally, the document proposes medical infrastructure required to successfully revive a victim of sudden cardiac arrest during a sporting event.

The Relationship between Emergency Response Time and Out-Of-Hospital Cardiac Arrest Prognosis: A Meta-Analysis

Objective

To assess the relationship between emergency response time and prognosis of patients with out-of-hospital cardiac arrest.

Design

Systematic review.

Methods

Relevant observational studies were identified by a search of PubMed and ISI databases to 30 January 2014. Primary outcome was survival to discharge. The weighted mean differences (WMD) for response time were calculated for those survivals to discharge and death in hospital. We also carried out a dose response meta-analysis for assessing summary odds ratio (OR) of survival by response time.

Results

A total of 13 studies with 804,998 patients included in the meta-analysis. The WMD of response time between survivals to discharge group and death in hospital group was 1.976 (95% confidence interval [CI] = 1.161-2.792; p<0.001). Sensitivity analyses by only included prospective cohorts showed the WMD of response time between two groups was 1.115 (95% CI=0.508-1.723; p<0.001). Dose-response relationship between response time and survival to discharge risk was observed statistically significant (χ2=39.86, p<0.001). In linear model, the summary OR was 0.914 (95% CI=0.889-0.940) for every 1 minutes delay in response time. In spline model, the survival OR decreased along with the response time, especially when response time less than 7 minutes.

Conclusions

Emergency response time is an important risk factor for prognosis after OHCA in adults. The EMS team must arrive as soon as possible to the site of the event. (Hong Kong j.emerg.med. 2015;22:345-351)

Sudden Cardiac Death During Sports Activities in the General Population

Regular exercise reduces cardiovascular and overall mortality. Participation in sports is an important determinant of cardiovascular health and fitness. Regular sports activity is associated with a smaller risk of sudden cardiac death (SCD). However, there is a small risk of sports-related SCD. Sports-related SCD accounts for approximately 5% of total SCD. SCD among athletes comprises only a fraction of all sports-related SCD. Sport-related SCD has a male predominance and an average age of affliction of 45 to 50 years. Survival is better than for other SCD. This review summarizes links between sports and SCD and discusses current knowledge and controversies.