Sudden Cardiac Arrest During Competitive Sports

Dec 07, 2017
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Authors:
Landry CH, Allan KS, Connelly KA, et al., on behalf of the Rescu Investigators.
Citation:
Sudden Cardiac Arrest During Participation in Competitive Sports. N Engl J Med 2017;377:1943-1953.
Summary By:
Eugene H. Chung, MD, MPH, FACC

Study Questions:

What is the incidence of sudden cardiac arrest (SCA) during participation in competitive and noncompetitive sports among young persons, what are the underlying causes of SCA, and what is the potential efficacy of a systematic pre-participation screening program?

Methods:

This retrospective study used the Rescu Epistry database of out-of-hospital cardiac arrests, a prospective population-based registry in Ontario, Canada. All emergency medical service–attended cardiac arrests (including both deaths and cases of successful resuscitation), between 2009 and 2014, occurring during sport in subjects 12-45 years of age, were analyzed. Competitive sport was defined as an activity that was organized and certified by an official sports association. Noncompetitive sport was defined as sport or recreational activity that was not formally organized or sanctioned. Either type of sport was associated with the arrest if the arrest occurred during or within 1 hour of exerting the equivalent of 3 metabolic equivalents. Identified cases were then cross-referenced with first responder reports, in-hospital medical data, autopsy reports, and interviews with patients or family members.

Results:

A total of 3,825 persons between ages 12-45 years old had an out-of-hospital cardiac arrest in the stated time frame. A total of 74 SCAs occurred during a sport over an estimated 18.5 million person-years of observation. Of these 74 cases, 16 were classified as SCA during competitive sports versus 58 during noncompetitive sports. The sports most associated with events were race events and soccer (four cases each). The incidence of SCA was 0.76 per 100,000 athlete-years. Of the 16 cases of SCA, there were nine deaths (two cases of hypertrophic cardiomyopathy, three cases of anomalous coronary arteries, two primary arrhythmia events, and two cases of myocardial ischemia). In terms of pre-participation cardiac screening of competitive athletes, the authors concluded that at most 3 out of the 16 cases could have been identified via screening.

Conclusions:

Sixteen cases of SCA among athletes during competitive sports were identified, resulting in an incidence of 0.76 per 100,000 athlete-years. SCA as a consequence of structural heart disease (hypertrophic cardiomyopathy) was found in two.

Perspective:

  1. The incidence of SCA during competitive sport participation is rare and confirmed by this study.
  2. This study found, as have other recent studies, that structurally normal hearts on autopsy are more common than previously thought.
  3. In active individuals over 35 years of age, myocardial ischemia remains a common etiology of SCA.
  4. This study provides interesting insight into the potential cost-effectiveness of screening. It is not, however, a direct study of findings and outcomes from pre-participation screening, with or without an electrocardiogram (ECG).
  5. SCA in athletes can occur away from the organized event (during training or practice) and may be actually more common at rest, even in hypertrophic cardiomyopathy. If “noncompetitive” cases are included, the incidence calculation is several times higher.
  6. The population studied was different from that of other recent studies in the United States and the United Kingdom. Only 3% were participating in basketball. The number playing American-style football was probably even less. Ethnicity data are not provided.
  7. Pre-participation evaluation presents an opportunity to not just screen for concerning conditions, but to educate about warning signs and symptoms. Education and training on reading an athlete’s ECG using the latest criteria (if one chooses to include the ECG), emergency action plans (e.g., cardiopulmonary resuscitation training and automated external defibrillator availability), and shared decision making involving all stakeholders are paramount to caring for the athlete.

Keywords: Arrhythmias, Cardiac, Athletes, Autopsy, Cardiomyopathy, Hypertrophic, Cardiopulmonary Resuscitation, Death, Sudden, Cardiac, Defibrillators, Electrocardiography, Heart Arrest, Heart Failure, Myocardial Ischemia, Out-of-Hospital Cardiac Arrest, Secondary Prevention, Soccer, Sports


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