Sports-Related Cardiac Arrest Seen as Rare in Middle Age

Deborah Brauser

April 06, 2015

LOS ANGELES, CA — Occurrences of sports-associated sudden cardiac arrest (SCA) in middle-aged athletes appear to be few, especially in those without previous cardiovascular risk factors or symptoms, new research suggests[1].

Further results from the Oregon Sudden Unexpected Death Study (Oregon-SUDS), which were published today in Circulation, showed that only 5% of 1247 cases of SCA in individuals between the ages of 35 and 65 years happened during some form of sports activity. The mean age for the occurrences was 51.1 years, and there was a significantly higher rate among men for sports SCA than among women (risk ratio [RR] 18.68; 95% CI 2.50–139.56).

Interestingly, these events were more likely to be witnessed, and survival to hospital discharge was significantly higher vs non–sports-associated SCA.

"The middle-aged are becoming a bigger and bigger part of our society. And there's a huge recognition of how lifestyle can prevent heart disease and other conditions," principal investigator Dr Sumeet S Chugh (Heart Institute at Cedars-Sinai Medical Center, Los Angeles, CA) told heartwire from Medscape.

"Given the uniqueness of this population and our ability to take a deeper dive into the data, we found some important observations: about 16% already had known heart conditions, but almost two-thirds had either some kind of symptom or risk factor," Chugh added, referring to the group experiencing SCA during sports activities. "You could argue that this could inform future prevention of SCA in sports."

First Study of Its Kind

The investigators, including first author Dr Eloi Marijon (Cedars-Sinai Medical Center), note that although there has been extensive research on SCA among young athletes, there is little information on associations with specific sports activities, and no studies have examined these issues in middle-aged individuals—at least in the US.

"Recent European experience has emphasized that . . . the largest burden of sports-associated SCA results from events among middle-aged participants," they write. "A better understanding of burden (absolute as well as relative to other non–sports-related SCAs) and characteristics of SCA during sports in middle-aged population is likely to inform preventive strategies."

The researchers examined data for from the Oregon-SUDS trial for individuals classified as middle-aged and who had an SCA between 2002 and 2013. Oregon-SUDS is an ongoing, prospective study examining SCAs that occur out of hospitals.

Only 63 of the study participants had a sports-related SCA, "yielding an incidence of 21.7 (95% CI 8.1–35.4) per million per year" vs an incidence of 555 per million per year for nonsports SCA.

The most common type of sports SCA was jogging (27%), followed by basketball (17%), cycling (14%), miscellaneous gym activities (11%), and golfing (8%). Volleyball, tennis, and soccer each had 3% of the incidents. The remaining 14% were classified as "other sports."

A total of 76% of these events occurred while the individuals were actually participating in the sports activity, while the remaining 24% occurred within the hour after stopping. Sports facilities, including gyms, were the sites of 58% of sports SCA. Of the remaining 42%, most occurred in public parks or on jogging trails.

Not only were sports-associated SCAs more likely to be witnessed than nonsports SCAs (87% vs 52%, respectively; P<0.001), but these events were more likely to lead to bystander CPR (44% vs 25%; P=0.001). The survival-to-hospital-discharge rate was 23.2% for the sports SCA cases (95% CI 118.8–34.6) vs 13.6% for the nonsports SCA cases (95% CI 11.6–15.5; P=0.04).

"Exercise Ambassadors" Needed

Of the 43 cases of sports SCA where cause was assessed, 84% were associated with coronary artery disease. "Whether a cautionary note needs to be raised with respect to sports in those with established coronary artery disease is a clinical question that needs further investigation," write the researchers.

Chugh noted that "there were a bunch of people who had symptoms" before their sports-related SCA. "This makes you wonder if they were supposed to be doing sports in spite of symptoms and if there was some way this could have been preempted," he added.

Overall, "sports-associated SCA in middle age represents a relatively small proportion of the overall SCA burden, reinforcing the idea of the high-benefit/low-risk nature of sports activity," write the investigators.

"Especially in light of current population aging trends, our findings emphasize that targeted education could maximize both safety and acceptance of [this type of] activity in the older athlete."

Chugh pointed out that encouragement for exercise or sports activity in this population should come only after an assessment of possible musculoskeletal limitations. But if there are no problems, "exercise activity is the best thing you can do for yourself—not just for heart disease but for overall mortality."

He practices what he preaches. "I'm a 50-year-old long-distance runner and think clinicians should really be ambassadors for exercise activities for their middle-aged patients and follow the stepwise screening guidelines that have been laid out in the literature," he said, adding that this is especially important in patients not habituated to exercise.

"I'd recommend actually writing an exercise prescription in a way where it takes patients 6 to 8 weeks to come to a level that they would like to continue in the long term," Chugh concluded.

The study was funded in part by grants by the National Heart, Lung, and Blood Institute. The study authors report no relevant financial relationships.

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