COMMENTARY

Lessons From the Save of Soccer Player Christian Eriksen's Life

John Mandrola, MD

Disclosures

June 28, 2021

The resuscitation of Danish professional soccer player Christian Eriksen on the pitch, in front of millions of people, is a chance to consider how the United States could do better in the prevention and treatment of sudden cardiac death (SCD).  

The now-famous video shows Eriksen collapse.  He's unresponsive; medics come immediately to his aid and begin cardiopulmonary resuscitation (CPR). One shock from an automatic external defibrillator (AED) vanquishes his ventricular fibrillation (VF) and restores regular rhythm. Another video shows Eriksen conscious and awake  as he is rolled off the field.

Early CPR and AED

My partner Bill Dillon, an interventional cardiologist, runs a nonprofit called Start-the-Heart, which trains college-aged adults to teach CPR to the general public. It's the see-one-do-one-teach-one philosophy of medical training.

Dillon told me that Eriksen's resuscitation was ideal. Responders recognized the two most important first signs when assessing a person who has collapsed: he was unconscious and not breathing. These two features prompted CPR. The next step is to place an AED and deliver a shock if the patient is in VF. That too was done. Eriksen went from "being gone," as the team doctor said in the news conference, to being alive.  

Eriksen had an excellent outcome, but sudden death due to ventricular tachyarrhythmias remains a leading cause of death—as it is often a manifestation of atherosclerotic coronary artery disease or heart failure. The incidence of SCD in the United States ranges between 180,000 and 450,000 cases annually, and SCD accounts for over 50% of all deaths from coronary heart disease (CHD) and 15% to 20% of all deaths. In the United States, survival from an out-of-hospital cardiac arrest varies from 8% to 16%, depending on the state.

According to Dillon, the recent awareness of SCD in athletes, which has led to AEDs at sporting venues, has been most beneficial for the fans because they are much more likely to experience a life-threatening arrhythmia. Stories abound in our hospital about an AED successfully used on a parent of a student athlete.

The Danish System for Cardiac Arrest

The fact that Eriksen happens to be Danish is a coincidence. But that he was playing for his national team in his home country at the time may have been significant. It turns out that Denmark sets a high bar in the care of cardiac arrest.

By email, Carolina Malta Hansen, MD, and Jannik Pallisgaard, MD, from the Copenhagen Cardiovascular Research Center pointed me to some of the impressive Danish initiatives in the care of people who have cardiac arrest outside the hospital. There are the simple things, such as mandatory CPR training in middle school and when getting a driver's license.

Then there are the bigger initiatives. In 2011, Denmark began the first nationwide AED registry, which, crucially, is linked to emergency dispatch centers that can pinpoint the location of the nearest AED. Danish health authorities bolster AED use via frequent public campaigns on the importance of AED registration and availability. (A point Dillon made was that too often in the United States, the AED is locked up after hours.)

Hansen and Pallisgaard wrote that these efforts are associated with an impressive increase in bystander defibrillation. A study of patients who had out-of-hospital cardiac arrest in Denmark found that the chance of bystander defibrillation nearly tripled (13.8% vs 4.8%) and 30-day survival almost doubled (28.8% vs 16.4%), when the nearest AED was accessible. Similar efforts in Stockholm, Sweden, have also been associated with favorable results.

Another clever Danish initiative is the citizen responder HeartRunner program, which has more than 115,000 CPR-trained responders who can be notified by a smartphone app of a nearby cardiac arrest. A pilot study of this program found that citizen responders arrived before emergency medical services nearly half the time, and this was associated with a more than threefold increase in the odds of bystander defibrillation. Perhaps the most impressive part of this program is that its proponents will actually test whether it improves survival in the HeartRunner randomized controlled trial.

In northern Europe, the government and the public seem fully committed to this public health goal. Meanwhile, in the United States, we lean on specialty organizations like the American Heart Association, motivated middle-aged cardiologists like my partner who design do-it-yourself programs, and niche efforts using drones. The American sclerosis on this problem perplexes me—it's not like we have a shortage of heart disease.

Screening Athletes

Eriksen makes me think about screening. The ideal scenario would be to identify athletes at risk for this condition and exclude them from sports—thereby preventing VF in the first place. If only it were that easy. Screening pioneers Wilson and Jungner famously wrote in the 1960s that screening for disease was admirable but in practice there were snags.

The case of Christian Eriksen exemplifies one of these snags—the false negative. We know, for instance, from Sanjay Sharma, one of the top sports cardiologists in the world, that Eriksen had passed extensive testing—at least before 2019 when he played in the Premier League in the United Kingdom. Despite screening at the highest level, Eriksen still required emergency resuscitation.

This is no knock on his previous doctors. The problem with screening for sudden death risk in athletes is that while hypertrophic cardiomyopathy is relatively easy to identify, other causes of ventricular arrhythmia, such as focal cardiomyopathy, myocarditis, and idiopathic ventricular tachycardia, are difficult or impossible to identify before an event.

I spoke with Yale electrophysiologist Rachel Lampert, who has published widely on the topic of arrhythmias in athletes. She made the point that no screening program is 100% sensitive, but that doesn't mean we shouldn't do it. She likened it to seatbelts: some people wearing seatbelts will die in car crashes, but many more lives are saved. Lampert emphasized that screening and prompt treatment with CPR and available AEDs are complementary.

I worry more about the other major snag of screening—the false positive. Although professional athletes are screened by experts, such as Lampert and Sharma, most screening of high school and college athletes is done by average clinicians.

As an electrophysiologist, I commonly see young athletic people referred for an "abnormal" ECG, which isn't abnormal but instead is a manifestation of athleticism and youth. Many clinicians in the primary care and cardiology clinic are unfamiliar with athletic adaptation. "John, the kid can run a 4-minute mile, but his resting heart rate is 32! Should we not do a monitor or echocardiogram?" (Answer: No.)

Unfamiliarity with the athletic pattern on ECGs and echocardiograms can lead to testing cascades that expose the athlete to potential harms—and possibly inappropriate disqualification from sports. If every athlete underwent screening from Lampert and Sharma, I would worry less.

ICD and Return to Sport

We know from reports that Eriksen received an implantable cardioverter defibrillator (ICD). Must he retire? Daley Blind is a professional soccer player who returned to play after having an ICD; he has suggested that the same may be possible for Eriksen.

In the matter of return to play with an ICD, we have more evidence than Blind's anecdote. Again, Rachel Lampert and her colleagues published a prospective cohort study of nearly 400 athletes (median age, 33 years; 33% female) who had returned to play after getting an ICD. Running, basketball, and soccer were the most common sports. The authors reported no occurrences of death, resuscitated arrest or arrhythmia, or shock-related injury. Shocks occurred in 10% of the athletes.

The results were similar with longer follow-up (44 months): no tachyarrhythmia-related deaths and a rate of lead failure similar to that in nonathletic patients with devices, which should reassure those worried that vigorous activity might result in more lead failures. The authors rightly conclude: "These data suggest that a blanket recommendation against competitive sports for all patients with ICDs is not warranted."

Lampert's biggest concern about return to sport is not the device but the underlying disease. She told me that arrhythmogenic right ventricular cardiomyopathy (exercise is known to worsen this disease) and catecholaminergic polymorphic ventricular tachycardia (which may lead to multiple shocks) are the most worrying. Fortunately, these conditions are rare. She noted that collision sports like US football and ice hockey were not represented in the registry.

Of course, the most important factor in return to play is a shared decision-making process with the patient. Some athletes may want to retire from sports, others want to return. But at least we have (some) data to guide this decision. Lampert was careful to point out that an uncontrolled study of 400 motivated athletes could not completely exclude all possible complications.
 

Conclusion

Obviously, from Eriksen's perspective, life would be better if he never had an arrest. But his excellent outcome teaches many lessons about a major public health problem. Given the high prevalence and mortality from out-of-hospital cardiac arrest, isn't it time the United States got a little more Danish?  

John Mandrola practices cardiac electrophysiology in Louisville, Kentucky, and is a writer and podcaster for Medscape. He espouses a conservative approach to medical practice. He participates in clinical research and writes often about the state of medical evidence. 

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