Survival Improving in Sports-Related Sudden Cardiac Arrest

Pauline Anderson

January 21, 2022

The survival rate following a sports-related cardiac arrest (SrSCA) almost tripled over a recent 12-year period, due in large part to increased bystander use of automated external defibrillators (AEDs) and cardiopulmonary resuscitation (CPR), results of a new study from France suggest.

Lead author Nicole Karam, MD, PhD, associate professor in interventional cardiology, University of Paris, credits concerted educational efforts for the improved outcomes.

Doctors could play a role in this ongoing awareness effort, Karam told | Medscape Cardiology. "We really have a mission of educating patients as to what a sudden cardiac arrest is, how to recognize it, and how to manage it if it happens in front of you."

Physicians might also consider not only encouraging patients to participate in sports as a primary prevention strategy but also informing them about warning signs, she added.

"In every consultation we do, we could tell patients that if some day they have chest pain, or some discomfort, they should come back to us for more exams" before resuming their sport.

The study was published online January 17 in the Journal of the American College of Cardiology.

In recent years, French experts have deployed strategies to reduce the burden of SrSCA. For example, France implemented legislation in 2007 that authorizes the use of AEDs by the lay public.

When an AED is deployed in a stadium or elsewhere, there's usually an educational session explaining how to use it, along with other information for the public on performing CPR, said Karam. An AED is credited with saving the life of Danish soccer star Christian Eriksen in the middle of Denmark's game last June against Finland at the European Championships. Eriksen suffered cardiac arrest on the pitch but was quickly treated with a defibrillator by team medical staff and taken to a nearby hospital. He was released from hospital 5 days later.

The new analysis included patients aged 18-75 years from the Paris-Sudden Death Expertise Center (Paris-SDEC) dataset. Researchers examined SrSCA cases during six 2-year periods spanning the years 2005-2018.

A medical assessment is mandatory in France to participate in a competitive sport, but there's no such restriction for those engaged in leisure sports activities.

"If you decide to go jogging on Sunday, nobody is going to ask you whether you've seen a doctor or not," said Karam.

This is important because it's typically "the 40- or 45- or 50-year-old guy who's putting on weight and doing sports" who dies of sudden cardiac arrest, not the competitive player who's screened, she added.

The study identified 377 cases of SrSCA, including 20 among young competitive athletes (5.3%). The rest were among middle-aged recreational sports participants.

The mean age of cases was 49.6 years. Most (95.2%) were male.

The incidence of SCA did not change significantly during the study: 6.24 per million inhabitants/year in the last 2-year period vs 7.0 per million inhabitants/year in the first period (P = .51).

This finding should be interpreted with caution, said Karam. "Even if we didn't see a major decrease in incidence, there was probably a little bit of improvement" because more people participated in sports over time.

There were no significant differences during the study in the mean age of victims, proportion of men, and prevalence of previously known heart disease. There were also no differences in the proportion of SCA occurring at home or in the presence of a bystander.

However, there was a sharp increase in use of bystander CPR (94.7% in the last period vs 34.9% in the first; P < .001) and of AEDs (28.8% vs 1.6%; P < .001).

Causes of SrSCA were determined in 61% of cases. Among identified cases, coronary artery disease was the main cause (68.7%), followed by non-ischemic structural heart diseases (16.9%), and electric heart diseases (9.6%).

Among the 54.4% of cases occurring in sports facilities, the rate of CPR reached 97.9% in the last 2-year period compared to 50% at the beginning of the study (P = .002). AED use reached 34.9% during the last study period vs 3.1% initially (P = .002).

The overall survival rate to hospital discharge was 66.7% in the last 2-year period vs 23.8% in the first period (P < .001). In sports facilities, this rate increased to 78.7% vs 43.8% initially (P = .003).

Further improvements may come from targeting at-risk populations and selecting better tests "that are able to actually show which patients are going to have a sudden cardiac arrest," said Karam.

"The idea is to try to extrapolate what we have done in SrSCA to the entire population and try to get this kind of result with all-comer sudden cardiac arrest, and not only those during sports."

Although screening is important, it's difficult to screen large segments of the population. Karam believes education is the "key" to improving SCA outcomes.

Past research showed more than half of SCA victims had warning symptoms, mainly chest pain and dyspnea, several days or weeks before a sudden cardiac arrest. Patients should know that if they experience such symptoms, they should see their doctor before resuming sports, and bystanders should know how to do CPR and use an AED, said Karam.

In an accompanying editorial, Michael J. Ackerman, MD, PhD, and John R. Giudicessi, MD, both at Mayo Clinic, Rochester, Minnesota, said the study demonstrates the "impressive impact" of increased bystander CPR awareness and improved public AED use.

But the stable incidence of SrSCA during the study period is "sobering," and seems to indicate "minimal progress" in terms of preventing SrSCA, they write.

"Considering the substantive advances in our understanding of the pathogenesis of SCA-predisposing conditions," this finding "suggests that the field has been unable to translate this wealth of knowledge into the implementation and/or optimization of effective SrSCA prevention strategies," Ackerman and Giudicessi say.

The editorial noted artificial intelligence, ECG, and auscultation algorithms can accurately detect subclinical signs of asymptomatic left ventricular dysfunction, hypertrophic cardiomyopathy, QT prolongation, and valvular heart disease.

Perhaps it's time to consider incorporating such technologies — which could one day allow for more accurate, timely, and cost-effective identification of disease — into the preparticipation screening process for individuals involved in sports at all levels, the editorialists conclude.

The study received funding from the French National Institute of Health and Medical Research (INSERM), University of Paris, French Federation of Cardiology. Karam has disclosed no relevant financial relationships. Ackerman is a consultant for Abbott, ARMGO Pharma, Boston Scientific, Daiichi-Sankyo, Invitae, LQT Therapeutics, Medtronic, and UpToDate; and he and Mayo Clinic are involved in an equity/royalty relationship with AliveCor and Anumana. However, none of these entities were involved in this study.

J Am Coll Cardiol. Published online January 17, 2022. Abstract, Editorial

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