Sports-related sudden death in the general population

Effect of knee positions on cardiac compression variables in cardiopulmonary resuscitation of rescuer; Manikin study

The aim of the study was to analyze the effect of knee positions on cardiac compression variables in cardiopulmonary resuscitation (CPR) using the manikin. Adult with career of CPR instructor (n=9; mean age, 27.11±6.60 years; mean heights, 177.39±4.40 cm; mean weights, 69.45±14.85 kg) participated in the experiment, and each participant performed cardiac compression from two different knee positions. Cardiac compression was 30 times per minute for each position with order of position randomized. The results obtained from variables of cardiac compression force were composed of compression velocity, elapsed time, decay rate, and loading rate in maximum and minimum medial-lateral, anterior-posterior (AP), vertical direction respectively. The above variables in 20.3 cm of knee position showed effective result than that of 50 cm of knee position, while maximum AP compression force increased. Given the often predictable setting of sports and exercise rehabilitation related with cardiac arrest, CPR relative to change of knee position were significantly associated with more efficient cardiac compression variables. These data have significant implications for health services program in fields of sports and exercise rehabilitation.

Competence of general practitioners in requesting and interpreting ECGs - a case vignette study

BACKGROUND

Performing electrocardiography is common in general practice, but the quality of indication setting and diagnostic accuracy have been disputed.

OBJECTIVES

To assess the competence of general practitioners (GPs) in their decision-making process with regard to recording and interpreting an electrocardiogram (ECG) and evaluating the relevance of the result for management.

METHODS

An online case vignette survey was performed among GPs and cardiologists (in 2015). Nine cases describing situations for which Dutch clinical guidelines recommend or advise against recording an ECG were presented. In each case, the participant had to make choices on recording an ECG, interpreting it, and using the result in a management decision. The reference standard for each ECG diagnosis was set by the expert author team.

RESULTS

Fifty GPs who interpret ECGs themselves, eight GPs who do not and 12 cardiologists completed the survey. Adherence to guidelines recommending an ECG was high for suspected atrial fibrillation, suspected arrhythmia present during consultation, including bradycardia, but much lower for progressive heart failure and stable angina. Diagnostic accuracy of GPs was best in atrial fibrillation (96%), sick sinus syndrome (85%) and old myocardial infarction (82%), but poor in left anterior fascicular block (16%) and incomplete right bundle branch block (10%). GPs often acknowledged the low relevance of the results of a non-indicated ECG.

CONCLUSION

GPs do not fully adhere to Dutch cardiovascular guidelines on indications for recording ECGs. Diagnostic accuracy was high for atrial fibrillation, sick sinus syndrome and old myocardial infarction and poor for left anterior fascicular block and incomplete right bundle branch block.

Epidemiology of sudden cardiac death in Cameroon: the first population-based cohort survey in sub-Saharan Africa

Background

Incidence estimates of sudden cardiac death (SCD) in sub-Saharan Africa (SSA) are unknown.

Method

Over 12 months, the household administrative office and health community committee within neighbourhoods in two health areas of Douala, Cameroon, registered all deaths among 86 188 inhabitants aged >18 years. As part of an extended multi-source surveillance system, the Emergency Medical Service (EMS), local medical examiners and district hospital mortuaries were also surveyed. Whereas two physicians investigated every natural death, two cardiologists reviewed all unexpected natural deaths.

Results

There were 288 all-cause deaths and 27 (9.4%) were SCD. The crude incidence rate was 31.3 [95% confidence interval (CI): 20.3–40.6]/100 000 person-years. The age-standardized rate by the African standard population was 33.6 (95% CI: 22.4–44.9)/100 000 person-years. Death occurred at night in 37% of cases, including 11% of patients who died while asleep. Out-of-hospital sudden cardiac arrest occurred in 63% of cases, 55.5% of which occurred at home. Of the 88.9% cases of witnessed cardiac arrest, 63% occurred in the presence of a family member and cardiopulmonary resuscitation was attempted only in 3.7%.

Conclusion

The burden of SCD in this African population is heavy with distinct characteristics, whereas awareness of SCD and prompt resuscitation efforts appear suboptimal. Larger epidemiological studies are required in SSA in order to implement preventive measures, especially in women and young people.

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.

Preparticipation screening-the way forward is smart screening

The image of a young athlete collapsing on the pitch, followed by resuscitation, leaves an unforgettable impression. However, this impression should not seduce us into resuscitating the debate for large-scale preparticipation screening without doing the smart thing: taking a step back to review what we know to be effective, and what has been shown not to be effective. What we should do is use this momentum to focus on what we still need to know.

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.

Sudden Cardiac Death in Children and Adolescents

Sudden cardiac death (SCD) is a rare but devastating event in children and adolescents. Etiologies include congenital heart disease, cardiomyopathies, primary arrhythmia syndromes, and miscellaneous conditions. Challenges in the diagnosis and prevention of SCD in the young are reviewed.

Risk Factors of Sudden Cardiac Death in the Young: Multiple-Year Community-Wide Assessment

BACKGROUND

Prevention of sudden cardiac arrest (SCA) in the young remains a largely unsolved public health problem, and sports activity is an established trigger. Although the presence of standard cardiovascular risk factors in the young can link to future morbidity and mortality in adulthood, the potential contribution of these risk factors to SCA in the young has not been evaluated.

METHODS

We prospectively ascertained subjects who experienced SCA between the ages of 5 and 34 years in the Portland, Oregon, metropolitan area (2002-2015, catchment population ≈1 million). We assessed the circumstances, resuscitation outcomes, and clinical profile of subjects who had SCA by a detailed evaluation of emergency response records, lifetime clinical records, and autopsy examinations. We specifically evaluated the association of standard cardiovascular risk factors and SCA, and sports as a trigger for SCA in the young.

RESULTS

Of 3775 SCAs in all age groups, 186 (5%) occurred in the young (mean age 25.9±6.8, 67% male). In SCA in the young, overall prevalence of warning signs before SCA was low (29%), and 26 (14%) were associated with sports as a trigger. The remainder (n=160) occurred in other settings categorized as nonsports. Sports-related SCAs accounted for 39% of SCAs in patients aged ≤18, 13% of SCAs in patients aged 19 to 25, and 7% of SCAs in patients aged 25 to 34. Sports-related SCA cases were more likely to present with shockable rhythms, and survival from cardiac arrest was 2.5-fold higher in sports-related versus nonsports SCA (28% versus 11%; P=0.05). Overall, the most common SCA-related conditions were sudden arrhythmic death syndrome (31%), coronary artery disease (22%), and hypertrophic cardiomyopathy (14%). There was an unexpectedly high overall prevalence of established cardiovascular risk factors (obesity, diabetes mellitus, hypertension, hyperlipidemia, smoking) with ≥1 risk factors in 58% of SCA cases.

CONCLUSIONS

Sports was a trigger of SCA in a minority of cases, and, in most patients, SCA occurred without warning symptoms. Standard cardiovascular risk factors were found in over half of patients, suggesting the potential role of public health approaches that screen for cardiovascular risk factors at earlier ages.

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.

Myocardial Fibrosis in Competitive Triathletes Detected by Contrast-Enhanced CMR Correlates With Exercise-Induced Hypertension and Competition History

OBJECTIVES

This study analyzed the presence of myocardial fibrosis detected by late gadolinium-enhancement (LGE) cardiac magnetic resonance (CMR) in correlation with the performance of competitive triathletes objectified by an exercise test and individual competition history.

BACKGROUND

Myocardial fibrosis detected by LGE CMR has been reported to occur in 0% to 50% of asymptomatic athletes. However, the cause and mechanisms of myocardial fibrosis are unclear.

METHODS

Eighty-three asymptomatic triathletes undergoing >10 training h per week (43 ± 10 years of age; 65% male) and 36 sedentary controls were studied by using LGE and extracellular volume (ECV) CMR. Parameters of physical fitness were measured by spiroergometry. Triathletes reported their lifetime competition results.

RESULTS

LGE CMR revealed focal nonischemic myocardial fibrosis in 9 of 54 (17%) male triathletes (LGE⁺) but in none of the female triathletes (p < 0.05). LGE⁺ triathletes had higher peak exercise systolic blood pressure (213 ± 24 mm Hg) than LGE^- triathletes (194 ± 26 mm Hg; p < 0.05). Furthermore, left ventricular mass index was higher in LGE⁺ triathletes (93 ± 7 g/m²) than in LGE^- triathletes (84 ± 11 g/m²; p < 0.05). ECV in LGE^- myocardium was higher in LGE⁺ triathletes (26.3 ± 1.8%) than in LGE^- triathletes (24.4 ± 2.2%; p < 0.05). LGE⁺ triathletes completed longer cumulative distances in swimming and cycling races and participated more often in middle and Iron Man distances than LGE^- triathletes. A cycling race distance of >1,880 km completed during competition had the highest accuracy to predict LGE, with an area under the curve value of 0.876 (p < 0.0001), resulting in high sensitivity (89%) and specificity (79%). Multivariate analysis identified peak exercise systolic blood pressure (p < 0.05) and the swimming race distance (p < 0.01) as independent predictors of LGE presence.

CONCLUSIONS

Myocardial fibrosis in asymptomatic triathletes seems to be associated with exercise-induced hypertension and the race distances. There appears to be a safe upper limit, beyond which exercise may result in myocardial fibrosis.

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.

Clinical significance of ST depression at exercise stress testing in competitive athletes: usefulness of coronary CT during screening

BACKGROUND

Congenital coronary anomalies (CCAs) and coronary artery disease (CAD) arouse intense scientific and clinical interest in sports medicine and sports cardiology medical communities because of their potential to trigger sudden cardiac death (SCD) in athletes. Exercise stress testing represent the first instrumental assessment to evaluate electrocardiographic changes during effort. Coronary computed tomography angiography (CCTA) is an advanced accurate noninvasive imaging modality for excluding CAD and abnormalities of origin and course of coronary vessels. The aim of this study is to investigate with CCTA the clinical significance of ST depression suggestive for myocardial ischemia during exercise stress testing in athletes and to determine the prevalence of CAD and/or CCAs.

METHODS

Sixty-five consecutive athletes showing electrocardiographic findings positive or equivocal for myocardial ischemia on exercise stress testing during pre-participation screening were investigated with CCTA.

RESULTS

Among the 65 athletes investigated, 36 showed Myocardial Bridge (MB), one showed an anomalous coronary origin and seven showed CAD. Among 36 athletes with MB, 4 were associated with mild coronary artery stenosis. Three athletes with CAD needed percutaneous transluminal coronary angioplasty or coronary artery bypass surgery.

CONCLUSIONS

In competitive athletes even with excellent workload capacities, in absence of cardiomyopathy, the presence of ischemic electrocardiographic abnormalities could be mainly determined by a coronary congenital or acquired pathology. In this population CCTA is a useful imaging modality of choice for the risk stratification and for the diagnostic process, to allow eligible athletes to compete and to follow-up subjects requiring medical surveillance.

Sudden Cardiac Arrest during Participation in Competitive Sports

BACKGROUND

The incidence of sudden cardiac arrest during participation in sports activities remains unknown. Preparticipation screening programs aimed at preventing sudden cardiac arrest during sports activities are thought to be able to identify at-risk athletes; however, the efficacy of these programs remains controversial. We sought to identify all sudden cardiac arrests that occurred during participation in sports activities within a specific region of Canada and to determine their causes.

METHODS

In this retrospective study, we used the Rescu Epistry cardiac arrest database (which contains records of every cardiac arrest attended by paramedics in the network region) to identify all out-of-hospital cardiac arrests that occurred from 2009 through 2014 in persons 12 to 45 years of age during participation in a sport. Cases were adjudicated as sudden cardiac arrest (i.e., having a cardiac cause) or as an event resulting from a noncardiac cause, on the basis of records from multiple sources, including ambulance call reports, autopsy reports, in-hospital data, and records of direct interviews with patients or family members.

RESULTS

Over the course of 18.5 million person-years of observation, 74 sudden cardiac arrests occurred during participation in a sport; of these, 16 occurred during competitive sports and 58 occurred during noncompetitive sports. The incidence of sudden cardiac arrest during competitive sports was 0.76 cases per 100,000 athlete-years, with 43.8% of the athletes surviving until they were discharged from the hospital. Among the competitive athletes, two deaths were attributed to hypertrophic cardiomyopathy and none to arrhythmogenic right ventricular cardiomyopathy. Three cases of sudden cardiac arrest that occurred during participation in competitive sports were determined to have been potentially identifiable if the athletes had undergone preparticipation screening.

CONCLUSIONS

In our study involving persons who had out-of-hospital cardiac arrest, the incidence of sudden cardiac arrest during participation in competitive sports was 0.76 cases per 100,000 athlete-years. The occurrence of sudden cardiac arrest due to structural heart disease was uncommon during participation in competitive sports. (Funded by the National Heart, Lung, and Blood Institute and others.).

[Sudden cardiac death and anomalous connections of the coronary arteries: What is known and what is unknown?]

Some anomalous connections of the coronary arteries may be associated with a risk of sudden cardiac death. In opposite with others cardiac diseases at risk of sudden cardiac death, the relationship between these congenital abnormalities and the risk of sudden cardiac death are not well understood. A correction of the anomaly is generally indicated after an aborted sudden cardiac death. Primary prevention strategy after the discovery of an anomaly at risk is debated. Even if the absolute risk of sudden death is very low, a pre-participation screening in young athletes may be discussed due to a non-rare incidence.

An IoT-Based Computational Framework for Healthcare Monitoring in Mobile Environments

The new Internet of Things paradigm allows for small devices with sensing, processing and communication capabilities to be designed, which enable the development of sensors, embedded devices and other ‘things’ ready to understand the environment. In this paper, a distributed framework based on the internet of things paradigm is proposed for monitoring human biomedical signals in activities involving physical exertion. The main advantages and novelties of the proposed system is the flexibility in computing the health application by using resources from available devices inside the body area network of the user. This proposed framework can be applied to other mobile environments, especially those where intensive data acquisition and high processing needs take place. Finally, we present a case study in order to validate our proposal that consists in monitoring footballers’ heart rates during a football match. The real-time data acquired by these devices presents a clear social objective of being able to predict not only situations of sudden death but also possible injuries.

Higher survival rates in exercise-related out-of-hospital cardiac arrests, compared to non-exercise-related - a study from the Swedish Register of Cardiopulmonary Resuscitation

Background Despite the positive effects of physical activity, the risk of sudden cardiac arrest is transiently increased during and immediately after exercise. The purpose of this study was to assess the incidence of exercise-related out-of-hospital cardiac arrest in the general population and to compare characteristics and prognosis of these cardiac arrests with non-exercise-related out-of-hospital cardiac arrests. Methods Data from all cases of treated out-of-hospital cardiac arrest outside of home reported to the Swedish Register of Cardiopulmonary Resuscitation from 2011-2015 in three counties of Sweden were investigated (population 2.1 m). This registry captures almost 100% of all out-of-hospital cardiac arrests in Sweden. Results Of 1825 out-of hospital cardiac arrests, 137 (7.5%) were exercise-related, resulting in an incidence of 1.2 per 100,000 person-years. The 30-day survival rate was significantly higher among exercise-related out-of hospital cardiac arrests compared to non-exercise-related out-of-hospital cardiac arrests (54.3 % vs 19.4%, p < 0.0001). Patients suffering an exercise-related out-of-hospital cardiac arrest were on average 10 years younger than those who had a non-exercise-related out-of-hospital cardiac arrest, 56.4 years compared to 67.2 years. Exercise-related out-of-hospital cardiac arrests were more often witnessed (89.4% vs 78.6%, p = 0.002), had higher rates of bystander cardiopulmonary resuscitation (80.3% vs 61.0%, p < 0.0001) and were more frequently connected to an automated external defibrillator (20.4% vs 4.6%, p < 0.0001). Conclusions Cardiac arrests that occur in relation to exercise have a significantly better prognosis and outcome than non-exercise-related cardiac arrests. This may be explained by favourable circumstances but may also reflect that these persons experience a sudden cardiac arrest at a lower degree of coronary artery disease, due to their younger age and to exercise being a trigger.

[Sudden cardiac death: A better understanting for a better prevention]

Sudden cardiac death is defined as a natural and unexpected death, in a previous apparently healthy individual. It represents a major public health issue, with up to 50% of the cardiovascular mortality. Using data from the Paris Sudden Death Expertise Centre registry, this article summarises the main cardiovascular abnormalities associated with sudden cardiac death, the different preventives approaches, and provides a systematic diagnostic approach.

Cost Implications of Using Different ECG Criteria for Screening Young Athletes in the United Kingdom

BACKGROUND

High false-positive rates and cost of additional investigations are an obstacle to electrocardiographic (ECG) screening of young athletes for cardiac disease. However, ECG screening costs have never been systematically assessed in a large cohort of athletes.

OBJECTIVE

This study investigated the costs of ECG screening in athletes according to the 2010 European Society of Cardiology (ESC) recommendations and the Seattle and refined interpretation criteria.

METHODS

Between 2011 and 2014, 4,925 previously unscreened athletes aged 14 to 35 years were prospectively evaluated with history, physical examination, and ECG (interpreted with the 2010 ESC recommendations). Athletes with abnormal results underwent secondary investigations, the costs of which were based on U.K. National Health Service Tariffs. The impact on cost after applying the Seattle and refined criteria was evaluated retrospectively.

RESULTS

Overall, 1,072 (21.8%) athletes had an abnormal ECG on the basis of 2010 ESC recommendations; 11.2% required echocardiography, 1.7% exercise stress test, 1.2% Holter, 1.2% cardiac magnetic resonance imaging, and 0.4% other tests. The Seattle and refined criteria reduced the number of positive ECGs to 6.0% and 4.3%, respectively. Fifteen (0.3%) athletes were diagnosed with potentially serious cardiac disease using all 3 criteria. The overall cost of de novo screening using 2010 ESC recommendations was $539,888 ($110 per athlete and $35,993 per serious diagnosis). The Seattle and refined criteria reduced the cost to $92 and $87 per athlete screened and $30,251 and $28,510 per serious diagnosis, respectively.

CONCLUSIONS

Contemporary ECG interpretation criteria decrease costs for de novo screening of athletes, which may be cost permissive for some sporting organizations.

Exercise-Related Out-of-Hospital Cardiac Arrest Among the General Population in the Era of Public-Access Defibrillation: A Population-Based Observation in Japan

BACKGROUND

Exercise can trigger sudden cardiac arrest. Early initiation of cardiopulmonary resuscitation and automated external defibrillator use by laypersons could maximize the survival rate following exercise-related out-of-hospital cardiac arrest (OHCA).

METHODS AND RESULTS

OHCA data between 2005 and 2012 were obtained from a prospective population-based OHCA registry in Osaka Prefecture. Patients with OHCA of presumed cardiac origin and occurring before emergency medical service personnel arrival were included. The incidence trends of exercise-related OHCA over the 8-year study period were assessed. Among patients with bystander-witnessed, exercise-related OHCA, the trends in the initiation of bystander cardiopulmonary resuscitation, public-access defibrillation, and outcome were evaluated. The primary outcome was 1-month survival with favorable neurological outcome, defined as cerebral performance category 1 or 2. During the study period, 0.7% of OHCAs of cardiac origin (222/31 030) were exercise related. The incidence of exercise-related OHCA increased from 1.8 (per million population per year) in 2005 to 4.3 in 2012. Of these, 83.8% (186/222) were witnessed by bystanders. Among the patients with bystander-witnessed, exercise-related OHCA, the proportion that received bystander cardiopulmonary resuscitation (50.0% in 2005 and 86.2% in 2012) and public-access defibrillation (7.1% in 2005 and 62.1% in 2012) significantly increased during the study period. Furthermore, the rate of 1-month survival with favorable neurological outcome among these patients significantly improved (from 28.6% in 2005 to 58.6% in 2012).

CONCLUSIONS

The incidence rate of exercise-related OHCA was low in the study population. The increase in bystander cardiopulmonary resuscitation and public-access defibrillation rates were associated with improved outcome among patients with bystander-witnessed, exercise-related OHCA.

Acute effect of intermittent and continuous aerobic exercise on release of cardiac troponin T in sedentary men

BACKGROUND

Studies have shown that acute exercise can increase serum concentrations of cardiac biomarkers, including cardiac troponin T (cTnT). We investigated the acute effects of intermittent (IE) and continuous (CE) exercise at the same cardiac workload on myocardial necrosis biomarkers in sedentary men.

METHODS

Eleven sedentary healthy men aged 22.3±1.9years completed the study. The subjects were divided into two groups and performed, in random order, IE (intensity alternating between 50% (2min) and 80% (1min) HRreserve) or CE (60% HRreserve). The study was designed as a single-blinded randomised crossover trial performed on two distinct experimental days separated by a 1-week washout period. Each session consisted of 40min of aerobic exercise, either IE or CE, on a treadmill. Blood samples were taken before (PRE), immediately after (POST) and 1h after (POST-1) each exercise session.

RESULTS

hs-cTnT significantly increased immediately after exercise in both protocols and remained elevated at POST-1 (P<0.05). There was no significant difference between POST and POST-1 values(P>0.05). Neither CE nor IE caused any significant change in CK-MB (P>0.05). The results also showed that HR and RPP increased significantly following both exercise protocols (P=0.001).

CONCLUSIONS

In summary, both CE and IE results in increased serum concentrations of hs-cTnT in sedentary men. However, this increase does not seem to be caused by the irreversible death of cardiomyocytes. CE resulted in a greater hs-cTnT concentration than IE.

The forensic pathological analysis of sport-related sudden cardiac death in Southern China

Studies regarding sport-related sudden cardiac death (SCD) mainly focus on competitive athletes; similar data are rare in the general population, especially in China. We conducted a retrospective study (from September 1998 to August 2013) to investigate the aetiological distribution and epidemiological features of sport-related SCD in Southern China. Selections of cases are based on details, and two subgroups were established: one was the sport-related SCD group, and the other was the disease-free accident victims group which was matched with the sport-related SCD group in gender, age and year of death. Among the 3770 sudden-death cases, 1656 cases were SCD cases. A total of 65 cases (57 males) out of 1 656 SCD cases were sport-related. The age range of the 65 sport-related SCD cases was from 12 to 68 years old with a mean (35.92 ± 14.23) years old. Only two of these cases were competitive athletes. The most common circumstances of the 65 sport-related SCD cases were heavy physical labour (46.15%) and running (30.77%). The three leading forensic diagnoses were the coronary atherosclerotic disease (CAD, 28 cases), cardiomyopathy (CM, 14 cases) and sudden unexplained death (7 cases). CM was the most common forensic diagnosis in those ≤35 years old, while CAD was the most common one in those >35 years old. Left anterior descending in which atherosclerotic plaques was most commonly found was the principal artery branch associated with sport-related SCD. There was a statistically significant difference in the weight of hearts between the 65 sport-related SCD cases and 65 diseases-free accidental cases. This study highlights the need to attract public attention to sport-related SCD and to issue a prevention strategy to the public, and to make the SCD-related genetic sequencing a routine tool in both forensic pathological examination and clinic screening.

Out-of-hospital cardiac arrests during exercise among urban inhabitants in Japan: Insights from a population-based registry of Osaka City

BACKGROUND

The patient characteristics, pre-hospital interventions, and outcomes of out-of-hospital cardiac arrests (OHCA) occurring during exercise, have not been sufficiently investigated among the general population.

METHODS

OHCA data from 2009 to 2015 were obtained from the population-based OHCA registry in Osaka City, Japan. Patients who suffered OHCA, which occurred during exercise before the arrival of emergency medical service personnel, were included. The primary endpoint was one-month survival with a favourable neurological outcome after OHCA, defined using the Glasgow-Pittsburgh cerebral performance category scale 1 or 2.

RESULTS

During the 7-year study period, 16,278 OHCAs were observed, and 52 (0.3%) occurred during exercise (male, n=41 [79%]; median age, 62 years). These incidents occurred mainly during running activities (n=14), followed by swimming (n=8), dance/social dance (n=6), tennis (n=4), and weight training (n=3). Within these exercise-related OHCAs, 47 (90%) were of cardiac origin, 45 (87%) were bystander-witnessed cardiac arrests, 49 (94%) received bystander-initiated cardiopulmonary resuscitation, and 30 (57%) received public-access defibrillation (PAD). Overall, 56% (29/52) had one-month survival with a favourable neurological outcome after OHCA, which was significantly higher among OHCAs of cardiac origin with PAD (77%, 23/30) than among those of cardiac origin without PAD (35%, 6/17) and among those of non-cardiac origin (0%, 0/5) (p<0.001).

CONCLUSION

In Osaka, OHCAs during exercise represented a small subset of the overall OHCA burden, but occurred during a wide variety of exercise activities. Patients with OHCA of cardiac origin had a good prognosis, and PAD played an important role in improving patient outcomes.

[Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice]

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

[Sports in children with congenital heart diseases]

The practice of physical activity is one of the essential elements for health in general but also for the well-being and the quality of life. It is highly desirable to encourage physical activities in children with congenital heart diseases, taking into account all the benefits associated with this practice (quality of life, life expectancy) and this especially since these children often have limited capacity (due to their heart disease but also often by relative deconditioning). While there is a transient increase in risk of cardiac complications during intense activity, it would nevertheless be inappropriate to contra-indicate physical activities considering the well-known benefits in the medium and long term. The risks associated with the practice of physical activity must be assessed, on one hand, in terms of the severity of the heart disease, and on the other hand, on the nature and intensity of the activity. The stress test is here an essential tool because it helps to assess the physical capacity and cardiorespiratory adaptations to exercise. The international recommendations for competitive sports generally give an appropriate advice for a specific situation but the practice of moderate activity or leisure sports which are highly desirable should not be neglected and be strongly encouraged.

High physical fitness is associated with reduction in basal- and exercise-induced inflammation

C-reactive protein (CRP) increases after strenuous exercise. It has been a concern that prolonged strenuous exercise may be harmful and induce a deleterious inflammatory response. The purpose of this study was to (a) assess and quantify the magnitude of CRP response following an endurance cycling competition in healthy middle-aged recreational cyclists. (b) Identify important determinants of this response. (c) Identify the relationship between CRP, myocardial damage (cardiac Troponin I (cTnI)), and myocardial strain (B-type natriuretic peptide [BNP]). (d) Identify the relationship between CRP and clinical events, defined as utilization of healthcare services or self-reported unusual discomfort. Race time was used as a measure of physical fitness. A total of 97 individuals (43±10 years of age, 74 [76%] males) were assessed prior to and 0, 3, and 24 hours following the 91-km mountain bike race "Nordsjørittet" (Sandnes, Norway, June 2013). There was a highly significant increase in CRP from baseline to 24 hours (0.9 (0.5-1.8) mg/L vs. 11.6 (6.0-17.5) mg/L (median[IQR]), P<.001), with no correlation of CRP to cTnI and BNP at any time-point. CRP was strongly correlated to race time at baseline (r=.38, P<.001) and at 24 hours following the race (r=.43, P<.001), In multivariate models, race time was an independent predictor of CRP both at baseline and at 24 hours (P<.01). There was no relationship between CRP levels and clinical events. In conclusion, high physical fitness was associated with reduction in both basal- and exercise-induced CRP. No adverse relationship was found between high intensity physical exercise, CRP levels, and outcomes.

Sudden cardiac death during first-time jogging

With increased interest in fitness and health care, jogging has become more popular as an exercise to promote health. However, sudden cardiac death during sports or exercise has also been reported. Some apparently healthy elderly individuals take up sports for both recreation and health improvement based only on completion of a questionnaire, without undergoing medical evaluation. We report the case of a 66-year-old Japanese man who suddenly died of acute ischemic heart disease during first-time jogging. He collapsed an hour after starting. A trainer promptly started cardiopulmonary resuscitation. An automated external defibrillator (AED) was applied, and defibrillation was attempted once by bystanders. However, he remained in cardiopulmonary arrest until he reached the emergency department, where he was pronounced dead. The autopsy found concentric hypertrophy of the left ventricular wall without fibrosis or degeneration, atherosclerotic changes in the coronary arteries, and severe lung congestion. We diagnosed death from acute myocardial ischemia. We suspect that many healthy elderly individuals have provoked a heart attack by prematurely attempting moderate or vigorous exercise, as in this case. The elderly require comprehensive medical assessment before exercise can be started. Moreover, this case shows that an AED is not always helpful. J. Med. Invest. 64: 184-186, February, 2017.

[Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice]

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

No psychological distress in sportsmen aged 45 years and older after cardiovascular screening, including cardiac CT: The Measuring Athlete's Risk of Cardiovascular events (MARC) study

Background

Psychological distress caused by cardiovascular pre-participation screening (PPS) may be a reason not to implement a PPS program. We assessed the psychological impact of PPS, including cardiac computed tomography (CT), in 318 asymptomatic sportsmen aged ≥45 years.

Methods

Coronary artery disease (CAD) was defined as a coronary artery calcium score ≥100 Agatson units and/or ≥50% luminal stenosis on contrast-enhanced cardiac CT. Psychological impact was measured with the Impact of Event Scale (IES) (seven items) on a six-point scale (grade 0–5). A sum score ≥19 indicates clinically relevant psychological distress. A Likert scale was used to assess overall experiences and impact on sports and lifestyle.

Results

A total of 275 participants (86.5% response rate, 95% CI 83–90%) with a mean age of 54.5 ± 6.4 years completed the questionnaires, 48 (17.5%, 95% CI 13–22%) of whom had CAD. The median IES score was 1 (IQR 0–2, [0–23]). IES was slightly higher in those with CAD (mean rank 175 vs. 130, p < 0.001). One participant (with CAD) experienced clinically relevant psychological distress (IES = 23). Participants reported numerous benefits, including feeling safer exercising (58.6%, 95% CI 53–65%) and positive lifestyle changes, especially in those with CAD (17.2 vs. 52.1%, p < 0.001). The majority were satisfied with their participation (93.8%, 95% CI 91–97%).

Conclusion

Cardiovascular PPS, including cardiac CT, causes no relevant psychological distress in older sportsmen. Psychological distress should not be a reason to forego screening in sportsmen.

Electronic supplementary material

The online version of this article (doi: 10.1007/s12471-017-0948-5) contains supplementary material, which is available to authorized users.

Incidence and Etiology of Sudden Cardiac Death: New Updates for Athletic Departments

CONTEXT

Sudden cardiac death (SCD) in a young athlete is a tragic event and is the leading medical cause of death in this population. The precise incidence of SCD in young athletes has been subject of debate, with studies reporting drastically different rates (1:917,000 athlete-years (AYs) to 1:3000 AYs) depending on the methodological design of the investigation or the targeted population.

EVIDENCE ACQUISITION

A literature search was performed in PubMed using the terms: incidence, sudden cardiac death, sudden death, sudden cardiac arrest, etiology, pathology, registry, athlete, young, children, and adolescents. Articles were reviewed for relevance and included if they contained information on the incidence of SCD in athletes or young persons up to the age of 35 years.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 5.

RESULTS

Studies of high quality and rigor consistently yield an incidence of 1:50,000 AYs in college athletes and between 1:50,000 and 1:80,000 AYs for high school athletes, with certain subgroups that appear to be at particularly high risk, including the following: men, basketball players, and African Americans. Initial reports suggest that the most common cause of SCD is hypertrophic cardiomyopathy (HCM). However, more comprehensive investigations in the United States and international populations-athletes, nonathletes, and military-support that the most common finding on autopsy in young individuals with SCD is actually a structurally normal heart (autopsy-negative sudden unexplained death).

CONCLUSION

SCD is the leading cause of death in athletes during exercise and usually results from intrinsic cardiac conditions that are triggered by the physiologic demands of vigorous exercise. Current rates of SCD appear to be at least 4 to 5 times higher than previously estimated, with men, African Americans, and male basketball players being at greatest risk. Emerging data suggest that the leading finding associated with SCD in athletes is actually a structurally normal heart (autopsy-negative sudden unexplained death).

Primary prevention of cardiovascular disease: A review of contemporary guidance and literature

Cardiovascular disease is a significant and ever-growing problem in the United Kingdom, accounting for nearly one-third of all deaths and leading to significant morbidity. It is also of particular and pressing interest as developing countries experience a change in lifestyle which introduces novel risk factors for cardiovascular disease, leading to a boom in cardiovascular disease risk throughout the developing world. The burden of cardiovascular disease can be ameliorated by careful risk reduction and, as such, primary prevention is an important priority for all developers of health policy. Strong consensus exists between international guidelines regarding the necessity of smoking cessation, weight optimisation and the importance of exercise, whilst guidelines vary slightly in their approach to hypertension and considerably regarding their approach to optimal lipid profile which remains a contentious issue. Previously fashionable ideas such as the polypill appear devoid of in-vivo efficacy, but there remain areas of future interest such as the benefit of serum urate reduction and utility of reduction of homocysteine levels.

[Spanish adaptation of the 2016 European Guidelines on cardiovascular disease prevention in clinical practice]

The VI European Guidelines for Cardiovascular Prevention recommend combining population and high-risk strategies with lifestyle changes as a cornerstone of prevention, and propose the SCORE function to quantify cardiovascular risk. The guidelines highlight disease specific interventions, and conditions as women, young people and ethnic minorities. Screening for subclinical atherosclerosis with noninvasive imaging techniques is not recommended. The guidelines distinguish four risk levels (very high, high, moderate and low) with therapeutic objectives for lipid control according to risk. Diabetes mellitus confers a high risk, except for subjects with type 2 diabetes with less than <10 years of evolution, without other risk factors or complications, or type 1 diabetes of short evolution without complications. The decision to start pharmacological treatment of arterial hypertension will depend on the blood pressure level and the cardiovascular risk, taking into account the lesion of target organs. The guidelines don't recommend antiplatelet drugs in primary prevention because of the increased bleeding risk. The low adherence to the medication requires simplified therapeutic regimes and to identify and combat its causes. The guidelines highlight the responsibility of health professionals to take an active role in advocating evidence-based interventions at the population level, and propose effective interventions, at individual and population level, to promote a healthy diet, the practice of physical activity, the cessation of smoking and the protection against alcohol abuse.

[Sudden cardiac death: Are women different?]

Sudden cardiac death is a major public health problem with around 40,000 cases per year in France. Epidemiological, clinical and prognostic differences according to gender have been described in most cardiovascular diseases, including sudden cardiac death. In this article, we will review gender differences in sudden cardiac death incidence, circumstance of occurrence, management, and prognosis.