American College of Sports Medicine and American Heart Association joint position statement: automated external defibrillators in health/fitness facilities

Resistance Training for Older Adults: Position Statement From the National Strength and Conditioning Association

Fragala, MS, Cadore, EL, Dorgo, S, Izquierdo, M, Kraemer, WJ, Peterson, MD, and Ryan, ED. Resistance training for older adults: position statement from the national strength and conditioning association. J Strength Cond Res 33(8): 2019-2052, 2019-Aging, even in the absence of chronic disease, is associated with a variety of biological changes that can contribute to decreases in skeletal muscle mass, strength, and function. Such losses decrease physiologic resilience and increase vulnerability to catastrophic events. As such, strategies for both prevention and treatment are necessary for the health and well-being of older adults. The purpose of this Position Statement is to provide an overview of the current and relevant literature and provide evidence-based recommendations for resistance training for older adults. As presented in this Position Statement, current research has demonstrated that countering muscle disuse through resistance training is a powerful intervention to combat the loss of muscle strength and muscle mass, physiological vulnerability, and their debilitating consequences on physical functioning, mobility, independence, chronic disease management, psychological well-being, quality of life, and healthy life expectancy. This Position Statement provides evidence to support recommendations for successful resistance training in older adults related to 4 parts: (a) program design variables, (b) physiological adaptations, (c) functional benefits, and (d) considerations for frailty, sarcopenia, and other chronic conditions. The goal of this Position Statement is to a) help foster a more unified and holistic approach to resistance training for older adults, b) promote the health and functional benefits of resistance training for older adults, and c) prevent or minimize fears and other barriers to implementation of resistance training programs for older adults.

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.

Survival from sports-related sudden cardiac arrest: In sports facilities versus outside of sports facilities

BACKGROUND

We sought to evaluate frequency, characteristics, and outcomes of sudden cardiac arrest (SCA) during sports activities according to the location of occurrence (in sports facilities vs those occurring outside of sports facilities).

METHODS AND RESULTS

This is an observational 5-year prospective national French survey of subjects 10 to 75 years old presenting with SCA during sports (2005-2010), in 60 French administrative regions (covering a population of 35 million people). Of the 820 SCA during sports, 426 SCAs (52%) occurred in sports facilities. Overall, a substantially higher survival rate at hospital discharge was observed among SCA in sports facilities (22.8%, 95% CI 18.8-26.8) compared to those occurring outside (8.0%, 95% CI 5.3-10.7) (P < .0001). Patients with SCA in sports facilities were younger (42.1 vs 51.3 years, P < .0001) and less frequently had known cardiovascular diseases (P < .0001). The events were more often witnessed (99.8% vs 84.9%, 0.0001), and bystander cardiopulmonary resuscitation was more frequently initiated (35.4% vs 25.9%, P = .003). Delays of intervention were significantly shorter when SCA occurred in sports facilities (9.3 vs 13.6, P=0.03), and the proportion of initially shockable rhythm was higher (58.8% vs 33.1%, P < .0001). Better survival in sports facilities was mainly explained by concomitant circumstances of occurrence (adjusted odds ratio 1.48, 95% CI 0.88-2.49, P = .134).

CONCLUSIONS

Sports-related SCA is not a homogeneous entity. The 3-fold higher survival rate reported among sports-related SCA is mainly due to cases that occur in sports facilities, whereas SCA during sports occurring outside of sports facilities has the usual very low rate of survival.

Sudden cardiac arrest during sports activity in middle age

BACKGROUND

Sports-associated sudden cardiac arrests (SCAs) occur mostly during middle age. We sought to determine the burden, characteristics, and outcomes of SCA during sports among middle-aged residents of a large US community.

METHODS AND RESULTS

Patients with SCA who were 35 to 65 years of age were identified in a large, prospective, population-based study (2002-2013), with systematic and comprehensive assessment of their lifetime medical history. Of the 1247 SCA cases, 63 (5%) occurred during sports activities at a mean age of 51.1±8.8 years, yielding an incidence of 21.7 (95% confidence interval, 8.1-35.4) per 1 million per year. The incidence varied significantly by sex, with a higher incidence among men (relative risk, 18.68; 95% confidence interval, 2.50-139.56) for sports SCAs compared with all other SCAs (relative risk 2.58; 95% confidence interval, 2.12-3.13). Sports SCA was also more likely to be a witnessed event (87% versus 53%; P<0.001) with cardiopulmonary resuscitation (44% versus 25%; P=0.001) and ventricular fibrillation (84% versus 51%; P<0.0001). Survival to hospital discharge was higher for sports-associated SCA (23.2% versus 13.6%; P=0.04). Sports SCA cases presented with known preexisting cardiac disease in 16% and ≥1 cardiovascular risk factors in 56%, and overall, 36% of cases had typical cardiovascular symptoms during the week preceding the SCA.

CONCLUSIONS

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

Outcomes of out-of-hospital cardiac arrest by public location in the public-access defibrillation era

BACKGROUND

The strategy to place public-access automated external defibrillators (AEDs) has not yet been established in real settings.

METHODS AND RESULTS

This, prospective, population-based observational study in Osaka, Japan, included consecutive out-of-hospital cardiac arrest (OHCA) patients with resuscitation attempts during 7 years, from January 2005 through December 2011. The trends in the proportion of public-access AED use and 1-month survival with neurologically favorable outcome were evaluated by location. Factors associated with neurologically favorable outcome (defined as cerebral performance category 1 or 2) after ventricular fibrillation were also assessed using multiple logistic regression analysis. A total of 9453 bystander-witnessed OHCAs of cardiac origin were documented and 894 (9.5%) of them occurred at public places. The proportion of public-access AED use significantly increased from 0.0% (0/20) in 2005 to 41.2% (7/17) in 2011 at railway stations and from 0.0% (0/7) to 56.5% (13/23) at sports facilities. Mean time from collapse to shock was 5.0 minutes among those who received shocks with public-access AEDs. The proportion of neurologically favorable outcome was 28.0% (33/118) at railway stations, 51.6% (48/93) at sports facilities, 23.3% (20/86) in public buildings, and 41.9% (13/31) in schools. In multivariate analysis, early defibrillation, irrespective of bystander or emergency medical service (EMS) personnel, was significantly associated with neurologically favorable outcome (adjusted odds ratio for 1-minute increment, 0.89; 95% confidence interval, 0.87 to 0.92).

CONCLUSIONS

This large, population-based OHCA registry demonstrated that earlier shock, irrespective the shock provider (bystander or EMS personnel), contributed to improving outcome, and a public-access defibrillation program was successfully implemented so that shocks with public-access AEDs were delivered to over 40% of bystander-witnessed OHCAs and time to shock was shortened in some kinds of public places.

Medical malpractice and the sports medicine clinician

More individuals are participating in athletics today than ever before. Physicians treating athletes confront unique diagnostic and treatment challenges and an increased risk of legal liability. The key areas regarding liability are preparticipation examinations, determination of eligibility, evaluation of significant on-field injuries, and information disclosure. The issues surrounding preparticipation physicals and determination of eligibility are closely linked. Physicians must be prepared to seek guidance from specialists, particularly when there are cardiac, spinal, or neurologic issues. Appropriate on-field evaluation of potential concussions, spinal injuries, and heat stroke are key areas of concern for the physician. Privacy issues have become more complex in the age of federal regulation. Physicians and all athletic staff should be aware of privacy laws and ensure proper consent documentation is obtained from all athletes or their parents. All athletic programs should develop a plan that details roles and procedures to be followed in a medical emergency. Sports caregivers must take affirmative steps that better protect their patients from harm and physicians from legal liability.

The role of automated external defibrillators in athletics

CONTEXT

Sudden cardiac arrest is the leading cause of death in young athletes. The purpose of this review is to summarize the role of automated external defibrillators and emergency planning for sudden cardiac arrest in the athletic setting.

EVIDENCE ACQUISITION

Relevant studies on automated external defibrillators, early defibrillation, and public-access defibrillation programs were reviewed. Recommendations from consensus guidelines and position statements applicable to automated external defibrillators in athletics were also considered.

RESULTS

Early defibrillation programs involving access to automated external defibrillators by targeted local responders have demonstrated a survival benefit for sudden cardiac arrest in many public and athletic settings.

CONCLUSION

Schools and organizations sponsoring athletic programs should implement automated external defibrillators as part of a comprehensive emergency action plan for sudden cardiac arrest. In a collapsed and unresponsive athlete, sudden cardiac arrest should be suspected and an automated external defibrillator applied as soon as possible, as decreasing the time interval to defibrillation is the most important priority to improve survival in sudden cardiac arrest.

The Risk in Exercise Training

Although exercise training is unequivocally of benefit relative to the risk of cardiovascular disease, there is a definable risk of complications during exercise training. In younger individuals, the risk is almost exclusively related to the presence of congenital abnormalities, whereas in older (∼40 years) individuals, the risk is largely related to atherosclerotic disease. In both groups, the risk of the underlying pathology leading to clinical presentation is increased by higher intensity exercise. In older individuals, preexercise screening is of potential benefit but is not generally well done. Exercise prescription should favor lower intensity exercise during the early weeks of an exercise program. Subjective methods, which do not rely on the results of an exercise test, including the Rating of Perceived Exertion and the Talk Test, are to be recommended because preliminary exercise testing is performed inconsistently. There are inadequate data regarding the spontaneous exercise training intensity in both healthy individuals and patients.

Automated external defibrillators in National Collegiate Athletic Association Division I Athletics

BACKGROUND

Sudden cardiac death is the leading cause of death in athletes. Evidence on current sudden cardiac death prevention through preparticipation history, physicals, and noninvasive cardiovascular diagnostics has demonstrated a low sensitivity for detection of athletes at high risk of sudden cardiac death. Data are lacking on automated external defibrillator programs specifically initiated to respond to rare dysrhythmia in younger, relatively low-risk populations.

METHODS

Surveys were mailed to the head athletic trainers of all National Collegiate Athletic Association Division I athletics programs listed in the National Athletic Trainers' Association directory. In all, 303 surveys were mailed; 186 departments (61%) responded.

RESULTS

Seventy-two percent (133) of responding National Collegiate Athletic Association Division I athletics programs have access to automated external defibrillator units; 54% (101) own their units. Proven medical benefit (55%), concern for liability (51%), and affordability (29%) ranked highest in frequency of reasons for automated external defibrillator purchase. Unit cost (odds ratio = 1.01; 95% confidence interval, 1.01-1.0), donated units (odds ratio = 1.92; confidence interval, 3.66-1.01), institution size (odds ratio =.0001; confidence interval, 1.3 E-4 to 2.2E-05), and proven medical benefit of automated external defibrillators (odds ratio = 24; confidence interval, 72-8.1) were the most significant predictors of departmental defibrillator ownership. Emergency medical service response time and sudden cardiac death event history were not significantly predictive of departmental defibrillator ownership. The majority of automated external defibrillator interventions occurred on nonathletes.

CONCLUSIONS

Many athletics medicine programs are obtaining automated external defibrillators without apparent criteria for determination of need. Usage and maintenance policies vary widely among departments with unit ownership or access. Programs need to approach the issue of unit acquisition and implementation with knowledge of the surrounding emergency medical service system, geography of their individual sports medicine facilities, numbers and relative risk of their athletes, and budgetary constraints.