The FIFA medical emergency bag and FIFA 11 steps to prevent sudden cardiac death: setting a global standard and promoting consistent football field emergency care

National Athletic Trainers' Association Position Statement: Emergency Action Plan Development and Implementation in Sport

OBJECTIVE

An emergency action plan (EAP) is a written document detailing the preparations and on-site emergency response of health care professionals and other stakeholders to medical emergencies in the prehospital setting. The EAP is developed to address any type of catastrophic injury response and should not be condition specific. The objective of this National Athletic Trainers' Association position statement is to provide evidence-based and consensus-based recommendations for developing and implementing an EAP for sports settings.

METHODS

These recommendations were developed by a multidisciplinary expert panel that performed (1) a comprehensive review of existing EAP evidence, (2) a modified Delphi process to define consensus recommendations, and (3) a strength of recommendation taxonomy determination for each recommendation.

RESULTS

An EAP is an essential tool designed to facilitate emergency preparedness and an efficient, coordinated emergency response during an athletic event. A comprehensive EAP should consider modes to optimize patient outcomes, the various stakeholders needed to develop the plan, the factors influencing effective implementation of the EAP, and the roles and responsibilities to ensure a structured response to a catastrophic injury.

CONCLUSIONS

These evidence-informed recommendations outline the necessary steps for emergency planning and provide considerations for the immediate management of patients with catastrophic injuries. Increasing knowledge and implementation of the EAP to manage patients with catastrophic injuries improves the overall response and decreases errors during an emergency.

FIFA Initiatives Improved Survival After Loss of Consciousness During Football Games

Loss of consciousness (LOC) during football games is associated with very high mortality rates. In order to address football medical emergencies, in 2013 FIFA implemented the "FIFA 11 steps to prevent sudden cardiac death" program and distributed the FIFA Medical Emergency Bag. The purpose of this work was to identify independent survival factors after LOC on the pitch and to investigate the effectiveness of the FIFA initiatives. An internet search was performed to identify football players suffering LOC on the pitch between 1990 and 2021. A total of 268 cases could be identified and were dichotomized according to the implementation date of the FIFA medical emergency bag. There was 55% mortality after LOC, while cardiogenic LOC was more often (82% vs. 20%) fatal than traumatic LOC. Mortality in developing countries was higher than in developed countries. From the year 2013 survival improved significantly for both traumatic and cardiogenic cases. The location of the LOC significantly influenced survival (OR: 0.20 and p<0.001). LOC on the football field is associated with increased mortality and requires separate monitoring based on a traumatic vs. non-traumatic cause. FIFA initiatives significantly reduced mortality after LOC but significant differences were identified between developed and developing countries.

The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions

Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.

The cardiac preparticipation sports evaluation

PURPOSE OF REVIEW

Sudden cardiac death (SCD) is the leading cause of death in young athletes during sports participation. Preparticipation cardiovascular screening aims to identify those at an increased risk of SCD. This review aims to provide a background of SCD in young athletes, to discuss the various screening recommendations of major medical societies, and to review recent evidence and current practice.

RECENT FINDINGS

Numerous studies have evaluated various preparticipation screening practices, particularly regarding the inclusion of ECG as part of an initial evaluation to identify conditions with an increased risk of SCD. Some analyses have shown ECG inclusion to provide increased screening sensitivity and specificity, though others have shown no benefit when compared with evaluation with history and physical examination alone. Furthermore, in countries for which more extensive screening protocols have been employed, postimplementation statistics have not shown a significant decrease in SCD.

SUMMARY

SCD in young athletes primarily results from underlying cardiac disease. Various preparticipation screening recommendations exist globally, with the common goal of decreasing the rates of SCD by identifying youth at risk during sports participation. Current guidelines in the United States support universal preparticipation evaluation using history and physical examination, with cardiology referral if abnormalities are identified.

FIFA football nurse - A task sharing approach in sports and exercise medicine practice in grassroots women's football in low- and middle- income settings. A study protocol for a cluster randomised controlled trial

Football (soccer) is a very popular team sport among African women and girls, with player numbers continuing to rise at all levels of the sport. Whereas the participation in football and associated injuries are on the rise, there are not enough sports and exercise medicine (SEM) personnel to attend to these women football players. While Africa may not currently have enough SEM trained medical doctors and/or physiotherapists, it has relatively higher numbers of other healthcare workers; for example, nurses, who lead healthcare services provision from community to tertiary levels. The primary objective of this study will be to compare sports medicine practices; injury prevention behaviours; injury risk parameters; incidence and prevalence of injuries and illnesses in teams with and without a Football Nurse during one competitive season in Malawi's Women's football league. This study will be a cluster randomised control trial will recruit 24 teams from the Women's Football League in Malawi, which will be randomised to either the intervention group or the control group. A cohort of 12 nurses will receive training in basic football medicine; after which they will be attached to a total of 12 women's football teams (intervention group) during one competitive season. The Football Nurses will be directly report to a physiotherapist or doctor in their district to whom they will refer serious injuries for investigations, or further management. The teams with Football Nurses will be compared to other teams that will not have Football Nurses. We expect to develop a low cost, sustainable and context relevant solution to manage the treatment gap of football injuries/illnesses in underserved communities such as women's football. Trial registration number: Pan African Clinical Trial Registry (PACTR202205481965514).

Sudden cardiac arrest in athletes and strategies to optimize preparedness

Sudden cardiac arrest (SCA) is the leading cause of death in young athletes. Despite efforts to improve preparedness for cardiac emergencies, the incidence of out-of-hospital cardiac arrests in athletes remains high, and bystander awareness and readiness for SCA support are inadequate. Initiatives such as designing an emergency action plan (EAP) and mandating training in cardiopulmonary resuscitation (CPR) and automated external defibrillator use (AED) for team members and personnel can contribute to improved survival rates in SCA cases. This review provides an overview of SCA in athletes, focusing on identifying populations at the highest risk and evaluating the effectiveness of different screening practices in detecting conditions that may lead to SCA. We summarize current practices and recommendations for improving the response to SCA events, and we highlight the need for ongoing efforts to optimize preparedness through the implementation of EAPs and the training of individuals in CPR and AED use. Additionally, we propose a call to action to increase awareness and training in EAP development, CPR, and AED use for team members and personnel. To improve outcomes of SCA cases in athletes, it is crucial to enhance bystander awareness and preparedness for cardiac emergencies. Implementing EAPs and providing training in CPR and AED use for team members and personnel are essential steps toward improving survival rates in SCA cases.

The International Criteria for Electrocardiogram Interpretation in Athletes: Common Pitfalls and Future Directions

Preparticipation cardiovascular screening (PPCS) in young athletes is performed to detect conditions associated with sudden cardiac death. Many medical societies and sports governing bodies support the addition of a 12-lead electrocardiogram (ECG) to the history and physical to improve PPCS sensitivity. The current standard for ECG interpretation in athletes, the International Criteria, was developed to distinguish physiologic from pathologic ECG findings in athletes. Although application of the International Criteria has reduced the PPCS false-positive rate, interpretative challenges and potential areas of improvement remain. This review provides an overview of common pitfalls and future directions for ECG interpretation in athletes.

Sudden Cardiac Arrest in Basketball and Soccer Stadiums, the Role of Automated External Defibrillators: A Review. For the BELTRAN Study (BaskEtbaLl and soccer sTadiums: Registry on Automatic exterNal defibrillators)

Sudden cardiac arrest (SCA) during sports events has a dramatic impact on stadium-goers and the public and is often associated with poor outcomes unless treated with an automated external defibrillator (AED). Despite this, stadiums vary in AED use. This review aims to identify the risks and incidences of SCA, and the use of AEDs in soccer and basketball stadiums. A narrative review of all relevant papers was conducted. Athletes across all sports face an SCA risk of 1:50,000 athlete-years, with the greatest risk of SCA in young male athletes (1:35,000 person-years) and black male athletes (1:18,000 person-years). Africa and South America have the poorest soccer SCA outcomes at 3% and 4% survival. AED use on-site improves survival greater than defibrillation by emergency services. Many stadiums do not have AEDs implemented into medical plans and the AEDs are often unrecognisable or are obstructed. Therefore, AEDs should be used on-site, use clear signalling, have certified trained personnel, and be incorporated into stadiums' medical plans.

Sudden death in young athletes: Is it preventable?

Sudden death in young athletes is a rare but always dramatic condition. Unlike all other rare diseases, the estimate of its real incidence is made complex not only because of the uncertain number of correctly identified cases (numerator) but also because of the uncertain estimation of the real number of the reference population, the athletes (denominator). New elements of complexity are also emerging with regard to prevention. The current two pillars of prevention are pre-participation screening (proactive strategy) and promoting use / access to the automated external defibrillator (reactive strategy). The standardization of procedures implemented over the past two decades for pre-participation screening can now allow us to assess the impact of this approach. The result is complex to evaluate. While screening may allow the identification of conditions potentially associated with SDA, and therefore the adoption of specific treatments, in about 0.4% of screened subjects, a single study investigated the yield in terms of mortality showing a positive predictive value of 4.7% with 25% sensitivity. Conversely, the reactive strategy appears considerably effective, due to the widespread use of the automated external defibrillators in sports facilities, calling for a homogeneous implementation worldwide. On a broader perspective, the vast attention devoted to SDA prevention in the world of sports represents a major driver for transfer of a reactive prevention strategy to the general population.

Masters Age Football And Cardiovascular Risk (MAFACARI)

BACKGROUND

Football (soccer) is popular among those of Masters age (≥35 years). Although regular exercise improves health, strenuous exercise causes a transient increase in cardiac risk.

AIM

The aim of this survey of Masters Age Footballers was to gain insight into cardiac risk factors, symptoms, and knowledge, attitudes and beliefs about myocardial infarction (MI), and support for prevention.

METHODS

A web-based survey using REDCap was completed by 153 amateur Masters footballers from A grade competition (n=24), B or lower grade (n=95) or social games (n=34) in Sydney, Australia.

RESULTS

Participants were aged 49.3±7.5 years and primarily male (92.2%), Caucasian (88.9%) and university educated (75.2%). Risk factors included hypercholesterolaemia (37.3%), hypertension (19.6%), smoker (7.8%), overweight (40.5%) or obese (13.1%). One fifth (21.6%) reported ≥1 potential cardiac symptom during activity in the prior year, for which one quarter (24.2%) sought medical attention. Knowledge of typical MI symptoms was high (>80%) but lower (<40%) for less typical symptoms. Half (49.6%) were unconfident to recognise MI in themselves. Half (49.0%) would remain on the field for 5-10 minutes with chest pain. Only 39.9% were aware that warning signs may precede MI by days. They overestimated survival from cardiac arrest (43%). Participants supported training in automatic external defibrillators (AED) and CPR (84%), AEDs at games (85%) and cardiac education (>70%).

CONCLUSIONS

Cardiac risk factors are common In Masters footballers, with one in five experiencing possible cardiac symptoms in the prior year. While gaps exist in knowledge and optimal responses, strong support exists for preventive measures. This article is protected by copyright. All rights reserved.

Pitch-side Acute Severe Pain Management Decisions in European Elite football

This is the first study on acute severe pain management involving sport and exercise medicine Doctors who are leaders in football medicine in their respective countries. An online survey was designed describing the management of acute severe pain in this expert cohort. The survey captured participant sex, age, years working in sports medicine, core specialty and use of clinical practice guidelines (CPGs). Finally, three clinical vignettes exploring the management of acute pain were presented. Forty-four senior team doctors across 55 European countries completed the survey. There were no consistent guidelines proposed, with 33 (75%) participants indicating they did not use any. Methoxyflurane was proposed by 14 (32%) and 13 (30%) participants for female anterior cruciate ligament rupture and male ankle fracture, respectively. Strong opioids were not used in 17 (39%) and 6 (14%) participants regarding female cruciate injuries and male fractures, respectively. Despite 75% of participants having paediatric life support training, eight (18%) participants expressed uncertainty administering medications in this population, and 15 (34%) would avoid using strong opioids altogether. There is a tendency to undertreat pain and avoid strong opioids for reasons including lack of monitoring equipment, anti-doping concerns and lack of comfort treating paediatric patients with opioids.

Immediate Bystander Cardiopulmonary Resuscitation to Sudden Cardiac Arrest During Sports is Associated with Improved Survival-a Video Analysis

Background

Sudden cardiac arrest (SCA) during sports can be the first symptom of yet undetected cardiovascular conditions. Immediate chest compressions and early defibrillation offer SCA victims the best chance of survival, which requires prompt bystander cardiopulmonary resuscitation (CPR).

Aims

To determine the effect of rapid bystander CPR to SCA during sports by searching for and analyzing videos of these SCA/SCD events from the internet.

Methods

We searched images.google.com, video.google.com, and YouTube.com, and included any camera-witnessed non-traumatic SCA during sports. The rapidity of starting bystander chest compressions and defibrillation was classified as < 3, 3–5, or > 5 min.

Results

We identified and included 29 victims of average age 27.6 ± 8.5 years. Twenty-eight were males, 23 performed at an elite level, and 18 participated in soccer. Bystander CPR < 3 min (7/29) or 3–5 min (1/29) and defibrillation < 3 min was associated with 100% survival. Not performing chest compressions and defibrillation was associated with death (14/29), and > 5 min delay of intervention with worse outcome (death 4/29, severe neurologic dysfunction 1/29).

Conclusions

Analysis of internet videos showed that immediate bystander CPR to non-traumatic SCA during sports was associated with improved survival. This suggests that immediate chest compressions and early defibrillation are crucially important in SCA during sport, as they are in other settings. Optimal use of both will most likely result in survival. Most videos showing recent events did not show an improvement in the proportion of athletes who received early resuscitation, suggesting that the problem of cardiac arrest during sports activity is poorly recognized.

Pre-participation Cardiovascular Screening in Young Competitive Athletes

Purpose of Review

The purpose of this review was to highlight the current recommendations, data, and limitations for methods of cardiovascular screening in athletes.

Recent Findings

While the history and physical (H&P) alone remains the cornerstone for preparticipation cardiovascular screening (PPCS) in athletes, the advent of modern electrocardiographic (ECG) screening criteria has drastically increased sensitivity and decreased false positive rates for screening. Advanced imaging techniques remain an important component of secondary testing after an athlete has an abnormal initial screening exam, however, the use of imaging for universal screening has not been rigorously tested to date. Current disqualification guidelines have now begun to emphasize shared decision making between the provider and athlete in situations of clinical equipoise.

Summary

All major medical and sporting societies recommend PPCS using a focused medical history and physical examination for all competitive athletes, but there remains controversy about the role of ECG and advanced imaging in PPCS. Future research should focus on the creation of a randomized trial that is powered for mortality that can truly assess the utility of PPCS in athletes.

FIFA Sudden Death Registry (FIFA-SDR): a prospective, observational study of sudden death in worldwide football from 2014 to 2018

OBJECTIVE

To investigate the underlying causes and regional patterns of sudden death in football (soccer) players worldwide to inform and improve existing screening and prevention measures.

METHODS

From 2014 to 2018 cases of sudden cardiac death (SCD), survived sudden cardiac arrest (SCA) and traumatic sudden death were recorded by media monitoring (Meltwater), a confidential web-based data platform and data synchronisation with existing national Sudden Death Registries (n=16). Inclusion criteria were met when sudden death occurred during football-specific activity or up to 1 hour afterwards. Death during other activities was excluded.

RESULTS

A total of 617 players (mean age 34±16 years, 96% men) with sudden death were reported from 67 countries; 142 players (23%) survived. A diagnosis by autopsy or definite medical reports was established in 211 cases (34%). The leading cause in players >35 years was coronary artery disease (76%) and in players ≤35 years was sudden unexplained death (SUD, 22%). In players ≤35 years the leading cause of SCD varied by region: cardiomyopathy in South America (42%), coronary artery anomaly in North America (33%) and SUD in Europe (26%). Traumatic sudden death including commotio cordis occurred infrequently (6%). Cardiopulmonary resuscitation (CPR) resulted in a survival rate of 85% with the use of an automated external defibrillator (AED) compared with 35% without.

CONCLUSIONS

Regional variation in SCD aetiology should be verified by expansion of national registries and uniform autopsy protocols. Immediate access to an AED at training and competition sites, as well as CPR training for players, coaches and staff members, is needed to improve survival from SCA.

Current controversies in pre-participation cardiovascular screening for young competitive athletes

INTRODUCTION

Pre-participation cardiovascular screening (PPCS) in athletes is recommended by numerous medical and sporting societies. While there is consensus that young athletes should be screened prior to participation in competitive sports, there are on-going debates regarding the true incidence of sudden cardiac death (SCD), the most frequent causes of SCD, and the optimal methods for PPCS.

AREAS COVERED

This review focuses on the current evidence for the incidence of SCD, causes of SCD, and the pros and cons of a history and physical exam (H&P) and electrocardiogram (ECG) in PPCS of young competitive athletes.

EXPERT OPINION

With significant controversy surrounding PPCS in athletes, a large-randomized trial powered for mortality is needed to assess the utility of PPCS and to define the optimal screening methods to detect cardiovascular diseases that may lead to SCD in competitive athletes. Until a trial of this caliber is created, controversy will remain and heterogeneity in care will exist. Future research should also define the optimal timing and frequency of PPCS given age-related penetrance of certain diseases, create evidence-based history questionnaires, continue to optimize ECG screening criteria, and create more learning modules for ECG interpretation in athletes.

A preliminary audit of medical and aid provision in English Rugby union clubs: compliance with Regulation 9

BACKGROUND

Governing bodies are largely responsible for the monitoring and management of risks associated with a safe playing environment, yet adherence to regulations is currently unknown. The aim of this study was to investigate and evaluate the current status of medical personnel, facilities, and equipment in Rugby Union clubs at regional level in England.

METHODS

A nationwide cross-sectional survey of 242 registered clubs was undertaken, where clubs were surveyed online on their current medical personnel, facilities, and equipment provision, according to regulation 9 of the Rugby Football Union (RFU).

RESULTS

Overall, 91 (45. 04%) surveys were returned from the successfully contacted recipients. Of the completed responses, only 23.61% (n = 17) were found to be compliant with regulations. Furthermore, 30.56% (n = 22) of clubs were unsure if their medical personnel had required qualifications; thus, compliance could not be determined. There was a significant correlation (p = -0.029, r = 0.295) between club level and numbers of practitioners. There was no significant correlation indicated between the number of practitioners/number of teams and number of practitioners/number of players. There were significant correlations found between club level and equipment score (p = 0.003, r = -0.410), club level and automated external defibrillator (AED) access (p = 0.002, r = -0.352) and practitioner level and AED access (p = 0.0001, r = 0.404). Follow-up, thematic analysis highlighted widespread club concern around funding/cost, awareness, availability of practitioners and AED training.

CONCLUSION

The proportion of clubs not adhering overall compliance with Regulation 9 of the RFU is concerning for player welfare, and an overhaul, nationally, is required.

Sudden cardiac arrest on the field of play: turning tragedy into a survivable event

Sudden cardiac arrest remains the leading cause of death in exercising athletes, and recent studies have shown that it occurs more frequently than historical estimates. While out-of-hospital cardiac arrest often proves fatal, advance preparation can improve outcomes and the chance of survival. First responders to a collapsed athlete on the field of play may include team medical personnel, coaches, other athletes, officials, venue staff, emergency medical services personnel, or lay bystanders. Prompt and accurate recognition of sudden cardiac arrest, a comprehensive and rehearsed emergency action plan, early cardiopulmonary resuscitation, and immediate access to and use of an automated external defibrillator are each pivotal links in the chain of survival. This review summarises the components of an effective emergency action plan, highlights the critical role of automated external defibrillators, and reviews the diagnosis and management of sudden cardiac arrest on the field of play.

Early recognition of sudden cardiac arrest in athletes during sports activity

INTRODUCTION

Sudden cardiac arrest (SCA) in athletes is an unexpected life-threatening event, which is often not recognised early and cardiopulmonary resuscitation (CPR) is not always initiated immediately. We describe key features to rapidly recognise non-traumatic SCA in athletes during sports activity.

METHODS

We reviewed videos and images of athletes suffering from non-traumatic SCA during sports activity. We searched Google images, Google videos and YouTube.com using the keywords 'sudden cardiac death athlete' and 'resuscitation athlete'. We analysed (1) the athlete's performance before syncope, (2) the athlete's performance at the start of syncope, (3) the position of the body, and (4) the athlete's facial expressions before CPR. We analysed our data by describing these four features to answer our research question.

RESULTS

We analysed the sequence of events in six well-known soccer players in whom a camera-witnessed non-traumatic SCA occurred during their athletic activity. All six athletes showed no changes before syncope. Four became unstable while standing and unexpectedly collapsed falling on their back. Two suddenly 'dropped dead' and fell face down. All six had their eyes wide open with a fixed gaze and fixed pupils.

CONCLUSIONS

Sudden unexpected loss of consciousness in an athlete in action and a fixed gaze eye position are key features of SCA. Immediate cardiac massage should follow. The described features to immediately recognise SCA in athletes during sports activity should be taught to everyone involved in athletic activity leading to earlier recognition of SCA followed by earlier CPR.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current Evidence, Knowledge Gaps, Recommendations and Future Directions

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for cardiovascular screening in athletes remains an issue of considerable debate. At the center of the controversy is the addition of a resting electrocardiogram (ECG) to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation cardiovascular screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcomes-based evidence at this time precludes AMSSM from endorsing any single or universal cardiovascular screening strategy for all athletes, including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate cardiovascular screening strategy unique to their athlete population, community needs, and resources. The decision to implement a cardiovascular screening program, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence-base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. AMSSM is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

AMSSM Position Statement on Cardiovascular Preparticipation Screening in Athletes: Current evidence, knowledge gaps, recommendations and future directions

Cardiovascular screening in young athletes is widely recommended and routinely performed prior to participation in competitive sports. While there is general agreement that early detection of cardiac conditions at risk for sudden cardiac arrest and death (SCA/D) is an important objective, the optimal strategy for cardiovascular screening in athletes remains an issue of considerable debate. At the centre of the controversy is the addition of a resting ECG to the standard preparticipation evaluation using history and physical examination. The American Medical Society for Sports Medicine (AMSSM) formed a task force to address the current evidence and knowledge gaps regarding preparticipation cardiovascular screening in athletes from the perspective of a primary care sports medicine physician. The absence of definitive outcome-based evidence at this time precludes AMSSM from endorsing any single or universal cardiovascular screening strategy for all athletes, including legislative mandates. This statement presents a new paradigm to assist the individual physician in assessing the most appropriate cardiovascular screening strategy unique to their athlete population, community needs and resources. The decision to implement a cardiovascular screening programme, with or without the addition of ECG, necessitates careful consideration of the risk of SCA/D in the targeted population and the availability of cardiology resources and infrastructure. Importantly, it is the individual physician's assessment in the context of an emerging evidence base that the chosen model for early detection of cardiac disorders in the specific population provides greater benefit than harm. AMSSM is committed to advancing evidenced-based research and educational initiatives that will validate and promote the most efficacious strategies to foster safe sport participation and reduce SCA/D in athletes.

Football injuries during the 2014 FIFA World Cup

Background

FIFA has surveyed match injuries in its tournaments since 1998.

Aim

To analyse the incidence and characteristics of match injuries incurred during the 2014 FIFA World Cup in comparison to previous FIFA World Cups.

Methods

The chief physicians of the participating teams reported all newly incurred injuries of their players after the match on a standardised report form. 124 (97%) forms were returned.

Results

A total of 104 injuries were reported, equivalent to an incidence of 1.68 injuries per match (95% CI 1.36 to 2.00). 64 (63.4%) injuries were caused by contact with another player. Thigh (26; 25%) and head (19; 18%) were the most frequently injured body parts. The most frequent diagnosis was thigh strain (n=18). Five concussions and three fractures to the head were reported. While most thigh strains (15/17; 88.2%) occurred without contact, almost all head injuries (18/19; 94.7%) were caused by contact. 0.97 injuries per match (95% CI 0.72 to 1.22) were expected to result in absence from training or match. Eight injuries were classified as severe. The incidence of match injuries in the 2014 FIFA World Cup was significantly lower than the average of the four preceding FIFA World Cups, both for all injuries (2.34; 95% CI 2.15 to 2.53) and time-loss injuries (1.51; 95% CI 1.37 to 1.65).

Conclusions

The overall incidence of injury during the FIFA World Cups decreased from 2002 to 2014 by 37%. A detailed analysis of the injury mechanism is recommended to further improve prevention strategies.

F-MARC: promoting the prevention and management of sudden cardiac arrest in football

Sudden cardiac death is the most common cause of unnatural death in football. To prevent and urgently manage sudden cardiac arrest on the football field-of-play, F-MARC (FIFA Medical and Research Centre) has been fully committed to a programme of research, education, standardisation and practical implementation. This strategy has detected football players at medical risk during mandatory precompetition medical assessments. Additionally, FIFA has (1) sponsored internationally accepted guidelines for the interpretation of an athlete's ECG, (2) developed field-of-play-specific protocols for the recognition, response, resuscitation and removal of a football player having sudden cardiac arrest and (3) introduced and distributed the FIFA medical emergency bag which has already resulted in the successful resuscitation of a football player who had a sudden cardiac arrest on the field-of-play. Recently FIFA, in association with the Institute of Sports and Preventive Medicine in Saarbrücken, Germany, established a worldwide Sudden Death Registry with a view to documenting fatal events on the football field-of-play. These activities by F-MARC are testimony to FIFA's continued commitment to minimising sudden cardiac arrest while playing football.

Echocardiography in the evaluation of athletes

Echocardiography is currently a widely available imaging technique that can provide useful data in the field of sports cardiology particularly in two areas: pre-participation screening and analysis of the cardiac adaptation induced by exercise.

The application of pre-participation screening and especially, the type and number of used diagnostic tests remains controversial. Echocardiography has shown though, higher sensitivity and specificity as compared to the ECG, following a protocol adapted to athletes focused on ruling out the causes of sudden death and the most common disorders in this population. It is still a subject of controversy the actual cost of adding it, but depending on the type of sport, echocardiography might be cost-effective if added in the first line of examination.

Regarding the evaluation of cardiac adaptation to training in athletes,  echocardiography has proved to be useful in the differential diagnosis of diseases that can cause sudden death, analysing both the left ventricle (hypertrophy cardiomyopathy, dilated cardiomyopathy, left ventricle non compaction) and the right ventricle (arrhythmogenic right ventricular cardiomyopathy).

The aim of this paper is to review the current knowledge and the clinical practical implications of it on the field of echocardiography when applied in sport cardiology areas.

Sudden Cardiac Death in Athletes

Physical activity confers substantial health benefits to healthy individuals and patients alike. Occasionally, however, exercise may act as a trigger for arrhythmic death in athletes who harbor an occult pathological substrate. The majority of sudden cardiac deaths (SCDs) in young athletes (≤35 years old) are secondary to inherited cardiac diseases, while ischaemic heart disease predominates in older athletes. In the absence of compulsory national or international registries of SCD in athletes, it is difficult to define the exact scale of the problem. In addition, the lack of post-mortem evaluation by pathologists with expertise in cardiac adaptation to exercise and inherited cardiac diseases casts doubt to the reliability of the reported causes. The proposed preventative strategies focus primarily on preventing deaths by cardiovascular evaluation of athletes and the use of automated external defibrillators in athletic venues. Cardiovascular screening of first-degree relatives, though often neglected, has the potential to avert further tragedies given the inherited nature of most conditions predisposing to SCD in the young. This article provides an overview of the epidemiology and causes of SCD in athletes and explores potential prevention strategies.

Sudden cardiac death in the soccer field: a retrospective study in young soccer players from 2000 to 2013

Soccer is the most popular sport in the world, with over 200 million active players. Sudden cardiac death (SCD) represents the most striking as well as the most common cause of death in the soccer field. Underlying cardiovascular pathologies predispose to life threatening ventricular arrhythmias and SCD in soccer players. Up to thousands to hundred thousands players might have an underlying condition that predisposes them for SCD. After several media striking SCD events in soccer players the Fédération Internationale de Football Association (FIFA) has made screening recommendations that are more thorough than the ones recommended for the American Heart Association and the European Society of Cardiology. We present a retrospective search through Internet databases that resulted in 54 soccer players with SCD events from 2000 until 2013. In this article, we will describe and discuss the conditions of those cases of SCD in order to provide more knowledge of the factors that may precipitate SCD in young soccer players.

Evaluation of a New Shirt-Based Electrocardiogram Device for Cardiac Screening in Soccer Players: Comparative Study With Treadmill Ergospirometry

Background

Prevention of cardiac events during competitive sports is fundamental. New technologies with remote monitoring systems integrated into clothing could facilitate the screening of heart disease. Our aim was to evaluate the feasibility of Nuubo system during a field stress test performed by soccer players, comparing results with treadmill ergospirometry as test reference.

Methods

Nineteen male professional soccer players (19.2 ± 1.6 years) were studied. Wireless electrocardiographic monitoring during a Yo-Yo intermittent recovery test level 1 in soccer field and subsequent analysis of arrhythmias were firstly performed. Subsequently, in a period no longer than 4 weeks, each player underwent cardiopulmonary exercise testing in hospital.

Results

During Yo-Yo test, electrocardiogram (ECG) signal was interpretable in 16 players (84.2%). In the other three players, ECG artifacts did not allow a proper analysis. Estimation of maximum oxygen consumption was comparable between two exercise tests (VO₂ max 53.3 ± 2.4 vs. 53.7 ± 3.0 mL/kg/min for Yo-Yo test and ergometry respectively; intra-class correlation coefficient 0.84 (0.63 - 0.93), P < 0.001). No arrhythmias were detected in any player during both tests.

Conclusions

The use of Nuubo’s technology allows an accurate single-lead electrocardiographic recording and estimation of reliable performance variables during exercise testing in field, and provides a new perspective to cardiac remote monitoring in collective sports.

Sudden cardiac death in athletes

A 'paradox of sport' is that in addition to the undisputed health benefits of physical activity, vigorous exertion may transiently increase the risk of acute cardiac events. In general, the risk of sudden cardiac death (SCD) approximately doubles during physical activity and is 2- to 3-fold higher in athletes compared to nonathletes. The incidence of SCD in young athletes is in fact very low, at around 1-3 per 100,000, but attracts much public attention. Variations in incidence figures may be explained by the methodology used for data collection and more importantly by differences between subpopulations of athletes. The incidence of SCD in older (≥ 35 years) athletes is higher and may be expected to rise, as more and older individuals take part in organized sports. SCD is often the first clinical manifestation of a potentially fatal underlying cardiovascular disorder and usually occurs in previously asymptomatic athletes. In the young (<35 years), SCD is mainly due to congenital/inherited cardiac abnormalities, whilst coronary artery disease (CAD) is the most common cause in older athletes. Cardiac screening including family/personal history, physical examination and resting electrocardiogram (ECG) may identify individuals at risk and has the potential to decrease the risk of SCD in young athletes. Screening including the ECG has a high sensitivity for underlying disease in young athletes, but the specificity needs to be improved, whereas the sensitivity of screening without the use of ECG is very low. The screening modality recommended for young athletes is of limited value in older athletes, who should receive individualized screening with cardiac stress testing for patients with high risk of underlying CAD. As cardiovascular screening will never be able to identify all athletes at risk, adequate preparedness is vital in case of a potentially fatal event at the sporting arena/facility. Firstly, we will review the magnitude of the problem of SCD in athletes of different ages, as well as the aetiology. Secondly, we will focus on how to prevent SCD in athletes of all ages, reviewing cardiovascular screening recommendations as well as emergency preparedness and arena safety.