Sports-related sudden death in the general population

International Criteria for Reporting Study Quality for Sudden Cardiac Arrest/Death Tool

BACKGROUND

Studies reporting on the incidence of sudden cardiac arrest and/or death (SCA/D) in athletes commonly lack methodological and reporting rigor, which has implications for screening and preventative policy in sport. To date, there are no tools designed for assessing study quality in studies investigating the incidence of SCA/D in athletes.

METHODS AND RESULTS

The International Criteria for Reporting Study Quality for Sudden Cardiac Arrest/Death tool (IQ-SCA/D) was developed following a Delphi process. Sixteen international experts in sports cardiology were identified and invited. Experts voted on each domain with subsequent moderated discussion for successive rounds until consensus was reached for a final tool. Interobserver agreement between a novice, intermediate, and expert observer was then assessed from the scoring of 22 relevant studies using weighted and unweighted κ analyses. The final IQ-SCA/D tool comprises 8 domains with a summated score of a possible 22. Studies are categorized as low, intermediate, and high quality with summated IQ-SCA/D scores of ≤11, 12 to 16, and ≥17, respectively. Interrater agreement was "substantial" between all 3 observers for summated IQ-SCA/D scores and study categorization.

CONCLUSIONS

The IQ-SCA/D is an expert consensus tool for assessing the study quality of research reporting the incidence of SCA/D in athletes. This tool may be used to assist researchers, reviewers, journal editors, and readers in contextualizing the methodological quality of different studies with varying athlete SCA/D incidence estimates. Importantly, the IQ-SCA/D also provides an expert-informed framework to support and guide appropriate design and reporting practices in future SCA/D incidence trials.

What is the most appropriate age for the first cardiac screening of athletes?

For sporting organisations that conduct screening of athletes, there are very few consistent guidelines on the age at which to start. Our review found the total rate of sudden cardiac arrest or death is very low between the ages of 8-11 years (less than 1/100,000/year), increasing to 1-2/100,000/year in both elite athletes and community athletes aged 12-15 years and then steadily increases with age. The conditions associated with sudden cardiac death in paediatric athletes and young adult athletes are very similar with some evidence that death from coronary artery abnormalities occurs more frequently in athletes 10-14 years old. The decision when to begin a screening program involves a complex interplay between requirements and usual practices in a country, the rules of different leagues and programs, the age of entry into an elite program, the underlying risk of the population and the resources available. Given the incidence of sudden cardiac arrest or death in young people, we recommend beginning cardiac screening no earlier than 12 years (not later than 16 years). The risk increases with age, therefore, starting a program at any point after age 12 has added value. Importantly, anyone with concerning symptoms (e.g. collapse on exercise) or family history of an inherited cardiac condition should see a physician irrespective of age. Finally, no screening program can capture all abnormalities, and it is essential for organisations to implement a cardiac emergency plan including training on recognition and response to sudden cardiac arrest and prompt access to resuscitation, including defibrillators.

[Physical activity to reduce cardiovascular risk -Why deprive yourself ?]

Sports-related sudden death is an uncommon event, affecting mainly middle-aged men who practice leisure sports, and is related to unknown coronary artery disease. In athletes, cardiac causes are also predominant, with a greater proportion of structural and electrical heart disease. If first-aid resuscitation measures are initiated, survival easily exceeds 50%, and this is an excellent educational illustration of how to improve the prognosis of non-sport-related cardiac arrest. Prevention of a sport-related cardiovascular event remains difficult, and relies on clinical examination, questioning (including family history) and resting ECG in participants >35 years old. The non-contraindication visit is also an opportunity to pass on to the patient the rules of good sports "hygiene" and life-saving gestures in the event of sudden death during sport in one of the partners (and the importance of regularly educating oneself in life-saving gestures...).

New Insights and Recommendations for Athletes With Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) has long been considered to be a high-risk cardiac condition for which exercise was thought to increase the risk of sudden cardiac death (SCD). This was founded in part by initial autopsy studies reporting HCM to be a leading medical cause of SCD among young athletes. Most forms of competitive sport and exercise were therefore thought to increase the risk of SCD to a prohibitive level. Resultant expert consensus guideline recommendations universally restricted athletes with HCM from participation in moderate- to vigourous-intensity sport and exercise in a binary "yes" or "no" clinical decision making process with the goal of reducing the risk of sports-related SCD. HCM is, however, a heterogeneous genetic condition with variable penetrance and risk. The degree to which sports and exercise increases the risk of SCD at an individual patient level continues to be an area of clinical uncertainty. Emerging data and clinical experience from the past several decades have provided important new insights into exercise-related risks and have brought into question the appropriateness of overly restrictive binary clinical decision making for exercise recommendations in HCM. This includes an improved understanding of the overall prevalence of HCM in the general population, improved observational estimates of the risk of SCD related to continued sport and exercise participation, and a general shift toward improved patient-centred approaches to care through shared decision making processes. The rules by which the game is played may be changing for athletes with HCM.

Cardiovascular risk of veterans' football: An observational cohort study with follow-up

BACKGROUND

The cardiac stress for veteran football players during match is considerable. In this specific elderly population, the kinetics of exercise-induced cardiac troponin I (cTnI) and B-Type natriuretic peptide (BNP) could potentially be related to cardiovascular risk factors (CVRF) and cardiovascular disease and are therefore be investigated for their usefulness as an complement to established screening measures.

METHODS

cTnI and BNP was measured in 112 veteran football players (age: 51 ± 10 years) within 30 minutes pre- and post-match. Players with elevated cTnI (cTnI-positive) and a control group (out of the 112 veteran players) with normal cTnI (cTnI-negative) underwent cardiac follow-up 4.2 ± 3.5 months post-match, comprising history, resting and stress ECG (including 30 minutes pre- and post cTnI and BNP), and echocardiography.

RESULTS

In 33 players (29%) cTnI and in 6 players BNP (5%) exceeded the upper range limit for increased risk of myocardial damage (cTnI ≥ 5 ng/l) and myocardial wall stress (BNP ≥ 100 pg/ml) post-match, respectively. No correlation was observed between Δ cTnI (pre- vs. post-match) and the number of CVRF (r = -0.06, p = 0.50). Follow-up was conducted in 62 players (31 cTnI-positive and 31 cTnI-negative players) of which 6 (10%, 3 cTnI positive and 3 cTnI negative players) had cardiac abnormalities (hypertrophic cardiomyopathy n = 2, coronary artery disease n = 2, coronary artery anomaly n = 1, hypertensive heart disease n = 1).

CONCLUSION

Veterans' football matches elicit increases in BNP and particularly cTnI in a considerable number of players. However, these biochemical alterations do not indicate acute cardiac damage as evidenced by follow-up. Routine determination of cardiac biomarkers is unlikely to improve cardiovascular screening in veteran football players.

All-cause mortality risks among participants in mass-participation sporting events

OBJECTIVES

Exercise transiently increases the risk for sudden death, whereas long-term exercise promotes longevity. This study assessed acute and intermediate-term mortality risks of participants in mass-participation sporting events.

METHODS

Data of participants in Dutch running, cycling and walking events were collected between 1995 and 2017. Survival status was obtained from the Dutch Population Register. A time-stratified, case-crossover design examined if deceased participants more frequently participated in mass-participation sporting events 0-7 days before death compared with the reference period (14-21 days before death). Mortality risks during follow-up were compared between participants and non-participants from the general population using Cox regression.

RESULTS

546 876 participants (median (IQR) age 41 (31-50) years, 56% male, 72% runners) and 211 592 non-participants (41 (31-50) years, 67% male) were included. In total, 4625 participants died of which more participants had partaken in a sporting event 0-7 days before death (n=23) compared with the reference period (n=12), and the mortality risk associated with acute exercise was greater but did not reach statistical significance (OR 1.92; 95% CI 0.95 to 3.85). During 3.3 (1.1-7.4) years of follow-up, participants had a 30% lower risk of death (HR 0.70; 95% CI 0.67 to 0.74) compared with non-participants after adjustment for age and sex. Runners (HR 0.65; 95% CI 0.62 to 0.69) and cyclists (HR 0.70; 95% CI 0.64 to 0.77) had the best survival during follow-up followed by walkers (HR 0.88; 95% CI 0.80 to 0.94).

CONCLUSION

Participating in mass-participation sporting events was associated with a non-significant increased odds (1.92) of mortality and a low absolute event rate (4.2/100 000 participants) within 7 days post-event, whereas a 30% lower risk of death was observed compared with non-participants during 3.3 years of follow-up. These results suggest that the health benefits of mass sporting event participation outweigh potential risks.

Sudden Death In Sports: Modern Concepts

Regular physical activity provides significant health benefits and reduces the risk of premature death from any cause, including cardiovascular diseases (CVD). However, physical activity may provoke sudden cardiac death (SCD), especially in presence of unrecognized diseases. It is essential to identify risk factors that contribute to SCD in athletes and to implement effective prevention of such episodes. For this purpose, SCD registries are being created, medical terminology is being unified, and schedules of medical examination are being developed. The best strategy to combat SCD during sport activities is a combination of primary prevention by screening examination to identify athletes with CVD at risk and a proper planning of first aid measures during sports events, including the availability of an automatic external defibrillator on site.

Sudden Cardiac Death in Young Athletes: JACC State-of-the-Art Review

Athletes epitomize the healthiest segment of society. Despite this premise, sudden cardiac death may occur in apparently healthy athletes, attracting significant attention not only in the medical community but also in laypersons and media. The incidence of sudden cardiac death is variably reported, and epidemiological burden differs among cohorts. Athletes appear to be at risk of developing fatal arrhythmias when harboring a quiescent cardiac disorder. Primary cardiomyopathies, ion channelopathies, and coronary artery anomalies are prevalent causes in young individuals. Cardiac assessment of athletes can be challenging because these individuals exhibit a plethora of electrical, structural, and functional physiological changes that overlap with cardiac pathology. A diagnosis of cardiac disease in a young athlete is not necessarily an indication to terminate competition and sports participation. International guidelines, traditionally focused on disqualification of individuals with cardiac disease, have recently adopted a more liberal attitude, based on a careful assessment of the risk and on a shared-decision making approach.

Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A 20-Year Study

BACKGROUND

Understanding the incidence, causes, and trends of sudden cardiac death (SCD) among young competitive athletes is critical to inform preventive policies.

METHODS

This study included National Collegiate Athletic Association athlete deaths during a 20-year time frame (July 1, 2002, through June 30, 2022). Athlete deaths were identified through 4 separate independent databases and search strategies (National Collegiate Athletic Association resolutions list, Parent Heart Watch database and media reports, National Center for Catastrophic Sports Injury Research database, and insurance claims). Autopsy reports and medical history were reviewed by an expert panel to adjudicate causes of SCD.

RESULTS

A total of 143 SCD cases in National Collegiate Athletic Association athletes were identified from 1102 total deaths. The National Collegiate Athletic Association resolutions list identified 117 of 143 (82%), the Parent Heart Watch database or media reports identified 89 of 143 (62%), the National Center for Catastrophic Sports Injury Research database identified 63 of 143 (44%), and insurance claims identified 27 of 143 (19%) SCD cases. The overall incidence of SCD was 1:63 682 athlete-years (95% CI, 1:54 065-1:75 010). Incidence was higher in male athletes than in female athletes (1:43 348 [95% CI, 1:36 228-1:51 867] versus 1:164 504 [95% CI, 1:110 552-1:244 787] athlete-years, respectively) and Black athletes compared with White athletes (1:26 704 [1:20 417-1:34 925] versus 1:74 581 [1:60 247-1:92 326] athlete-years, respectively). The highest incidence of SCD was among Division I male basketball players (1:8188 [White, 1:5848; Black, 1:7696 athlete-years]). The incidence rate for SCD decreased over the study period (5-year incidence rate ratio, 0.71 [95% CI, 0.61-0.82]), whereas the rate of noncardiovascular deaths remained stable (5-year incidence rate ratio, 0.98 [95% CI, 0.94-1.04]). Autopsy-negative sudden unexplained death (19.5%) was the most common postmortem examination finding, followed by idiopathic left ventricular hypertrophy or possible cardiomyopathy (16.9%) and hypertrophic cardiomyopathy (12.7%), in cases with enough information for adjudication (118 of 143). Eight cases of death were attributable to myocarditis over the study period (1 case from January 1, 2020, through June 30, 2022), with none attributed to COVID-19 infection. SCD events were exertional in 50% of cases. Exertional SCD was more common among those with coronary artery anomalies (100%) and arrhythmogenic cardiomyopathy (83%).

CONCLUSIONS

The incidence of SCD in college athletes has decreased. Male sex, Black race, and basketball are associated with a higher incidence of SCD.

Cardiac magnetic resonance assessment of athletic myocardial fibrosis; Benign bystander or malignant marker?

The benefits of exercise are irrefutable with a well-established dose-dependent relationship between exercise intensity and reduction in cardiovascular disease. Differentiating the physiological adaptation to exercise, termed the "athlete's heart" from cardiomyopathies, has been advanced by the advent of more sophisticated imaging modalities such as cardiac magnetic resonance imaging (CMR). Myocardial fibrosis on CMR is a mutual finding amongst seemingly healthy endurance athletes and individuals with cardiomyopathy. As a substrate for arrhythmias, fibrosis is traditionally associated with increased cardiovascular risk. In this article, we discuss the aetiologies, distribution and potential implications of myocardial fibrosis in athletes.

Clinical Outcomes in Adult Patients With an Anomalous Right Coronary Artery from the Left Sinus of Valsalva

An anomalous origin of the right coronary artery from the opposite sinus of Valsalva with an intramural course (R-ACAOS-IM) may cause sudden cardiac death in children and adolescents. However, the natural history and management of patients in whom this anomaly is detected later during adulthood remains uncertain. The goals of this study were to assess the impact of an R-ACAOS-IM on the clinical outcomes in an adult population and to determine if adult patients with this anomaly who do not have significant coronary artery disease (CAD) can be managed safely without surgical intervention. A database review identified patients aged >35 years with anomalous coronary arteries diagnosed by cardiac catheterization or coronary computed tomography angiography. The outcomes of patients with R-ACAOS-IM were compared with patients with anomalous left circumflex coronary arteries with retroaortic course (LCx-RA) (an anomaly not associated with ischemic events). The primary outcome was all-cause mortality. The study population consisted of 185 patients aged 59 ± 12 years. Clinical characteristics were similar in the R-ACAOS-IM (n = 88) and LCx-RA (n = 97) groups. At a follow-up of 6.6 ± 4.5 years, there was no difference in mortality (hazard ratio 0.64, 95% confidence interval 0.32 to 1.28, p = 0.20) when adjusted for gender, age, and CAD. A subgroup analysis of 88 patients with no obstructive CAD managed nonoperatively found no difference between the LCx and R-ACAOS-IM groups in mortality (hazard ratio 2.45, 95% confidence interval 0.45 to 13.40, p = 0.30). There was no significant difference between the 2 groups in the composite outcome of death, nonfatal myocardial infarction, or survived cardiac arrest. The outcome of adult patients who have anomalous R-ACAOS-IM are similar to patients who have anomalous LCx-RA with a known benign course. In conclusion, these results suggest that most patients who survive this anomaly into adulthood may be managed conservatively without intervention.

BEAT-IT: A de-novo cardiac screening programme in Maltese adolescents

AIMS

Sudden cardiac death (SCD) in young individuals is often unexpected, provoking substantial emotional stress for family and friends of the deceased. Cardiac screening may identify individuals who harbour disorders linked to SCD. The feasibility and diagnostic yield of a nationwide cardiac screening programme in adolescents has never been explored.

METHODS

All individuals eligible for cardiac screening (students aged 15 years) were systematically invited to enrol. Students were provided with a health questionnaire. ECGs were acquired at school. A physician led consultation was carried out on site. Participants with an abnormal screen were then referred for secondary evaluation to the nation's tertiary centre. Feasibility criteria included a) participation rate >60%, b) adherence to secondary evaluation >80%, and c) cost per individual screened equating to <€100. The diagnostic yield was also evaluated.

RESULTS

At the end of enrolment, 2708 students gave consent (mean 15 years, 50.4% male), equating to 67.9% of the eligible cohort. Overall, 109 participants (4.0%) were referred for further evaluation. An abnormal electrocardiogram (ECG) was the most common reason for referral (3.7%). Fifteen individuals (0.6%) were diagnosed with a cardiac condition. Nine (0.3%) had a condition linked to SCD (n = 1 Long-QT syndrome, n = 1 Hypertrophic Cardiomyopathy, n = 5 Wolff-Parkinson White, n = 2 coronary anomalies). The yield was similar in athletes and non-athletes (p = 0.324). The cost per cardiac individual screened equated to €51.15.

CONCLUSION

A nationwide systematic cardiac screening programme for adolescent athletes and non-athletes is feasible and cost-efficient, provided that responsible centres have the appropriate infrastructure.

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action

Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents' families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.

Congenital coronary artery anomalies in sports medicine. Why to know them

The anomalous origin of a coronary artery (AOCA) is a challenging topic, due to its rarity, the complexity of the pathophysiological aspects, the clinical presentation (often silent), the difficulty of diagnosis, and the potential risk of causing acute cardiovascular events up to sudden cardiac death, particularly when triggered by heavy physical exercise or sport practice. Increasing interest in sport medical literature is being given to this topic. This paper reviews current knowledge of AOCAs in the specific context of the athletic setting addressing epidemiological and pathophysiological aspects, diagnostic work-up, sports participation, individual risk assessment, therapeutic options, and return to play decision after surgery.

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.

[Analysis of sudden cardiac death in competitive athletes, possibilities for reducing cases]

INTRODUCTION

Sudden cardiac death in athletes is rare (0.5 to 1 per 100 000 athlete years), but sudden cardiac death in known athletes causes general shock.

OBJECTIVE

Our research aim was to collect and study as many sudden cardiac death cases as possible, judge the role of stress and look for ways to reduce fatal tragedies.

METHOD

From registers and newspaper articles found on the Internet, we collected 360 (including 14 women) athletes' sudden cardiac death cases where the sport, age and place of death (during training/competition/after) could be determined. From these, a single database has been prepared in order of the year of death. The cases were grouped and analyzed by sports. Based on our results and literature data, we made recommendations to reduce fatalities.

RESULTS AND CONCLUSION

There were more sudden cardiac deaths in competitions than in trainings (239 vs. 99), but tragedies also happened during warm-ups and chess without physical exertion, furthermore, there was no sudden cardiac death in the stakeless training of marathon/half marathon/triathlon athletes; all these prove the role of stress, so we recommend a psychological conversation before a high-stakes race. There were also a lot of sudden cardiac deaths (79/360) during team sports trainings, so we recommend reanimation readiness there as well. After training/competition, sudden cardiac death happened mainly in sports requiring high static effort, where post-competition monitoring is also recommended. Those who died in training were younger than those who died during the race (p<0.01), so young people should be monitored more closely for medical and (under)fitness. Marathon runners and triathletes were older than team athletes (p<0.005) and only died in competition, so for them a basic examination and an ECG within 1 month before competition are recommended. Conclusions drawn from literature data: sports medicine examination should be standardized and documented in an accessible way; since resuscitation started earlier and professionally is more effective, all competitors should receive reanimation training. Orv Hetil. 2023; 164(29): 1155-1163.

Masters athlete screening study (MASS): incidence of cardiovascular disease and major adverse cardiac events and efficacy of screening over five years

BACKGROUND

The efficacy of cardiovascular screening in Masters athletes (MAs) (≥35 y), and whether screening decreases their risk of major adverse cardiac events (MACEs) is unknown.

PURPOSE

To evaluate the effectiveness of yearly cardiovascular screening, and the incidence of cardiovascular disease (CVD) and MACE over five years.

METHODS AND RESULTS

MAs (≥35 y) without previous history of CVD underwent yearly cardiovascular screening. Participants with an abnormal screen underwent further evaluations. In the initial year, 798 MAs (62.7% male, 55 ± 10 y) were screened; 11.4% (n = 91) were diagnosed with CVD. Coronary artery disease (CAD) was the most common diagnosis (n = 64; 53%). During follow-up, there were an additional 89 CVD diagnoses with an incidence rate of 3.58/100, 4.14/100, 3.74/100, 1.19/100, for years one to four, respectively. The most common diagnoses during follow-up were arrhythmias (n = 33; 37%). Increasing age (OR = 1.047, 95% confidence interval (CI): 1.003-1.094; P = 0.0379), Framingham Risk Score (FRS) (OR = 1.092, 95% CI: 1.031-1.158; P = 0.003), and LDL cholesterol (OR = 1.709, 95% CI: 1.223-2.401; P = 0.002) were predictive of CAD, whereas moderate intensity activity (min/wk) (OR = 0.997, 95% CI: 0.996-0.999; P = 0.002) was protective. Ten MACE (2.8/1000 athlete-years) occurred. All of these MAs were male, and 90% had ≥10% FRS. All underwent further evaluations with only two identified to have obstructive CAD.

CONCLUSION

MACE occurred despite yearly screening. All MAs who had an event had an abnormal screen; however, cardiac functional tests failed to detect underlying CAD in most cases. It may be appropriate to offer computed coronary tomography angiography in MAs with ≥10% FRS to overcome the limitations of functional testing, and to assist with lifestyle and treatment modifications.

Prevalence and pattern of focal and potential diffuse myocardial fibrosis in male and female marathon runners using contrast-enhanced cardiac magnetic resonance

OBJECTIVES

This study analyzed the prevalence and pattern of focal and potential diffuse myocardial fibrosis detected by late gadolinium enhancement (LGE) and extracellular volume (ECV) imaging in male and female marathon runners using cardiac magnetic resonance (CMR).

METHODS

Seventy-four marathon runners were studied including 55 males (44 ± 8 years) and 19 females (36 ± 7 years) and compared to 36 controls with similar age and sex using contrast-enhanced CMR, exercise testing, and blood samples.

RESULTS

Contrast-enhanced CMR revealed focal myocardial fibrosis in 8 of 74 runners (11%). The majority of runners were male (7 of 8, 88%). LGE was typically non-ischemic in 7 of 8 runners (88%) and ischemic in one runner. ECV was higher in remote myocardium without LGE in male runners (25.5 ± 2.3%) compared to male controls (24.0 ± 3.0%, p < 0.05), indicating the potential presence of diffuse myocardial fibrosis. LV mass was higher in LGE + males (86 ± 18 g/m2) compared to LGE- males (73 ± 14 g/m2, p < 0.05). Furthermore, LGE + males had lower weight (69 ± 9 vs 77 ± 9 kg, p < 0.05) and shorter best marathon finishing times (3.2 ± 0.3 h) compared to LGE- males (3.6 ± 0.4 h, p < 0.05) suggesting higher training load in these runners to accomplish the marathon in a short time.

CONCLUSION

The high frequency of non-ischemic myocardial fibrosis in LGE + male runners can be related to increased LV mass in these runners. Furthermore, a higher training load could explain the higher LV mass and could be one additional cofactor in the genesis of myocardial fibrosis in marathon runners.

KEY POINTS

• A high frequency of myocardial fibrosis was found in marathon runners. • Myocardial fibrosis occurred typically in male runners and was typically non-ischemic. • Higher training load could be one cofactor in the genesis of myocardial fibrosis in marathon runners.

Sudden Cardiac Arrest During Sports Activity in Older Adults

BACKGROUND

Sports activity among older adults is rising, but there is a lack of community-based data on sports-related sudden cardiac arrest (SrSCA) in the elderly.

OBJECTIVES

In this study, the authors investigated the prevalence and characteristics of SrSCA among subjects ≥65 years of age in a large U.S.

POPULATION

METHODS

All out-of-hospital sudden cardiac arrests (SCAs) were prospectively ascertained in the Portland, Oregon, USA, metro area (2002-2017), and Ventura County, California, USA (2015-2021) (catchment population ∼1.85 million). Detailed information was obtained for SCA warning symptoms, circumstances, and lifetime clinical history. Subjects with SCA during or within 1 hour of cessation of sports activity were categorized as SrSCA.

RESULTS

Of 4,078 SCAs among subjects ≥65 years of age, 77 were SrSCA (1.9%; 91% men). The crude annual SrSCA incidence among age ≥65 years was 3.29/100,000 in Portland and 2.10/100,000 in Ventura. The most common associated activities were cycling, gym activity, and running. SrSCA cases had lower burden of cardiovascular risk factors (P = 0.03) as well as comorbidities (P < 0.005) compared with non-SrSCA. Based on conservative estimates of community residents ≥65 years of age who participate in sports activity, the SrSCA incidence was 28.9/100,000 sport participation years and 18.4/100,000 sport participation years in Portland and Ventura, respectively. Crude survival to hospital discharge rate was higher in SrSCA, but the difference was nonsignificant after adjustment for confounding factors.

CONCLUSIONS

Among free-living community residents age ≥65 years, SrSCA is uncommon, predominantly occurs in men, and is associated with lower disease burden than non-SrSCA. These results suggest that the risk of SrSCA is low, and probably outweighed by the high benefit of exercise.

Echocardiography in the preparticipation screening: an old topic revisited

BACKGROUND

Preparticipation screenings have been conceived for the potential to prevent sudden cardiac death in young athletes by early identification of hidden cardiac diseases. Commonly used protocols include family history collection, physical examination, and resting electrocardiogram. Transthoracic echocardiography has been hypothesized to have a primary role in the preparticipation screening.

AIMS

The present study aimed to evaluate the additional role of echocardiogram in identifying cardiovascular abnormalities that might be undetected by commonly used preparticipation screening.

METHODS

We retrospectively reviewed Ferrari Formula Benessere, a corporate wellness program database, and analyzed data recorded from 2017 to 2022 to compare two medical models: a 'standard' preparticipation screening including medical history, physical examination, electrocardiogram and exercise stress testing versus an 'advanced' preparticipation screening comprising history, physical examination, electrocardiogram, exercise stress testing and echocardiography.

RESULTS

From an initial sample size of 7500 patients, we included 500 patients (420 male, 33.69 ± 7.9 mean age) enrolled for the first time in the corporate wellness program between 2017 and 2022. Three hundred and thirty-nine (67.8%) patients had no abnormal findings at 'standard' preparticipation screening and, even if they would have not required further evaluation, we performed echocardiography anyway ('advanced' preparticipation screening): 31 (9.1%) showed some abnormal cardiovascular findings at echocardiography, such as patent foramen ovalis, bicuspid aortic valve, aortic root ectasia or mitral valve prolapse.

CONCLUSIONS

Screening echocardiogram showed an additional value (about 10% more) in detecting patients with cardiovascular abnormalities, otherwise undiagnosed with the 'standard' preparticipation screening protocol.

Incidence of Cardiac Arrest During Sports Among Women in the European Union

BACKGROUND

Women represent a growing proportion of sports participants. Still, few original data regarding sudden cardiac arrest during sports (Sr-SCA) in women are available.

OBJECTIVES

The authors sought to assess the incidence, characteristics, and outcomes of women presenting with Sr-SCA.

METHODS

Data were analyzed from 3 population-based European registries (ESCAPE-NET 2020 Horizon Program) that prospectively and exhaustively collect every case of SCA: SDEC (Paris-Sudden Death Expertise Center), ARREST (AmsteRdam REsuscitation Studies), and SRCR (Swedish Register for Cardiopulmonary Resuscitation). Sr-SCA was defined as SCA during or ≤1 hour after cessation of sports activity.

RESULTS

Of 34,826 SCA between 2006 and 2017, 760 Sr-SCA (2.2%) were identified, including 54 in women. The average annual incidence of Sr-SCA in women in the 3 registries ranged from 0.10 per million (95% CI: 0.01-0.71 per million) to 0.38 per million (95% CI: 0.14-1.04 per million). Overall, the average annual incidence rate of Sr-SCA in women was 0.19 per million (95% CI: 0.14-0.24 per million), >10-fold lower compared with men (2.63 per million [95% CI: 2.45-2.83 per million]; P < 0.0001). When extrapolating to the total European population and accounting for age and sex, this yields 98 cases per year (95% CI: 72-123 cases per year) in women and 1,350 cases per year (95% CI: 1,256-1,451 cases per year) in men. Subject characteristics and circumstances of occurrence were similar in women vs men. Bystander response, time to defibrillation, and survival rate at hospital admission (58.8% vs 58.5%; P = 0.99) and 30 days did not differ significantly between women and men.

CONCLUSIONS

These findings emphasize the dramatically lower risk of Sr-SCA in women compared with men, despite similar subject characteristics. This should be considered in designing preparticipation screening strategies in the future.

Cardiac cycle timing intervals in university varsity athletes

Cardiac cycle timing events in varsity athletes serve an important function for baseline assessment but are not reported in the literature. The purpose of this study was to characterise the cardiac cycle timing intervals and contractility parameters in university-level varsity athletes. 152 males and 93 females were assessed using a non-invasive seismocardiography cardiac sensor attached to the sternum for 1-minute. Shorter isovolumic relaxation time (IVRT), systolic time, mitral valve open to E-wave (MVO to E) time, rapid ejection period (REP), atrial systole to mitral valve closure (AS to MVC) time, and diastolic performance index (IVRT/systolic time) were found in females, while heart rate was lower in males. Varying differences in timing intervals were found between sports. Systolic times were longer in male and female basketball players, while diastole was shortest in male football players, who also had higher heart rates than the other male sport athletes. These results add reference cardiac cycle timing data to the literature and imply that male and female athletes show different cardiac characteristics. Team differences suggest that different training for different sports can result in unique cardiac function changes, however, these appear to be related to the sex of the participants. The addition of these cardiac cycle timing intervals adds a valuable comparative tool to better understand cardiac physiology in the varsity athletic population.HIGHLIGHTS Given the lack of data in the literature on athlete's cardiac cycle timing intervals, we provide normative values for healthy, university varsity athletes, including stratification by sex and sport.Male and female athletes show different cardiac cycle timing intervals, including the systolic and isovolumic relaxation timing intervals.Differences in cardiac cycle timing intervals are also present when comparing different sports.

The benefits of physical activity in middle-aged individuals for cardiovascular disease outcomes

Regular physical activity (PA) has a positive role in preventing cardiovascular disease (CVD). Due to a trend toward a more sedentary lifestyle, the middle-aged population (35-65 years) is at greater risk of developing CVD. It is well established that PA improves cardiorespiratory fitness and reduces the risk of cardiovascular mortality and cardiovascular events, including stroke, coronary heart disease, heart failure, hypercholesterolemia, atherosclerosis, diabetes, and blood pressure. PA can potentially decrease oxidative stress and systemic inflammation, which are the two main underlying mechanisms leading to CVD. By reducing CRP, TNF-α, INF-γ, NF-κB and increasing IL-10, IL-4, and IL-8, PA can prevent the initiation and progression of CVD in middle-aged adults, highlighting the importance of being physically active for this age group. The general recommendation for PA to prevent CVD is at least 150 min/week at a moderate level of intensity; the type of PA should be adapted to the fitness level and medical condition of the individual. However, standardized guidelines for middle-aged individuals with cardiovascular events still need to be established.

Association between basic life support and survival in sports-related sudden cardiac arrest: a meta-analysis

AIMS

To evaluate the association of basic life support with survival after sports-related sudden cardiac arrest (SR-SCA).

METHODS AND RESULTS

In this systematic review and meta-analysis, a search of several databases from each database inception to 31 July 2021 without language restrictions was conducted. Studies were considered eligible if they evaluated one of three scenarios in patients with SR-SCA: (i) bystander presence, (ii) bystander cardiopulmonary resuscitation (CPR), or (iii) bystander automated external defibrillator (AED) use and provided information on survival. Risk of bias was evaluated using Risk of Bias in Non-randomized Studies of Interventions. The primary outcome was survival at the longest follow up. The meta-analysis was conducted using the random-effects model. The Grading of Recommendations Assessment, Development, and Evaluations (GRADE) approach was used to rate certainty in the evidence. In total, 28 non-randomized studies were included. The meta-analysis showed significant benefit on survival in all three groups: bystander presence [odds ratio (OR) 2.55, 95% confidence interval (CI) 1.48-4.37; I2 = 25%; 9 studies-988 patients], bystander CPR (OR 3.84, 95% CI 2.36-6.25; I2 = 54%; 23 studies-2523 patients), and bystander AED use (OR 5.25, 95% CI 3.58-7.70; I2 = 16%; 19 studies-1227 patients). The GRADE certainty of evidence was judged to be moderate.

CONCLUSION

In patients with SR-SCA, bystander presence, bystander CPR, and bystander AED use were significantly associated with survival. These results highlight the importance of witness intervention and encourage countries to develop their first aid training policy and AED installation in sport settings.

Mitral Valve Prolapse and Sudden Cardiac Death in Athletes at High Risk

Mitral valve prolapse (MVP) is the most frequent valvulopathy in the general population, with usually a favourable prognosis. Although it can be associated with some complications, ventricular arrhythmias (VA) and sudden cardiac death (SCD) are the most worrying. The estimated risk of SCD in MVP is between 0.2% to 1.9% per year, including MVP patients with and without severe mitral regurgitation (MR). The association between SCD and MVP is expressed by a phenotype called "malignant MVP" characterized by transthoracic echocardiography (TTE) findings such as bileaflet myxomatous prolapse and mitral annulus disjunction (MAD), ECG findings such as repolarization abnormalities, complex ventricular arrhythmias (c-VAs) and LV fibrosis of papillary muscles (PMs) and inferobasal wall visualized by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Therefore, attention is raised for patients with "arrhythmic MVP" characterized from an ECG point of view by frequent premature ventricular contractions (PVCs) arising from one or both PMs as well as by T-wave inversion in the inferolateral leads. In athletes, SCD is the most frequent medical cause of death and in young subjects (< 35 years) usually is due to electrical mechanism affecting who has a silent cardiovascular disease and are not considered per se a cause of increased mortality. In MVP, SCD was reported to happen during sports activity or immediately after and valve prolapse was the only pathological aspect detected. The aim of the present paper is to explore the association between SCD and MVP in athletes, focusing attention on ECG, TTE in particular, and CMR findings that could help to identify subjects at high risk for complex arrhythmias and eventually SCD. In addition, it is also examined if sports activity might predispose patients with MVP to develop major arrhythmias.

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.

Incidence and prevalence of hamstring injuries in field-based team sports: a systematic review and meta-analysis of 5952 injuries from over 7 million exposure hours

OBJECTIVE

This study aimed to systematically review and meta-analyse the incidence and prevalence of hamstring injuries in field-based team sports. A secondary aim was to determine the impact of other potential effect moderators (match vs training; sport; playing surface; cohort age, mass and stature; and year when data was collected) on the incidence of hamstring injury in field-based team sports.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

CINAHL, Cochrane Library, MEDLINE Complete (EBSCO), Embase, Web of Science and SPORTDiscus databases were searched from database inception to 5 August 2020.

ELIGIBILITY CRITERIA

Prospective cohort studies that assessed the incidence of hamstring injuries in field-based team sports.

METHOD

Following database search, article retrieval and title and abstract screening, articles were assessed for eligibility against predefined criteria then assessed for methodological quality using the Critical Appraisal Tool for prevalence studies. Meta-analysis was used to pool data across studies, with meta-regression used where possible.

RESULTS

Sixty-three articles were included in the meta-analysis, encompassing 5952 injuries and 7 262 168 hours of exposure across six field-based team sports (soccer, rugby union, field hockey, Gaelic football, hurling and Australian football). Hamstring injury incidence was 0.81 per 1000 hours, representing 10% of all injuries. Prevalence for a 9-month period was 13%, increasing 1.13-fold for every additional month of observation (p=0.004). Hamstring injury incidence increased 6.4% for every 1 year of increased average cohort age, was 9.4-fold higher in match compared with training scenarios (p=0.003) and was 1.5-fold higher on grass compared with artificial turf surfaces (p<0.001). Hamstring injury incidence was not significantly moderated by average cohort mass (p=0.542) or stature (p=0.593), was not significantly different between sports (p=0.150) and has not significantly changed over the last 30 years (p=0.269).

CONCLUSION

Hamstring injury represents 10% of all injuries in field-based team sports, with 13% of the athletes experiencing a hamstring injury over a 9-month period most commonly during matches. More work is needed to reduce the incidence of hamstring injury in field-based team sports.

PROSPERO REGISTRATION NUMBER

CRD42020200022.

Cardiac Events in World-Class Athletes: An Internet-Based Study

PURPOSE

This study aimed at assessing the prevalence of adverse cardiac events, as identified in the media, in world-class athletes according to their sex and sports discipline.

METHODS

All female and male athletes from 30 individual Olympic sports who ranked in the international yearly top 10 between 2006 and 2018 were included. The name of each of them was associated in a Google search with selected key terms related to heart disease and/or acute cardiac events after their inclusion date. Global and sex-specific adverse cardiac event hazard function λ were calculated for each sport. Global and sex-specific prevalences of cardiac events were calculated, then compared (Fisher's exact test) between all sports.

RESULTS

From the 2471 athletes included, 15 cases of cardiac events (prevalence of 0.61%) were reported; 2 sudden cardiac deaths (0.08%) occurred in male athletes. The other events were related to arrhythmic events ( n = 13), mainly supraventricular arrhythmias ( n = 9). All surviving athletes were able to continue their career, mostly after ablation procedure. Male endurance athletes accounted for seven events, among which three events occurred among short-distance triathletes. Events among women were comparatively rare ( n = 4), and all were observed among short-distance triathletes.

CONCLUSIONS

A relatively unexpected high prevalence of cardiac events in endurance elite athletes was observed as compared with other sports, mainly, in short-distance male and female triathletes. This raises the question of particular cardiovascular constraints in this discipline and underlines the urge of international longitudinal follow-up studies in these kinds of athletes.

Automated external defibrillators and basic life support practices in secondary schools: a nationwide study

AIM

Cardiac arrest prevention in schools has recently gained momentum. The survival benefit in schools who have access to defibrillators is clear, with far better survival outcomes in children or adults who sustain a cardiac arrest on school grounds. The main objectives of this study were to assess sudden cardiac arrest prevention in Maltese schools, specifically the availability of defibrillators and staff competence in delivering resuscitation.

METHODOLOGY AND RESULTS

An online-based questionnaire was distributed to all secondary schools across the Maltese archipelago. Data were collected, tabulated, and analysed using SPSS V.23. Most schools (n = 40, 74.1%) completed the questionnaire. Two schools documented a cardiac arrest in the past 10 years. 87.5% agreed that cardiac arrest prevention is an important health topic. Most have a defibrillator on the premises (n = 37, 92.5%). Only one defibrillator is usually available (n = 27, 75.0%). Despite the majority claiming its ease of accessibility (n = 35, 97.2%), most were not available on every floor (n = 37, 97.2%). Only one-third were close to a sporting facility (n = 11, 30.6%). Schools do not organise regular resuscitation courses (n = 21, 58.3%), with eight schools having five or more certified staff members (23.5%). The number of defibrillators did not influence the frequency of resuscitation courses at school (p = 0.607), and there was no association with the number of certified individuals (p = 0.860).

CONCLUSION

Defibrillators are not readily available at secondary schools and are often installed in low-risk areas. Most schools have only one staff member certified in resuscitation. These factors should be addressed with urgency.

Exercise preconditioning improves electrocardiographic signs of myocardial ischemic/hypoxic injury and malignant arrhythmias occurring after exhaustive exercise in rats

Exercise preconditioning (EP) has a good myocardial protective effect. This study explored whether EP improves electrocardiographic (ECG) signs of myocardial ischemic/hypoxic injury and the occurrence of malignant arrhythmia after exhaustive exercise. A total of 120 male SD rats were randomly divided into the control group (group C), early exercise preconditioning group (group EEP), late exercise preconditioning group (group LEP), exhaustive exercise group (group EE), early exercise preconditioning + exhaustive exercise group (group EEP + EE) and late exercise preconditioning + exhaustive exercise group (group LEP + EE). Changes in heart rate (HR), ST segment, T wave and QT corrected (QTc) intervals on ECG; hematoxylin-basic fuchsin-picric acid (HBFP) staining; and cTnI levels were used to study myocardial injury and the protective effect of EP. Compared with those in group C, the levels of plasma markers of myocardial injury, HBFP staining and ECG in group EE were significantly increased (P < 0.05). Compared with those in group EE, the levels of plasma markers of myocardial injury, HBFP staining and ECG in group EEP + EE and group LEP + EE were significantly decreased (P < 0.05). The results suggested that EP improved ECG signs of myocardial ischemic/hypoxic injury and malignant arrhythmias that occur after exhaustive exercise. The ST segment and T wave could also serve as indexes for evaluating exhaustive exercise-induced myocardial ischemia/hypoxia.

Optimization of exercise preconditioning duration in protecting from exhausted exercise-induced cardiac injury in rats

The effect of different duration of exercise preconditioning (EP) on protecting from exhaustive exercise-induced cardiac injury (EECI) has been optimized in rats. Male Sprague-Dawley rats were divided into six groups: the control group, exhaustive exercise (EE) group, EP 20-min + EE group, EP 40-min + EE group, EP 60-min + EE group and EP 80-min + EE group. The EP groups were subjected to treadmill running at the intensity of 74.0% V̇O_{2 max}. Changes of exercise capacity, cardiac pathology, myocardial enzymology, electrocardiogram (ECG), cardiac function, and mitochondrial respiratory function were compared. Compared to the C group, the EE group has shown significant decrease of exercise capacity, elevation of serum N-terminal pro B-type natriuretic peptide (NT-proBNP) and cardiac troponin-I (cTn-I) levels, cardiac morphology change, ECG disturbance, cardiac dysfunction and reduction of myocardial mitochondrial respiration function. Compared to the EE group, the EP groups have shown significant elevation of exercise capacity, decrease of serum NT-proBNP and cTn-I, improvement of cardiac function and myocardial mitochondrial electron transfer pathway complex I, II and IV activity. The correlation analyses showed protection of EP was proportional to EP duration from 20-min to 60-min. EE caused cardiac injury. EP could protect from EECI by alleviating myocardial damage, improving cardiac function and mitochondrial ETP complex I, II and IV activity. EP protection was positively correlated to EP duration from 20-min to 60-min with EP intensity fixed at 74.0% V̇O_{2 max}.

Sports-Related Sudden Cardiac Death Attributable to Myocarditis: A Systematic Review and Meta-analysis

BACKGROUND

The incidence of sports-related sudden cardiac death (SrSCD) attributable to myocarditis is unknown. With the known association between SARS-CoV-2 (COVID-19) and myocarditis, an understanding of pre-pandemic rates of SrSCD due to myocarditis will be important in assessing a change of risk in the future. The objective was to ascertain the incidence of SrSCD or aborted sudden cardiac death (SCD) attributable to myocarditis in the general population.

METHODS

A literature search through PubMed/Medline and Ovid/Embase was completed. Studies of SrSCD with autopsy data or clear-cause aborted SrSCD were included. SrSCD was defined as SCD which occurred within 1 hour of exercise. Data were abstracted by 2 independent reviewers using the MOOSE guidelines. Risk assessment was performed with the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Random-effects models were used to report the incidence and 95% CIs. The primary outcome was the incidence of SrSCD attributable to myocarditis, and the secondary outcome was SrSCD overall.

RESULTS

Fifteen studies were included comprising 347,092,437 person-years (PY). There were 1955 SrSCD or aborted SrSCD overall with an incidence of 0.93 (95% CI 0.47-1.82) per 100,000 PY. Fifty-three SrSCD were attributed to myocarditis with an incidence of 0.047 (95% CI 0.018-0.123) per 100,000 PY, or 1 death attributable to myocarditis in 2.13 million PY.

CONCLUSIONS

In this meta-analysis, the overall incidence of SrSCD was low. Furthermore, SrSCD attributed to myocarditis is exceedingly rare.

Sports-related sudden cardiac arrest in young adults

AIMS

Data on sports-related sudden cardiac arrest (SrSCA) among young adults in the general population are scarce. We aimed to determine the overall SrSCA incidence, characteristics, and outcomes in young adults.

METHODS AND RESULTS

Prospective cohort study of all cases of SrSCA between 2012 and 2019 in Germany and Paris area, France, involving subjects aged 18-35 years. Detection of SrSCA was achieved via multiple sources, including emergency medical services (EMS) reporting and web-based screening of media releases. Cases and aetiologies were centrally adjudicated. Overall, a total of 147 SrSCA (mean age 28.1 ± 4.8 years, 95.2% males) occurred, with an overall burden of 4.77 [95% confidence interval (CI) 2.85-6.68] cases per million-year, including 12 (8.2%) cases in young competitive athletes. While bystander cardiopulmonary resuscitation (CPR) was initiated in 114 (82.6%), automated external defibrillator (AED) use by bystanders occurred only in a minority (7.5%). Public AED use prior to EMS arrival (odds ratio 6.25, 95% CI 1.48-43.20, P = 0.02) was the strongest independent predictor of survival at hospital discharge (38.1%). Among cases that benefited from both immediate bystander CPR and AED use, survival rate was 90.9%. Coronary artery disease was the most frequent aetiology (25.8%), mainly through acute coronary syndrome (86.9%).

CONCLUSION

Sports-related sudden cardiac arrest in the young occurs mainly in recreational male sports participants. Public AED use remains disappointingly low, although survival may reach 90% among those who benefit from both bystander CPR and early defibrillation. Coronary artery disease is the most prevalent cause of SrSCA in young adults.

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.

Endurance training-induced cardiac remodeling in a guinea pig athlete's heart model

Besides the health benefits of regular exercise, high-level training-above an optimal level-may have adverse effects. In this study, we investigated the effects of long-term vigorous training and its potentially detrimental structural-functional changes in a small animal athlete's heart model. Thirty-eight 4-month-old male guinea pigs were randomized into sedentary and exercised groups. The latter underwent a 15-week-long endurance-training program. To investigate the effects of the intense long-term exercise, in vivo (echocardiography, electrocardiography), ex vivo, and in vitro (histopathology, patch-clamp) measurements were performed. Following the training protocol, the exercised animals exhibited structural left ventricular enlargement and a significantly higher degree of myocardial fibrosis. Furthermore, resting bradycardia accompanied by elevated heart rate variability occurred, representing increased parasympathetic activity in the exercised hearts. The observed prolonged QTc intervals and increased repolarization variability parameters may raise the risk of electrical instability in exercised animals. Complex arrhythmias did not occur in either group, and there were no differences between the groups in ex vivo or cellular electrophysiological experiments. Accordingly, the high parasympathetic activity may promote impaired repolarization in conscious exercised animals. The detected structural-functional changes share similarities with the human athlete's heart; therefore, this model might be useful for investigations on cardiac remodeling.

Risk Factors for Sudden Death in Athletes, Is There a Role for Screening?

Purpose of Review

Sudden cardiac death (SCD) in a young athlete is an infrequent yet devastating event often associated with substantial media attention. Screening athletes for conditions associated with SCD is a controversial topic with debate surrounding virtually each component including the ideal subject, method, and performer/interpreter of such screens. In fact, major medical societies such as the American College of Cardiology/American Heart Association and the European Society of Cardiology have discrepant recommendations on the matter, and major sporting associations have enacted a wide range of screening policies, highlighting the confusion on this subject. This review seeks to summarize the literature in this area to address the complex and disputed subject of screening young athletes for SCD.

Recent Findings

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause myocarditis, which is one acquired cardiac disease associated with SCD. The coronavirus 2019 (COVID-19) pandemic has therefore resulted in an increased incidence of an otherwise less common condition, providing an expanded dataset for further study of this condition. Recent findings indicate that cardiac complications of athletes with myocardial involvement of SARS-CoV-2 infection are rare. Other contemporary work in SCD screening has been focused on the implementation of various screening protocols and measuring their effectiveness.

Summary

No universal consensus exists for athlete screening for conditions associated with SCD with varying guidelines and protocols across cardiology and sport-specific organizations. No screening program will prevent all SCD; however, small programs managed by physicians familiar with the examination of an athlete that carefully personalize screening to the individual may maximize detection of dangerous cardiac conditions while minimizing false positives.

Characteristics of Second-Line Investigations of Middle-Aged Athletes Who Failed Preparticipation Examinations

OBJECTIVE

The role of exercise testing during preparticipation examinations (PPEs) of middle-aged athletes is uncertain. This study examined the characteristics of disqualifications after an initial PPE that includes an exercise test in competitive athletes older than 30 years. We investigated disqualification rates and reasons, second-line investigations performed, and final decisions regarding competitive sports participation.

DESIGN

Chart review.

SETTING

Sports medicine clinic.

PARTICIPANTS

Athletes aged >30 years that performed an exercise test as part of their annual PPE at our sports medicine clinic (n = 866).

INDEPENDENT VARIABLES

Age, sex, height, weight, sport type, cardiovascular risk factors, and abnormal PPE findings.

MAIN OUTCOME MEASURES

Additional investigations performed, approval/disqualification regarding competitive sports participation.

RESULTS

The initial disqualification rate of athletes was 9.8%. Three (3.6%) athletes were disqualified following questionnaire and physical examination, 19 (22.4%) because of resting electrocardiogram findings, and 65 (76.5%) following the exercise test. After additional work-up, only 5 athletes (0.4%) were ultimately found ineligible for competitive sports. From those, only 2 athletes (0.2%) were disqualified because of exercise test findings, which were episodes of supraventricular tachycardia and not ischemia-related.

CONCLUSIONS

The addition of an exercise test to the PPE of middle-aged athletes is of limited value. If exercise testing of older athletes is performed, arrhythmias are probably of higher significance than ST-T changes.

Hypertrophic Cardiomyopathy and Exercise: Mutually Exclusive or Beneficial?

Individuals with HCM have historically been held from participation in sports beyond mild-intensity exercise. Exercise improves functional capacity and indices of cardiac function even in those with HCM. Emerging data have demonstrated the safety of exercise in individuals with HCM. Improvement in risk stratification and a shared decision-making approach has led to a guideline endorsement for HCM providers to develop an informed plan for exercise and competitive athletics among the HCM population.

Incidence and Causes of Sudden Cardiac Death in Athletes

Sudden cardiac death (SCD) is the leading cause of medical death in athletes; however, many studies are significantly flawed making an accurate estimation of risk difficult. Incidence studies need to have accurate case ascertainment, a defined study population, and should be stratified by both sex and age. The risk of SCA/d in college-aged males is 1 in 35,000 person-years, black males 1 in 18,000 person-years, and higher-risk sports include men's basketball, men's soccer, and American football. Inherited cardiomyopathies and electrical conditions account for ∼ 2/3 of off SCA/d and can be detected with an ECG. More research is needed to provide more granular estimates.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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Cardiovascular Magnetic Resonance for Patients With COVID-19

COVID-19 is associated with myocardial injury caused by ischemia, inflammation, or myocarditis. Cardiovascular magnetic resonance (CMR) is the noninvasive reference standard for cardiac function, structure, and tissue composition. CMR is a potentially valuable diagnostic tool in patients with COVID-19 presenting with myocardial injury and evidence of cardiac dysfunction. Although COVID-19-related myocarditis is likely infrequent, COVID-19-related cardiovascular histopathology findings have been reported in up to 48% of patients, raising the concern for long-term myocardial injury. Studies to date report CMR abnormalities in 26% to 60% of hospitalized patients who have recovered from COVID-19, including functional impairment, myocardial tissue abnormalities, late gadolinium enhancement, or pericardial abnormalities. In athletes post-COVID-19, CMR has detected myocarditis-like abnormalities. In children, multisystem inflammatory syndrome may occur 2 to 6 weeks after infection; associated myocarditis and coronary artery aneurysms are evaluable by CMR. At this time, our understanding of COVID-19-related cardiovascular involvement is incomplete, and multiple studies are planned to evaluate patients with COVID-19 using CMR. In this review, we summarize existing studies of CMR for patients with COVID-19 and present ongoing research. We also provide recommendations for clinical use of CMR for patients with acute symptoms or who are recovering from COVID-19.

Effect of regular endurance exercises on management of cardiovascular health in middle-aged men

This study was conducted to investigate the effect of regular endurance exercises on the management of cardiovascular health in middle-aged men. The following conclusions were drawn as the result of comparatively analyzing middle-aged men who regularly performed triathlon and cycling exercises for more than 5 years. The effect of regular endurance exercises on cardiovascular health management in middle-aged men was found to be relatively positive. However, prolonged endurance exercises can cause cardiovascular disease which can adversely affect the cardiac function, and to date, no defining limit is known about the amount of exercise that improves the cardiovascular function while reducing the cardiovascular events. Therefore, aiming for exercises at moderate intensity that befit the individual’s fitness level as well as conducting regular examinations to predict and manage the risk of sudden cardiac death from exercising were considered as the more effective method of cardiovascular health management.

Better outcomes from exercise-related out-of-hospital cardiac arrest in males and in the young: findings from the Swedish Registry of Cardiopulmonary Resuscitation

BACKGROUND

Survival from out-of-hospital cardiac arrest (OHCA) is higher if the arrest is witnessed and occurs during exercise, however, there is contradicting data on prognosis with regards to sex and age. The purpose of this study was to compare the outcomes and circumstances of exercise-related OHCA in different age groups and between sexes in a large unselected population.

METHODS

Data from exercise-related OHCAs reported to the Swedish Registry of Cardiopulmonary Resuscitation from 2011 to 2014 and from 2016 to 2018 were analysed. All cases of exercise-related OHCA in which emergency medical services attempted resuscitation were included. The primary outcome was survival to 30 days.

RESULTS

In total, 635 cases of exercise-related OHCA outside of the home were identified. The overall 30-day survival rate was 44.5% with highest survival rate in the age group 0-35 years, compared with 36-65 years and >65 years (59.6% vs 46.0% and 40.4%, p=0.01). A subgroup analysis of 0-25 years showed a survival rate of 68.8%. Exercise-related OHCA in females (9.1% of total) were witnessed to a lower extent (66.7% vs 79.6%, p=0.03) and median time to cardiopulmonary resuscitation (CPR) was longer (2.0 vs 1.0 min, p=0.001) than in males. Females also had lower rates of ventricular fibrillation (43.4% vs 64.7%, p=0.003) and a lower 30-day survival rate (29.3% vs 46.0%, p=0.02).

CONCLUSION

In exercise-related OHCA, younger victims have a higher survival rate. Exercise-related OHCA in females was rare, however, survival rates were lower compared with males and partly explained by a lower proportion of witnessed events, longer time to CPR and lower frequency of a shockable rhythm.

Cardiopulmonary Resuscitation and Defibrillator Use in Sports

Sudden cardiac arrest (SCA) in young athletes is rare, with an estimated incidence ranging from 0.1 to 2 per 100,000 per athlete year. The creation of SCA registries can help provide accurate data regarding incidence, treatment, and outcomes and help implement primary or secondary prevention strategies that could change the course of these events. Early cardiopulmonary resuscitation (CPR) and defibrillation are the most important determinants of survival and neurological prognosis in individuals who suffer from SCA. Compared with the general population, individuals with clinically silent cardiac disease who practice regular physical exercise are at increased risk of SCA events. While the implementation of national preparticipation screening has been largely debated, with no current consensus, the number of athletes who will be diagnosed with cardiac disease and have an indication for implantable defibrillator cardioverter defibrillator (ICD) is unknown. Many victims of SCA do not have a previous cardiac diagnosis. Therefore, the appropriate use and availability of automated external defibrillators (AEDs) in public spaces is the crucial part of the integrated response to prevent these fatalities both for participating athletes and for spectators. Governments and sports institutions should invest and educate members of the public, security, and healthcare professionals in immediate initiation of CPR and early AED use. Smartphone apps could play an integral part to allow bystanders to alert the emergency services and CPR trained responders and locate and utilize the nearest AED to positively influence the outcomes by strengthening the chain of survival. This review aims to summarize the available evidence on sudden cardiac death prevention among young athletes and to provide some guidance on strategies that can be implemented by governments and on the novel tools that can help save these lives.

Automated external defibrillator and emergency action plan preparedness amongst masters athletes

OBJECTIVES

Sudden cardiac arrest/death (SCA/D) is the leading medical cause of death in athletes. Masters athletes (≥35 years old) are increasing in numbers and are responsible for the vast majority of sport-related SCDs. Automated external defibrillators (AEDs) and emergency action plans (EAPs) have been shown to unequivocally reduce SCD, however, their prevalence in masters athletics remains unknown. We sought to identify the perceived AED accessibility and EAP preparedness amongst a group of masters athletes.

METHODS

A 40-item survey was sent to 735 master athletes identified through the Masters Athlete Screening Study. Participants were athletes with no known significant cardiac history. The survey inquired on the availability and location of AEDs within exercise settings, the presence of EAPs, and participants' cardiac concerns.

RESULTS

Sixty-eight percent of athletes completed the survey. Ninety-seven percent and 99% of athletes believed CPR and AEDs were effective at saving lives, respectively. Thirty-eight percent of athletes were aware of an AED in proximity to where they exercise, with 40% aware of one available during competition events, and 28% during training events. Only 10% of athletes were aware of an EAP active in their place of exercise. Half of the athletes perceive their risk of cardiac arrest during exercise to be ≤0.5 in 100,000.

CONCLUSIONS

These findings indicate that nearly all athletes believe CPR and AED are effective at saving lives, but only a minority are aware of an AED near their place of exercise, with even fewer aware of an active EAP. Master athletes underestimate their own risk for exercise-related cardiac events, affirming the importance of educating masters athletes on their increased cardiac risk and the importance of EAPs.