Download Sudden Cardiac Arrest During Sports Activity in Middle Age

DOI: 10.1161/CIRCULATIONAHA.114.011988
Sudden Cardiac Arrest During Sports Activity in Middle Age
Running title: Marijon et al.; Sudden Cardiac Arrest during Sports
Eloi Marijon, MD, PhD1,2,3; Audrey Uy-Evanado, MD1; Kyndaron Reinier, MPH, PhD1;
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
Carmen Teodorescu, MD, PhD1; Kumar Narayanan, MD1; Xavier Jouven, MD, PhD2,3;
MD
D1
Karen Gunson, MD4; Jonathan Jui, MD, MPH5; Sumeet S. Chugh, M
1
The Heart Institute, Cedars-Sinai Medical Ce
C
Center,
nter, Los Angeles, C
CA;
A; 2Cardiology Dept,
European
Euro
Eu
ro
opean G
Georges
e rg
eo
ges Pompidou
Pom
mpi
pido
d u Ho
do
Hosp
Hospital,
spit
sp
ital
al,, Paris,
Pari
Pa
ris,
s,, F
France;
raance; 3 Pa
Paris
Pari
riss Descartes
ri
Deesc
scar
arte
tess University,
U iv
Un
iver
errsi
sity
ty,, Pa
ty
Pari
Paris,
riis,
s F
France;
ranc
ra
n e
4
Dept
D
ept
p of Pathology,
Paath
tholloggy, O
Oregon
regoon Heal
H
Health
ea th
h aand
ndd Sci
Science
ien
nce U
University,
nive
ni
vers
ve
rsit
rs
ity,
it
y, Po
Portland,
ortlland,, O
OR;
R;; 5De
Dept
D
pt off E
Emergency
mergeency
Medicine,
Medi
Me
dicinee, Or
Oreg
Oregon
egon
on Healt
Health
lthh an
andd Sc
Scienc
Science
ncee Un
Univ
University,
iver
ersity
ty, Po
Port
Portland,
r laand
nd, OR
Address for Correspondence:
Sumeet S. Chugh MD
Cedars-Sinai Medical Center
Advanced Health Sciences Pavilion
Suite A3100, 127 S. San Vicente Blvd.
Los Angeles, CA 90048
Tel: 310-423-1206
Fax: 310-423-3522
E-mail [email protected]
Journal Subject Code: Atherosclerosis:[135] Risk factors
1
DOI: 10.1161/CIRCULATIONAHA.114.011988
Abstract
Background—Sports-associated sudden cardiac arrests (SCAs) occur mostly during middle age.
We sought to determine burden, characteristics, and outcomes of SCA during sports among
middle aged residents of a large US community.
Methods and Results—SCA cases aged 35-65 years were identified in a large, prospective,
population-based study (2002-2013), with systematic and comprehensive assessment of their
lifetime medical history. Of the 1,247 SCA cases, 63 (5%) occurred during sports activities at a
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
mean age of 51.1±8.8 years, yielding an incidence of 21.7 (95%CI 8.1–35.4) per million per
among
men
year. The incidence varied significantly based on sex, with a higher incidence am
mong
n m
en ((RR
RR
RR
18.68 95%CI 2.50–139.56) for sports SCA, as compared to all other SCA (RR 2.58, 95%CI
2.12–3.13).
event
2.
.122–3
–3.1
.13)
13)
3).. Sports
S orrts SCA
Sp
SCA was also more likely to
o bbee a witnessed eve
v nt ((87
ve
87 vs. 53%, P<0.001),
with
w
ith
h cardiopulmonary
cardiopul
ulm
monary
nary
y resuscitation
reesus
esusccit
citati
tatioon
on (44
(44 vs.
vs. 25%,
25%, P=0.001)
P=0.00
P=
001)
00
1) and
annd
nd ventricular
venntr
tric
i ul
ic
ulaar fibrillation
fibr
fi
bril
illa
laati
tion
o (84
on
(844 vvs.
s.
51%,
P<0.0001).
51
1%, P
<0.0
<0
.0000
001)
1)). Survival
Surv
Surv
viv
val too hospital
hoosp
spit
itaal
it
al discharge
dissch
chaarge
ge was
was hhigher
igh
her for
or sports-associated
spo
port
rtsrt
s-aasssoci
sociiat
ated
e SCA
ed
SCA (23.2
(23.2 vs.
vss.
P=0.04).
Sports
with
cardiac
•11
13.6%, P=0.0
04)
4).. Sp
Spor
o ts
or
t SCA
CA ccases
ases
as
e ppresented
es
rese
re
sent
se
nted
nt
ed w
itth kknown
n wn ppre-existing
no
re-e
re
-eexi
x sttin
ingg ca
card
rdia
rd
i c disease
ia
dise
di
seas
se
asee in 16%, •
as
cardiovascular risk factor in 56%, and overall, 36% of cases had typical cardiovascular
symptoms during the week preceding SCA.
Conclusions—Sports-associated SCA in middle age represents a relatively small proportion of
the overall SCA burden, reinforcing the idea of the high benefit-low risk nature of sports activity.
Especially in light of current population aging trends, our findings emphasize that targeted
education could maximize both safety and acceptance of sports activity in the older athlete.
Key words: coronary artery disease, physical exercise, cardiopulmonary resuscitation, cardiac
arrest
2
DOI: 10.1161/CIRCULATIONAHA.114.011988
Introduction
Sudden Cardiac Arrest (SCA) represents a major public health issue worldwide, accounting for
almost half of cardiovascular mortality.1, 2 When occurring in the setting of sports, SCA
generates major societal attention and alarm, since the collapse usually occurs in a public setting,
in front of many witnesses, striking those considered to be the healthiest in the community.
SCA among young competitive athletes has been extensively investigated in the United
States,3, 4 allowing significant improvements in the field, notably initiation and optimization of
preventive strategies.5-9 However, except for limited data on specific recreational sport
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activities,10, 11 there are, to the best of our knowledge, no studies evaluating SCA during sports
among middle-aged subjects in any United States community. Recent Europeann experience
expe
p ri
rien
ence
en
ce has
has
a
emphasized that, in the community, the largest burden of sports-associated SCA results from
ev
events
ven
ents
ts aamong
mong
mo
ng m
middle-aged
iddl
id
d e-aged participants.12-15 A bbetter
dl
et er understandin
ette
understanding
in
ng off bburden
ur
urden
(absolute as well
as relative
relative to oother
therr nnon-sports
th
onn-sspoort
rtss re
rela
related
laate
tedd SC
SCAs)) aand
nd ccharacteristics
haraactter
eriistics off SC
SCA
CA du
duri
during
rinng
ri
ng ssports
port
po
r s in m
rt
middleidddleid
dl
aged ppopulation
aged
opul
op
ullat
atiion
ion is llikely
ikeelyy to iinform
ik
nfo
orm ppreventive
reeve
vent
ntiv
nt
ivee st
iv
sstrategies.
raateegi
gies
es..
Avail
Available
lab
able
l information
le
inf
nfor
orrma
m tiion hhas
as ttraditionally
radi
ra
diiti
tion
onal
on
ally
al
ly
y been
bee
eenn restricted
r sttri
re
r ct
cted
e tto
ed
o re
resu
resuscitation
susc
su
scit
sc
itat
it
atio
at
ionn va
io
vari
variables
riab
ri
able
ab
l s in the
le
immediate setting of the event. However, for a study to be meaningful from a clinical perspective
a detailed evaluation of the lifetime past medical history is needed, which is particularly
challenging to obtain for SCA where the majority will inevitably die in the field, and
consequently the information collected by Emergency Medical Services (EMS) is often restricted
to data regarding the resuscitation process. Details of the past medical history of SCA patients
(especially those that cannot be resuscitated) are thus usually sparse and very rarely considered
systematically. In this regard, information concerning prior cardiovascular risk factors, frequency
and type of symptoms in the weeks preceding SCA during sports, have not been previously
3
DOI: 10.1161/CIRCULATIONAHA.114.011988
characterized.
Using a large 12-year prospective study of SCA in a northwestern US metro region, with
a systematic comprehensive evaluation of the lifetime clinical history, we assessed the
characteristics and outcomes of SCA during sports in middle age compared to other SCAs (not
occurring during sports activity).
Methods
Setting, Definitions and Survey Methods
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The Oregon Sudden Unexpected Death Study (Oregon-SUDS) is an ongoing community based
166
prospective study of out-of-hospital SCA. Detailed methods have been published
ed
d previously.
pre
r vi
viou
ousl
usl
sly.
y 16,17
y.
Briefly, since February 1, 2002, cases of SCA in the Portland Oregon metropolitan area were
identified
den
nti
tifi
fied
fi
ed using
usi
sinng multiple
multiple
ul
sources that included th
the
he E
Emergency
mergency Me
Medical
edi
d caal Services
Se
(EMS) response,
response
the
he Medical
Medical Examiner’s
Exaamin
Ex
iner
err’ss office
off
ffic
icce and
and emergency
emer
em
errgenncyy departments
depa
partme
pa
ment
me
ntss of
of all
all
ll of
of th
the
he 16 llocal
occal hhospitals.
osspiitals
ls. Th
ls
T
Thee
county
emergency
medical
response
with
advanced
co
ounty
unty hhas
as a two-tiered
twoo-ttie
iere
reed em
emer
rge
g nc
ncyy me
ediica
call re
esp
spoonsse
se ssystem
ysste
tem
m wi
w
th iinvolvement
th
n olvveme
nv
ment
nt ooff ad
adva
ancced
cardiac life support
sup
uppo
port
po
rt staffed
staaff
ffed
d fire
fir
ire engine
engi
en
giine
n companies
com
omppan
anie
i s as well
ie
wel
elll as
a transporting
tra
rans
nspo
ns
po
ort
rtin
ingg ambulances.
in
ambu
am
bu
ulaanc
nces
es.
es
A comprehensive evaluation is performed for each case of unexpected death, including
analysis of the circumstances of arrest recorded by EMS personnel or the medical examiner, prearrest medical records, and available autopsy data. A process of in-house adjudication by three
physicians is employed to determine cases meeting criteria for SCA. In the event of a
disagreement regarding a specific case, the determination is based on the majority opinion. In the
present analysis we included middle-aged men and women, defined as male subjects aged 35–65
years, ascertained from February 2002 to January 2013. This study was approved by the
Institutional Review Boards of Cedars-Sinai Medical Center, Oregon Health and Science
4
DOI: 10.1161/CIRCULATIONAHA.114.011988
University and all participating hospitals.
Sudden cardiac arrest was defined as a sudden unexpected pulseless condition; if unwitnessed, subjects were included if observed alive and symptom-free within 24 hours of their
sudden arrest. During the adjudication process, patients with known non-cardiac causes of arrest
(e.g., trauma, overdose, pulmonary embolism, cerebrovascular accident, and terminal illness
such as cancer not in remission) were excluded.1, 15 SCA during sports was defined as death
occurring during sports activities or within one hour of cessation of sports activity. In most cases,
the event occurred as an unexpected collapse during physical exertion. Of note, SCA occurring
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during physical activity but not in the setting of sports (typically SCA during sexual intercourse)
was not considered as sports-associated SCA. Previous medical history was obtained
obtai
aiineed from
from a
comprehensive assessment of inpatient as well outpatient medical records/visits obtained from
he hospital
hosspit
ho
spit
ital
al systems
syyste
teems
ms in the Portland metropolita
an area.
arrea.
the
metropolitan
V
arriables
ri
Asse
sessseed
ed
Variables
Assessed
Va
ari
r ab
able
less considered
connsid
co
nsid
derred in
in the
the pr
pres
essen
entt an
anal
a ys
al
ysis
is inc
ncllude
nc
uded
ed demographics,
dem
emoogra
ogra
raph
phhiccs, circumstances
circcums
msta
taanc
nces
es off occurrence
occcu
curr
rreence
Variables
present
analysis
included
as well as res
sus
u ci
c ta
tati
tion
ti
on
n ddata.
atta.
a IIn
n ad
addi
diiti
t on
n tto
o ddetailed
etai
et
a leed in
ai
info
orm
rmat
atio
at
ionn ob
io
oobtained
tain
ta
ined
in
ed ffrom
rom
ro
m EM
EMS,
S, iindex
ndex
resuscitation
addition
information
hospital stay, and medical examiner medical records, a working group of the Oregon-SUDS
collected and assessed the lifetime past medical history for both deceased patients and consent
survivors, including assessment of symptoms prior to SCA.
Variables included: (i) time and location of each event; (ii) clinical and demographic
information (age, sex, personal history of known cardiovascular risk factors or heart disease, and
any symptoms during the preceding week). Symptom assessment was derived from multiple
sources, including family members at the scene of SCA, witnesses, and survivors of SCA. In
addition, available hospital and outpatient medical records for all subjects were systematically
5
DOI: 10.1161/CIRCULATIONAHA.114.011988
analyzed for information regarding symptoms. Symptoms were categorized as absent, present or
not evaluable based on the extent of information available, and the agreement of investigators.
Coronary Artery Disease (CAD) was defined as •50% lumen stenosis on coronary angiogram
prior to SCA event or identified at autopsy. In addition, subjects with past history of myocardial
infarction or coronary revascularization (either surgical or percutaneous coronary intervention)
were categorized as patients with CAD. History of heart failure was defined by a physician based
on medical records (in-hospital and/or outpatient visit) and/or low left ventricular ejection
fraction from echocardiogram, angiogram, or radionuclide multi-gated acquisition prior and
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unrelated to cardiac arrest; (iii) data regarding the setting and nature of sports activity at the time
of the event; (iv) circumstances of collapse (during sports activity or immediately
ly
y aafter),
f er), llocation
ft
ocat
oc
a ion
at
type
ype (sports facility or other area), presence of witnesses; (v) detailed information regarding
resuscitation
EMS
their
arrival
esuusc
scit
itat
atio
tio
ionn in
iincluding
cllud
udin
i g response time (time from
m EM
MS call to thei
eirr arri
riiva
vall on the scene),
bystander
resuscitation
initiation,
bysttan
a der cardiopulmonary
card
dio
opu
ulm
mon
nar
aryy re
res
susccittatiion (CPR)
susc
(C
CPR
R) in
nitiati
tiion,
on, the
t e presenting
th
prressen
nting
tiing ccardiac
arddiac
ar
diac rrhythm
hyth
hy
thm
th
m
(ventricular
pulseless
return
ven
entr
tric
tr
icul
ic
ular
ar ttachycardia/fibrillation,
achhyc
ac
hycard
card
dia
ia/f
/ ib
/f
ibri
riilla
lati
tion
ti
on, pu
on
ulssel
eles
ess el
es
eelectrical
ecctrric
i al aactivity
ctiivit
ct
ivit
ityy or
o aasystole),
sysstoole)
sy
ole)), re
etu
turn
rn ooff
spontaneous
circulation
(defined
palpable
conjunction
pontaneous ci
circ
rcul
rc
ulat
ul
atio
at
io
on (d
(def
efin
ef
ined
in
ed
d aass re
rreturn
tu
urn
n ooff a pa
palp
lp
pab
ablee ppulse
ulse
ul
se iin
n co
onj
njun
unct
un
ctio
ct
ionn wi
io
with
th a ssystolic
y tolic
ys
blood pressure of >60 mmHg); (vi) survival status to hospital discharge, available in the majority
of admitted cases (96%) — For survivors, neurologic status at discharge was evaluated using the
Cerebral Performance Categories (CPC) score from medical records, and a comparative analysis
was performed between sports-associated SCA and other SCA;14 (vii) autopsy report if
available.
Statistical Analysis
This report was prepared in compliance with the STROBE checklist for observational studies.18
The objective of the study was to provide comprehensive comparisons between sports SCA and
6
DOI: 10.1161/CIRCULATIONAHA.114.011988
non-sports SCA, including subject characteristics and survival to hospital discharge as well as
neurological outcomes. Case characteristics were reported as mean ± standard deviation,
proportions, median and Interquartile Ranges (IQR), as appropriate. Comparisons between
groups used Ȥ2 test for categorical variables, Fisher Exact test when appropriate and Student’s ttest or Mann-Whitney test for continuous variables.
For calculation of incidence rates, the population was limited to Multnomah County,
Oregon, the largest subset of the metro area residents (population 679,348, including 135,868
men and 133,598 women, aged 35 to 65 years, 2003 US Census Bureau data for the Multnomah
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
County) and for the 2002–2005 period (where all SCAs were recorded). All Multnomah County
esidents, aged 35 to 65, were included for calculation of annual incidence rates iin
n mi
m
ddle
dd
le-a
le
-age
-a
g d
ge
residents,
middle-aged
men and women (calculated per year per million residents).
Pred
Pr
edic
ed
ictors
ic
rss ooff survival to hospital discharg
rg
ge w
ere studied aamong
m ng
mo
gS
C cases with
CA
Predictors
discharge
were
SCA
esuusc
s itation attempted
atte
at
teempte
tedd (N=936).
(N=9
(N
=936
=9
36).
36
). Any
Any
ny variables
variab
ab
blees inn univariate
univa
vari
va
riaate
ate analyses
anaalyyses
an
yses with
withh a P value
val
a ue
ue <0.15
<0..15
15 were
wer
ee
resuscitation
ncl
clud
uded
ud
e in
ed
in the
the multivariate
mult
mu
ltiv
iv
var
aria
iate
t modeling.
mod
odel
elin
el
ing.
in
g. The
The association
asssoc
o iattionn of SCA
SCA
A with
witth favorable
faavo
vora
rabble
ble ou
out
tcome
tco
ome (sur
((survival
survvivval
va
included
outcome
o hospital discharge)
disc
di
scha
sc
h rg
ha
rge)
e was
e)
was
a thereafter
the
here
reeaft
f err adj
djus
dj
uste
us
teed fo
or th
hes
e e id
iden
enti
en
tifi
ti
fied
fi
ed con
onfo
on
foun
fo
undi
un
ding
di
ngg ffactors
acto
ac
to
ors in a singlee
to
adjusted
for
these
identified
confounding
multivariable logistic regression analysis, allowing estimation of odds ratios (ORs) and their
95% confidence intervals (CIs). As a sensitivity analysis, to better appreciate the likelihood for
survival when SCA occurs in the setting of sports activities, we performed additional analysis
using propensity score matching.19 We calculated each subject’s propensity score as the
predicted probability of having SCA during sports given the subject’s measured covariates (age,
gender, history of coronary artery disease, presence of witness, bystander cardiopulmonary
resuscitation, ventricular fibrillation, delay of intervention). We matched each case to the control
subject (i.e., a patient who suffered a non-sports SCA) with the closest propensity score, which
7
DOI: 10.1161/CIRCULATIONAHA.114.011988
resulted in a dataset with 66 (33/33) SCA matched cases. All data were analyzed using STATA
software version v11.0 (Lakeway Drive, TX).
Results
Patient Characteristics and Circumstances of SCA Occurrence
Between February 2002 and January 2013, there were a total of 63 subjects, middle-aged SCA
cases that occurred during sports activities (Table 1), mainly during jogging (27%), basketball
(17%) and cycling (14%) activities. Other sports activities included gym activities (11%), golfing
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
(8%), volleyball (3%), tennis (3%), soccer (3%), and others (14%). Sports-associated SCA
occurred during the actual sports activity in 45 cases (76%) and within the following
follow
wing
ng hour
hou
ourr in 14
14
(24%).
24%). More than half of the cases (58%) occurred in sports facilities such as a gym or a
stadium,
whereas
tad
diu
ium
m, w
m,
herreas
he
ass tthe
he remainder (42%) occurredd in
i the
the field (outside
(outsi
siide
d ooff ssports
ports facilities). Among
the
sports-associated
SCAs,
which
occurred
outside
occurred
he 228
8 sports-as
asssocciat
ated
e S
ed
CAss,
CA
s, w
h ch
hi
c oc
ccurrre
red ou
utsidee of
of ssports
poort
rtss ffacilities,
aci
cili
liti
li
t es, 118
8 oc
occu
curr
cu
rrred inn public
pu
ubllic
parks,
areas.
pa
park
rks,
rk
s jjogging
s,
oggi
og
ging
gi
ng ttrails
raills or oother
therr ddelineated
th
elin
el
inea
in
eate
ea
tedd ar
area
eas.
ea
Of the
he overall
ove
vera
rall
ra
l number
ll
num
u be
berr off middle-aged
mid
ddllee ag
aged
ed SCA
SCA cases
cas
a es in
in this
this region
reg
gio
ionn during
durrin
du
ingg the
th
he 10-year
10-y
10
-year periodd
(N=1,247), sports-associated SCA in middle age represented 5% of SCA cases in this age group,
yielding an overall incidence of 21.7 (95%CI 8.1–35.4) per million per year compared to 555.0
(95%CI 541.4–568.7) for non-sports-associated SCA. The incidence varied significantly
according to sex with a much higher incidence among men (vs. women) for sports-associated
SCA (RR 18.68 95%CI 2.50-139.56), as opposed to all other SCA where differences were
smaller (RR 2.58, 95%CI 2.12-3.13). Extrapolating to the overall population of the United
States, we estimated the total number of sports-associated SCA among the 35-65 year-old agegroup to be 2,269 (95%CI 772–3,773) events among men and 136 (95%CI 0–1,846) events
8
DOI: 10.1161/CIRCULATIONAHA.114.011988
among women per year.
The mean age of patients developing SCA during sports was 51.1±8.8 years, without
significant difference between men and women (51.1±9.1 vs. 50.3±4.6 years, P=0.86). Although
there was an apparent similar overall prevalence of cardiovascular risk factors (•1 cardiovascular
risk factors, 56.3 vs. 62.7%, P=0.40), sports SCA cases were less likely to present with smoking
(31.3 vs. 60.8%, P=0.001) and diabetes mellitus (8.3 vs. 28.4%, P=0.002). Sports SCA cases
were also less likely to have known heart disease compared to non-sports SCA (15.9 vs. 30.2%,
P=0.013) (Table 1). Among the 44 middle-aged participants with possible assessment of
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
symptoms during the week before the event, 14 (33%) presented with symptoms: typical chest
were
pain in nine, dyspnea in four, and typical influenza-like symptoms in one. Whilee tthere
heeree w
eree
er
significant
ignificant sex differences in incidence of sports-associated SCA with higher burden in men, no
significant
men
clinical
ign
nif
ific
ican
ic
an
nt differences
differren
dif
encces were identified between m
enn and women fo
for cl
clin
iniical
in
ic characteristics,
circumstances
and
outcomes.
ci
irccum
u stancess an
nd ou
out
tcom
omes
es.
es
Bystander
CPR,
By
yst
s an
ande
derr CP
de
C
R, Advanced
R,
Advvan
nce
ced
d Life-Support
Liife
fe-S
-Sup
-S
up
ppo
port
rt and
and Predictors
Preediicttor
orss of Survival
Surrvi
viva
vaal
data
resuscitation
survival
SCA,
association
Descriptive da
ata oon
n re
resu
susccit
su
itat
atio
at
ionn an
andd su
urv
viv
ival
al aafter
fte
terr SC
S
A, bbased
ased
as
ed oon
n th
thee as
asso
soci
so
c at
ci
atio
io
on wi
with
t sports,
are presented in Table 2. When compared to other SCAs, SCAs during sports were characterized
by a greater proportion of witnessed events (87 vs. 52%, P<0.001), bystander CPR (44 vs. 25%,
P=0.001), as well as a greater likelihood of presenting with a shockable rhythm (84 vs. 51%,
P<0.001). The mean response time (6.8±4 min) was very similar between both groups (P=0.99),
with the proportion of patients receiving intervention within 8 min being 77% and 79% in sports
SCA and non-sport SCA, respectively (P=0.44). Survival to hospital discharge was higher for
sports-associated SCA (23.2%, 95%CI 11.8–34.6) compared to SCA not associated with sports
(13.6%, 95%CI 11.6–15.5) (P=0.04) (Figure 1-Panel A).
9
DOI: 10.1161/CIRCULATIONAHA.114.011988
Among overall SCAs with resuscitation attempted, variables independently (multivariate
analysis) associated with survival included public location (OR 1.55, 95%CI 1.10–2.17,
P=0.011), presence of witness (OR 3.22, 95%CI 1.80–5.77, P<0.0001), and initial shockable
rhythm (OR 4.54, 95%CI 2.94–7.14, P<0.0001). SCA in the setting of sports activity was not
associated with higher survival after adjustment for resuscitation variables (OR 0.82, 95% CI
0.36–1.82, P=0.62) (Figure 1-Panel B). From the additional sensitivity analysis, the propensityscore matched odds ratio for survival was not significantly associated with sports-SCA: OR 0.84
(95% CI 0.19–3.80, P=0.82). In addition, no significant association was observed for age (”50
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
vs. >50 years) (OR 1.13, 95%CI 0.74–1.74, P=0.55) and delay in EMS response (<8min vs.
•8min) (OR 0.96, 95%CI 0.69–1.34, P=0.83).
Etiologies of SCA could be identified in 829 cases (66%), without significant difference
between
be
etw
wee
eenn the
the ssports-associated
por
orrts
ts-a
-associated and non sports-associated
sports-ass
sssoc
o iated SCA (688 vs.
v . 66%,
vs
66%
66
%, respectively, P=0.76).
P=0.76)
The
patterns
sports
are
relatively
T
hee ov
ooverall
erall pa
att
tteernns ooff caus
ccauses
ausses
es ooff SC
SCA
A aamong
monng spo
orts and
nd nnon-sports
on-s
on
-spo
poorts SC
SCA
A ar
re re
rela
lati
t ve
ti
vely
ly ssimilar
imil
im
ilar
il
arr
(Figure
with
coronary
disease:
among
Figu
Fi
gure
gu
r 22),
re
), w
ithh a pr
it
ppredominance
edomin
ominan
a ce ooff co
an
oro
ona
narry
ry aartery
r ery
rt
ery di
isea
isea
ease
se: am
se
amo
ong th
ong
thee 8829
299 ccases,
asess, 336
ases
6 oout
utt ooff 433
(84%)
sports-associated
SCA
CAD,
compared
out
84%) sports
s-aass
s oc
ocia
iate
ia
teed SC
CA we
were
r aassociated
re
ssoc
ss
o ia
oc
iate
tedd wi
te
with
th C
AD
D, co
comp
mpar
mp
a ed
ar
d tto
o 71
7177 ou
ut of 7786
8 (91%) forr
86
other SCAs. The phenotype of coronary artery disease among SCA cases, based on the setting of
occurrence (sports vs. non-sports) is reported in Table 3, for overall 181 (24%) of cases with
typical features of acute coronary syndrome (either on cardiac pathology or coronary
angiogram). Among those subjects with known coronary artery disease (517 subjects), 140
(27%) had undergone a revascularization procedure (percutaneous coronary intervention in 46%)
prior to developing SCA. Other causes of SCA included dilated cardiomyopathy (30),
hypertrophic cardiomyopathy (30), congenital heart disease (6), mitral valve prolapse (3),
myocarditis (3), and arrhythmogenic right ventricular dysplasia (2) (Figure 2).
10
DOI: 10.1161/CIRCULATIONAHA.114.011988
Discussion
To the best of our knowledge, this study represents the first comprehensive assessment of SCA
associated with sports activity among middle-aged participants in a US community. First, our
findings emphasize that sports-associated SCA eventually represented a relatively small
proportion of overall SCA in this population; a fact that is likely to encourage sports activities
among middle-aged athletes, after appropriate attention to any existing musculo-skeletal
limitations. Second, the comprehensive assessment of the lifetime past medical history revealed
that in almost two third of cases, patients present with either a previously documented significant
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
cardiovascular disease and/or symptoms prior to the event. This latter finding suggests that
utilization of educational and general awareness approaches may further decrease
see ssportsp rt
po
rtssassociated SCA burden.
An objective
obj
b eccti
tivve
ve assessment of sports-associated
sports-associiate
ated SCA in the community
c mm
co
mun
unity outlines the scope of
o
problem
difficult
a pr
roblem that
at ccan
an bbee di
diff
ffic
ff
icul
ic
ultt to aassess
ul
sssesss ddue
uee to
o a ddisproportionate
isspro
oport
porttio
iona
natte eemotional
moti
mo
t onall aand
nd llay
ay ppress
ress iimpact.
mpact
mp
The
design
our
study,
multiple
especially
Th
he de
desi
sign
gn ooff ou
ur st
stud
uddy,, bbased
ased
as
e oon
ed
n mu
m
ult
lttip
ple ssources
ouurc
r es off aascertainment,
scer
sc
ertaain
er
inm
ment
ment
nt,, was
was es
spe
peci
c al
ci
ally
ly uuseful
sefful
ful to
to
captured.
incidence
SCA
ensure that all
all cases
c se
ca
sess off interest
int
n er
eres
est were
es
wer
e e ca
apt
p ur
u ed
ed.. Th
Thee in
nci
c de
denc
ncee of ssports-associated
nc
poort
rtss as
sasso
soci
so
c at
ci
ated
ed S
C estimated
CA
d
in this study is highly similar to recently reported experiences among men in Europe (from 33 to
58 per million per year).12, 13 However, by evaluating sports-associated SCA as well as overall
SCAs in the same time period and geographical area, we were able to place the burden of sportsassociated SCA in the context of overall SCA burden, and report that it eventually represented a
small proportion of cases (one SCA out of 20). This finding suggests that in the context of SCA,
the overall risk-benefit ratio is in favor of sports activity.
In our population, the incidence ratio between men and women was 7-fold higher in
sports SCA compared to non-sports SCA. Whether this reflects an intrinsic difference in
11
DOI: 10.1161/CIRCULATIONAHA.114.011988
pathophysiology between sexes is still speculative, but some factors merit consideration. First,
men may have higher sports participation rates than women, which may contribute to the gender
differences in SCA rates. Consistent with this observation, the incidence of SCA in women was
transiently elevated during moderate to vigorous exertion but with a RR of only 2.38 (95% CI
1.23 to 4.60), while being almost 20-fold higher (RR 44.9, 95% CI 26.7 to 75.4) during vigorous
activity among men enrolled in the Physicians’ Health Study.20, 21 Similar gender differences
have also been reported in smaller retrospective studies in Finland and in the United States.22, 23
Second, the duration per sports session as well as the vigor and the method of physical activity
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
could differ between men and women. However, in considering inherent sex differences,
potential explanations could include a number of factors, such as differences in vuln
vvulnerable
uln
nerrab
able
le
ubstrate (underlying structural or electrical heart disorder), triggers and/or autonomic
substrate
modu
mo
dula
du
lattors
la
tors
rs.. T
hee ag
age
e-specific prevalence of coro
ona
n ry heart disease
see is kn
kno
ow to be lower in
own
modulators.
The
age-specific
coronary
known
m
idddle-aged
dd
wome
wo
menn (compared
me
( om
(c
ompa
pare
pa
redd too men),
re
men), and
annd a particularly
paartticuularly
arly
y lo
ow pprevalence
ow
reva
vale
lennce ha
le
hass be
een
n aalso
lo
ls
middle-aged
women
low
been
obbse
serv
rved
rv
e among
ed
amo
m ngg female
feema
emale
ale victims
victtim
vi
imss of SCA,
SCA
A, suggesting
sugg
su
gges
gg
e tiingg that
es
th
hatt w
om
men m
ay hhave
av
ve lo
low
wer ra
wer
rat
tess off ssports
ports
por
r ts
observed
women
may
lower
rates
yoca
yo
c rd
ca
rdia
i l is
ia
sch
hem
emia
ia aass th
he pr
prim
imar
im
aryy ca
ar
caus
use.
us
e 24 A
e.
Another
noth
no
ther
th
er interesting
intter
e es
esti
t ng fa
ti
factor
fact
c or rrelates
ct
elat
el
a es to
SCA with m
myocardial
ischemia
the
primary
cause.
coronary plaque rupture, which has been associated with a significant proportion of sportsrelated acute coronary syndrome and SCA.25 Overall, women are significantly more likely to
have plaque erosions (as opposed to plaque rupture) than men, potentially suggesting an
inherently lower likelihood of plaque rupture in the setting of exercise in women. Sex-related
differences in ventricular repolarization and vagal tone are also potential factors affecting sports
SCA pathophysiology.25
Subjects that suffer SCA during sports activity are generally perceived as previously
healthy individuals with the event being considered as truly “unexpected’. Our comprehensive
12
DOI: 10.1161/CIRCULATIONAHA.114.011988
assessment of the past medical history in these cases demonstrates that in more than half,
subjects had at least one cardiovascular risk factor. However, it is important to bear in mind that
the long-term benefits of regular exercise on cardiovascular health are well established,21, 26 and
habitual physical activity has been demonstrated to reduce coronary heart disease events. While
existence of a “sports paradox” has been recognized— vigorous activity can also acutely and
transiently increase the risk of SCA and acute myocardial infarction, especially in those not
habituated to exercise — overall, the long-term benefits outweigh the short-term risks related to
physical activity.21 Thus, the findings from this study should in no way discourage patients with
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
cardiovascular risk factors from engaging in regular, appropriate physical exercise within a
framework of simple guiding rules from the treating physician. Whether a cautio
cautionary
onary
nar nnote
otee ne
ot
nee
needs
eds
too be raised with respect to sports in those with established coronary artery disease, is a clinical
question
ques
qu
esti
es
tioon
ti
on tthat
hatt need
ha
needs
edss further investigation. Physic
ed
Physical
cal
al aactivity
ctivity counse
counseling
eli
l ngg m
must
ust be tailored to the
nneeds
eed
ed
ds and circ
circumstances
cum
mstan
anccess of tthe
he iindividual,
ndiv
nd
ivid
iv
dual, tthereby
hereb
by iincreasing
ncr
crreasi
easiingg the
the likelihood
like
keli
l hoodd ooff su
li
success
ucc
cces
e s an
es
andd
7-2
29
29
decreasing
exercise.
decr
de
crea
cr
easi
ea
s ng the
si
the
h risk
risk of cardiovascular
cardi
ard ovvasscu
cullar
ar events
eve
vent
ntss during
nt
duuri
r ng vvigorous
ig
gorrou
ouss ex
exe
erciise
erci
se.227-29
In
In this
th
his context,
conte
on extt,
education off patients
pat
atie
ieent
ntss with
wit recognized
rec
ecog
og
gni
nize
zeed cardiovascular
card
ca
rdio
rd
io
ova
vasc
s ul
sc
ulaar di
dise
seas
se
asee or rrisk
as
i k fa
is
fact
ctor
ct
orss re
or
rega
gard
ga
rdin
rd
ingg avoidance
in
disease
factors
regarding
of extreme exercise may minimize any potential harm,23 while maximizing the acceptance of
sports activity as a tool to improve cardiovascular fitness.21
Of interest, the proportion of patients with cardiovascular risk factors may appear higher
when compared to the first published community-based report on SCA during sports in France
(11%).12 Although differences in subjects’ characteristics may partly explain such differences,
the lower rates in Europe may reflect the challenges in retrieving the detailed lifetime medical
history in some studies. In addition, a significant proportion of the middle-aged subjects, who
eventually died during sports activity, exhibited cardiac symptoms within a short period (one
13
DOI: 10.1161/CIRCULATIONAHA.114.011988
week) preceding the SCA event. Taken together, these findings suggest that careful attention to
pre-existing heart disease and warning signs, along with public education and awareness in this
regard may have an important place in the overall strategy to reduce SCA associated with sports
activity.
Overall, only one third of witnessed SCA cases received bystander CPR indicating
substantial room for improvement in public knowledge and attitudes towards basic life
support.30-33 Bystander-CPR is more likely to be initiated for SCA during sports, and this may
have contributed to the higher likelihood of shockable rhythms at arrival of EMS, also extending
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
the window of opportunity for successful defibrillation.34, 35 The sports-associated SCA setting
has appeal for the public and can serve as a springboard to efficiently educate the
hee ppublic
u li
ub
licc
regarding
egarding basic life support. Therefore, these findings also have potential implications for prehospital
ho
osp
spit
ital
it
al eemergency
m rgen
me
ncy care policy-making to prom
promote
mote
ote community ed
education
duc
u at
atiion in basic life support.36,
37
7
38, 39
A
Although
l hough SC
lt
SCA
CA duri
dduring
uring
ingg ssport
port
po
rt iiss ass
aassociated
ssoc
sociaated w
with
ith a hhigher
igh
her
er ssurvival,
urvivval,38
urvi
itt seems
seem
se
emss that
em
th
hatt this
thi
h s is
mainly
ma
ain
inly
ly explained
exp
xpla
laiined
la
ined
d by
by the
the co
conc
concomitant
nccom
mit
itan
antt asso
an
aassociation
sso
soci
ciat
ci
atio
ionn wi
io
with
th
h ffactors
acto
ac
torss tthat
to
haat ha
have
vee a ppositive
osit
os
ittiv
i e im
impact
mpaactt oon
n th
the
he
resuscitation
esuscitation
n pr
proc
process,
o es
oc
ess,
s ssuch
s,
u h as pre
uc
presentation
rese
re
s nt
se
n attio
i n wi
with
th a sshockable
hock
ho
ckab
able
ab
le rrhythm
hyth
hy
thm
th
m aand
nd tthe
he ppresence
rese
re
senc
se
ncee of
nc
o
witnesses during the SCA. Sports facilities have been identified as being particularly suitable for
AED deployment,40 and where AED placement has largely been considered advisable.41 Our data
further emphasize the need for systematic availability of AEDs in public sports facilities.42
However, since a good proportion of SCA occurred outside sports facilities, there is still room
for improvement in public AED deployment. One potential strategy under consideration is AED
placement in strategic locations such as public parks and popular jogging trails. Additionally
public education to increase awareness also has an important role in improving bystander CPR.
Although our data are, to the best of our knowledge, the first to address the issue related
14
DOI: 10.1161/CIRCULATIONAHA.114.011988
to burden and outcomes among the middle age from the general population in a large US
community, with a particular efforts to provide data on past medical history, we acknowledge
some limitations. Firstly, due to the extremely low incidence of SCA among women, statistical
power to assess gender-related differences in sports SCA was limited. Second, we do not have
access to information regarding whether or not cases of sports-associated SCA underwent regular
training prior to the SCA. Regular training has been shown to reduce the incidence of SCA
during sports activity.21 Third, we are not able to provide details regarding the level of exercise at
the time of SCA for the entire period. Because there is no evidence to support a triggering effect
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
of light exertion for SCA,20 it may be possible that some of SCAs occurring during sports
activities were associated by chance and not related to the activity itself. Hence our
our use
usee of
of the
the
term
erm ‘sports-associated’ rather than ‘sports-related’ SCA. For the SCA cases which occurred
between
beetw
wee
eenn 20
2002
02 and
nd 22006,
006, an estimated metabolicc eq
eequivalent
uivalent (MET)
T sco
T)
score,
co
ore
re,, reflecting the intensity
off eexercise
was
x rcise wa
xe
as cal
ccalculated.
alcul
ulat
ul
ated
ed.43, 44 One
ed
One M
MET
ET iss th
the
he am
amount
mounnt
nt ooff en
energy
ner
erggy
gy spe
spent
pennt bby
y a pe
pers
person
rsson ssitting
i tiing
it
ng
quietly.
quie
qu
ietl
ie
tly.
tl
y. P
Physical
hysi
hy
sica
call aactivities
cti
tivviti
tiies w
were
ere cl
clas
classified
assi
siffied
fied iinto
nto
o tthree
hrreee ggroups:
roup
ro
upss: llight
up
ighht ((<4
ig
< M
<4
MET),
ET),
ET
), m
moderate
od
der
erat
atee (4
(4-6
4-6
MET), and he
heavy
eav
avyy (>
(>66 ME
M
METS)
TS)) sp
TS
sport
por
o t ac
aactivity.
tivi
ti
vity
vi
ty.. Ov
ty
Over
Overall,
eral
er
a l, amo
al
among
mong
mo
ng tthe
he 330
0 SC
SCA
A du
dur
during
rin
ng sp
spor
sports
orts
or
t activities
with estimated MET available between 2002 and 2006, light exertion was observed in 14% of
SCA cases, whereas moderate and vigorous were observed in 50% and 38%, respectively.
Finally, specific coronary pathology examination could provide important information especially
details of potential sex-specific abnormalities, but were not routinely performed by the medical
examiner in Portland, Oregon.
In conclusion, the burden of sports-associated SCA among middle-aged participants is
relatively low when compared to the overall SCA burden in the community. Our findings of a
high prevalence of established cardiovascular disease as well as symptoms that manifested in
15
DOI: 10.1161/CIRCULATIONAHA.114.011988
advance of SCA highlight a prevention gap that can potentially be closed. The significant
prevalence of known cardiovascular disease and prior symptoms in affected participants offers
an opportunity for targeted education in order to maximize both safety and acceptance of sports
activity in the middle-aged group.
Acknowledgments: We gratefully acknowledge the assistance of all Emergency Medical
Services personnel (American Medical Response, Portland/Gresham fire departments), the
Oregon State Medical Examiner’s office and the 16 hospitals in the Portland Oregon metro area.
We thank Professor David Celermajer (Sydney Medical School, Sydney) as well as Doctor
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
Wulfran Bougouin (Paris Sudden Death Expertise Center, Paris) for their helpful and
constructive review of the paper.
Funding Sources: This work was funded in part by National Heart, Lung, and Blood Institute
gran
ants
tss R
01HL
01
HL10
HL
051
5170
7 and R01HL122492 to Dr.. C
h gh. Dr. Chugh ho
hu
old
ldss the Pauline and Harold
grants
R01HL105170
Chugh.
holds
Pr
ric
icee Chair
C aiir in Cardiac
Ch
Car
ardi
diac
ac Electrophysiology
Eleect
c ro
roph
phys
ph
ysio
ys
iolo
logy
g at
gy
at the
the Heart
Heaart Institute,
In
nst
stit
itut
it
u e,, Cedars-Sinai
Cedar
edarss-S
Sin
i ai Medical
Med
edic
ical
al C
e te
en
ter,
r,
Price
Center,
L
os Angeles,
A geles, CA
An
A. E.M
M. is a V
isit
is
i in
ingg F
acultyy S
cient
ntiist att tthe
he C
ed
darrs-Sina
naii Heart
na
Heart Institute
Insttitu
titutee fun
ndeed
Los
CA.
E.M.
Visiting
Faculty
Scientist
Cedars-Sinai
funded
by rresearch
essea
e rc
rchh gran
ggrant
rantt supp
ssupport
upp
porrt fr
ffrom
om tthe
he F
on
nda
dati
tioon pour
ti
p ur la
po
la Recherche
Rech
Re
cher
ch
erch
chee Medicale,
ch
Medi
Me
diccale
cale
l , the
the Philip
Phhillip
ip
Fondation
Foun
Fo
unda
un
dati
da
tion
ti
on, an
on
andd th
thee Fr
Fren
ench
en
ch S
ocie
oc
iety
ie
ty ooff Ca
Card
rdio
rd
iolo
io
logy
lo
gy.
gy
Foundation,
French
Society
Cardiology.
Conflict of Interest Disclosures: None.
References:
1. Fishman GI, Chugh SS, Dimarco JP, Albert CM, Anderson ME, Bonow RO, Buxton AE,
Chen PS, Estes M, Jouven X, Kwong R, Lathrop DA, Mascette AM, Nerbonne JM, O'Rourke B,
Page RL, Roden DM, Rosenbaum DS, Sotoodehnia N, Trayanova NA, Zheng ZJ. Sudden
cardiac death prediction and prevention: report from a National Heart, Lung, and Blood Institute
and Heart Rhythm Society Workshop. Circulation. 2010;122:2335-2348.
2. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai
S, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Kissela BM,
Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A,
Matchar DB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Soliman EZ,
Sorlie PD, Sotoodehnia N, Turan TN, Virani SS, Wong ND, Woo D, Turner MB. Heart disease
16
DOI: 10.1161/CIRCULATIONAHA.114.011988
and stroke statistics--2012 update: a report from the American Heart Association. Circulation.
2012;125:e2-e220.
3. Harmon KG, Asif IM, Klossner D, Drezner JA. Incidence of Sudden Cardiac Death in
National Collegiate Athletic Association Athletes. Circulation. 2011;123:1594-1600.
4. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive
athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation. 2009;119:10851092.
5. Drezner JA, Levine BD, Vetter VL. Reframing the debate: Screening athletes to prevent
sudden cardiac death. Heart Rhythm. 2013;10:454-455.
6. Drezner JA. Contemporary approaches to the identification of athletes at risk for sudden
cardiac death. Curr Opin Cardiol. 2008;23:494-501.
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
7. Uberoi A, Stein R, Perez MV, Freeman J, Wheeler M, Dewey F, Peidro R, Hadley D, Drezner
J, Sharma S, Pelliccia A, Corrado D, Niebauer J, Estes NAM, Ashley E, Froelicher
Froelicheer V.
V
Interpretation
nterpretation of the Electrocardiogram of Young Athletes. Circulation. 2011;124:746-757.
2011;124
244:7
7466-7
-757
57..
57
8. Kaltman JR, Thompson PD, Lantos J, Berul CI, Botkin J, Cohen JT, Cook NR, Corrado D,
ShapiroDrezner J, Frick KD, Goldman S, Hlatky M, Kannankeril PJ, Leslie L,, Priori S, Saul JP, Shapiro
Mendoza
Friedman
Mend
Me
ndooza
nd
oza CK,
CK Siscovick
Siisc
scov
o ick D, Vetter VL, Boineauu R,
R, Burns KM, Fri
riedma
ri
maan RA. Screening for
Sudden
Cardiac
Death
Young:
Report
National
Heart,
Lung,
Blood
Su
uddden Cardi
diacc D
di
eath
ea
th iin
n th
thee Yo
oun
ung:
g: R
epor
ep
ortt Fr
From
om
m a Nat
attio
iona
n l He
na
Hea
art,, L
ungg, aand
un
ndd B
lood
lo
od IInstitute
n tiitu
ns
tute
te
Working
Group.
Work
Wo
rking Grou
up. Circulation.
Circ
rcul
ulaati
ation
ion. 2011;123:1911-1918.
20111;12
2011
;123:19111--19118.
9.. D
Drezner
Detect,
manage,
shift
the
athletes
with
cardiac
reezn
z er JJA.
A. D
A.
ettec
ectt,
t, m
anag
an
ag
ge, iinform:
nfoorm
nf
orm: a pparadigm
arad
adig
ad
ig
gm sh
hift iin
hift
n th
he care
care ooff at
thl
hlet
etes
et
ess w
ithh ca
it
ard
dia
iacc
disorders?
diso
ord
rders?
s? Br
B J Sports
Spoort
rtss Med.
Med 2013;47:4-5.
2013
20
13;4
;47:4-5.
5.
10.
Incidence
jogging
10 Thompson
Thom
Th
omps
pson
on PD,
PD Funk
Fun
unkk EJ,
EJ Carleton
Carl
Ca
rlet
eton
on RA,
RA Sturner
Stu
turn
rneer WQ.
WQ In
Inci
cide
denc
ncee of ddeath
eath
ea
th dduring
urin
ur
ingg jo
jogg
ggin
ingg in
Rhode Island from 1975 through 1980. JAMA. 1982;247:2535-2538.
11. Harris KM, Henry JT, Rohman E, Haas TS, Maron BJ. Sudden death during the triathlon.
JAMA. 2010;303:1255-1257.
12. Marijon E, Tafflet M, Celermajer DS, Dumas F, Perier MC, Mustafic H, Toussaint JF,
Desnos M, Rieu M, Benameur N, Le Heuzey JY, Empana JP, Jouven X. Sports-related sudden
death in the general population. Circulation. 2011;124:672-681.
13. Berdowski J, de Beus MF, Blom M, Bardai A, Bots ML, Doevendans PA, Grobbee DE, Tan
HL, Tijssen JG, Koster RW, Mosterd A. Exercise-related out-of-hospital cardiac arrest in the
general population: incidence and prognosis. Eur Heart J. 2013;34:3616-3623.
14. Marijon E, Bougouin W, Perier MC, Celermajer DS, Jouven X. Incidence of sports-related
sudden death in France by specific sports and sex. JAMA. 2013;310:642-643.
17
DOI: 10.1161/CIRCULATIONAHA.114.011988
15. Marijon E, Bougouin W, Celermajer DS, Périer MC, Dumas F, Benameur N, Karam N,
Lamhaut L, Tafflet M, Mustafic H, de Deus NM, Le Heuzey JY, Desnos M, Avillach P,
Spaulding C, Cariou A, Prugger C, Empana JP, Jouven X. Characteristics and outcomes of
sudden cardiac arrest during sports in women. Circ Arrhythm Electrophysiol. 2013;6:1185-1191.
16. Chugh SS, Jui J, Gunson K, Stecker EC, John BT, Thompson B, Ilias N, Vickers C, Dogra V,
Daya M, Kron J, Zheng ZJ, Mensah G, McAnulty J. Current burden of sudden cardiac death:
multiple source surveillance versus retrospective death certificate-based review in a large U.S.
community. J Am Coll Cardiol. 2004;44:1268-1275.
17. Reddy PR, Reinier K, Singh T, Mariani R, Gunson K, Jui J, Chugh SS. Physical activity as a
trigger of sudden cardiac arrest: the Oregon Sudden Unexpected Death Study. Int J Cardiol.
2009;131:345-349.
18. Vandenbroucke JP. The making of STROBE. Epidemiology. 2007;18:797-799.
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
19. Austin PC. An Introduction to Propensity Score Methods for Reducing the Effects of
Confounding in Observational Studies. Multivariate Behav Res. 2011;46:399-424.
2011;46:399-424
4.
Stampfer
MJ,
Albert
20. Whang W, Manson JE, Hu FB, Chae CU, Rexrode KM, Willett WC, Stampf
pfer
err M
J, A
lber
lb
ertt
CM. Physical exertion, exercise, and sudden cardiac death in women. JAMA. 2006;295:13991403.
21.
21
1. Albert
Alb rt CM,
Albe
CM,
M, Mittleman
Mit
i tl
tlem
em
man
n MA,
MA, Chae
Cha
h e CU,
CU, Lee
Lee IM,
IM
M, Hennekens
Henn
nnnek
eken
e s CH,
CH, Manson
Mans
Ma
n onn JE.
ns
JE. Triggering
Tri
rigg
gggerrin
i g of
o
sudden
Med.
uddden death from
fro
rom
m cardiac
card
ca
r ia
rd
iacc causes
caause
sess by vigorous
vig
goroous exertion.
exeert
ertionn. N En
Engl
gl J M
ed
d. 22000;343:1355-1361.
0000;3
343
43:1
:135
:1
35535
5 13361.
5611
22.
Med
1986;711:20522
2. Vuori
Vuor
Vu
orii I.
I. The
The cardiovascular
caardi
ardiov
ovvas
ascu
ula
l r risks
risk
ri
skss of
sk
of physical
phy
hyssica
call activity.
ca
activvity
act
vi y. Acta
Acta M
ed
d SScand
cand
can
nd SSuppl.
uppl
up
pl.. 19
pl
986
6;7
711
11::20505
214.
4.
23. Siscovick
Cardiol
23
Sisc
Si
scov
ovic
ickk DS.
DS Exercise
Exer
Ex
erci
cise
se and
and its
its role
rol
olee in sudden
sud
uddden cardiac
car
ardi
diac
ac death.
dea
eath
th Ca
Card
rdio
ioll Clin.
Clin
Cl
in 1997;15:467-472.
1997
19
97;1
;15:
5:46
4677-47
4722
24. Albert CM, McGovern BA, Newell JB, Ruskin JN. Sex differences in cardiac arrest
survivors. Circulation. 1996;93:1170-1176.
25. Deo R, Albert CM. Epidemiology and genetics of sudden cardiac death. Circulation.
2012;125:620-637.
26. Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl HW, 3rd, Blair SN. Comparison of
lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a
randomized trial. JAMA.1999;281:327-334.
27. Thompson PD, Franklin BA, Balady GJ, Blair SN, Corrado D, Estes NA, 3rd, Fulton JE,
Gordon NF, Haskell WL, Link MS, Maron BJ, Mittleman MA, Pelliccia A, Wenger NK, Willich
SN, Costa F, American Heart Association Council on Nutrition PA, Metabolism, American
Heart Association Council on Clinical C and American College of Sports M. Exercise and acute
cardiovascular events placing the risks into perspective: a scientific statement from the American
18
DOI: 10.1161/CIRCULATIONAHA.114.011988
Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on
Clinical Cardiology. Circulation. 2007;115:2358-2368.
28. Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, Coke LA, Fleg JL,
Forman DE, Gerber TC, Gulati M, Madan K, Rhodes J, Thompson PD, Williams MA, American
Heart Association Exercise CR, Prevention Committee of the Council on Clinical Cardiology
CoNPA, Metabolism CoC, Stroke N, Council on E and Prevention. Exercise standards for testing
and training: a scientific statement from the American Heart Association. Circulation.
2013;128:873-934.
29. Koller A, Shephard RJ, Balady GJ. Exercise as cardiovascular therapy. Circulation.
2000;101:E164.
30. Schober P, van Dehn FB, Bierens JJ, Loer SA, Schwarte LA. Public access defibrillation:
time to access the public. Ann Emerg Med. 2011;58:240-247.
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
31. Bobrow BJ, Vadeboncoeur TF, Spaite DW, Potts J, Denninghoff K, Chikani V, Brazil PR,
Ramsey B, Abella BS. The effectiveness of ultrabrief and brief educational videoss fo
training
forr tr
trai
aini
ning
ngg
lay
ay responders in hands-only cardiopulmonary resuscitation: implications for thee future
fu
utu
t ree ooff citizen
citi
ci
tize
z n
cardiopulmonary resuscitation training. Circ Cardiovasc Qual Outcomes. 2011;4:220-226.
2011;4
;4:2
:2
220
20-2
226
26.
32. Marijon E, Bougo
Bougouin
g uin W, Celermajer DS, Perier MC, Benameur N, Lamhaut L, Karam N,
Dumas
Duma
Du
mass F,
ma
F, Tafflet
Taf
afflet
ett M,
M, Prugger C, Mustafic H, Rifler
Rifl
fler
fl
er JP, Desnos M, Lee Heuzey
Heuz
He
u ey JY, Spaulding
CM,
P,, Ca
Cariou
A,, Em
Empana
X.. M
Major
disparities
after
CM
M, Avillach
A illach
Av
ch P
C
riou
ri
ou
uA
Empa
pana
pa
n JJP,
na
P,, JJouven
ouve
ou
venn X
ajjorr rregional
egiona
eg
nal di
na
disp
sppar
arit
i iees in
n ooutcomes
utco
ut
come
mess af
me
afte
t r
te
sudden
uddden cardiac
ac arrest
arrres
estt during
duuri
ring
ng sports.
sport
portts.
s Eur
Eu
ur Heart
Heaart
art J. 2013;34:3632-3640.
2013
20
0 3;3
;34:
4:33632
3632--3640.
6 40
33.
Sasson
C,, M
Meischke
H,, Abel
Abella
BS,
Berg
Bobrow
BJ,
Chan
Root
ED,
Heisler
M,,
33
3. Sa
Sass
s on C
ss
eissch
chkke
ke H
A
bel
ella
la B
S, B
ergg RA
er
RA,, Bo
Bobr
brrow
wB
J, C
han PS
han
PS, Roo
R
oot
ot E
D, H
eissleer
er M
Levy
Masoudi
vy JJH,
H, Link
Lin
i k M,
M M
a ouudi
as
d F,
F, Ong
Ong M, Sayre
Say
ayre
re MR,
MR,
R Rumsfeld
Rum
umsf
sfel
eldd JS,
JS Rea
Rea TD.
T . Increasing
TD
Incr
In
crea
easi
sing
g
cardiopulmonary
with
cardiopulmon
on
nar
aryy resuscitation
resu
re
s sc
su
scit
i attio
ionn provision
prov
pr
ovis
ov
i io
is
on in communities
com
ommu
munnit
mu
i iees wi
w
th llow
ow bbystander
ysta
ys
taand
nder
e ccardiopulmonary
er
ardi
ar
diop
di
opul
op
u monary
resuscitation
rates:
American
Heart
Association
esu
susc
scit
itat
atio
ionn ra
rate
tes:
s: a sscience
cien
ci
ence
ce aadvisory
dvis
dv
isor
oryy fr
from
om the
the Am
Amer
eric
ican
an H
eart
ea
rt A
ssoc
ss
ocia
iati
tion
on ffor
or hhealthcare
ealt
ea
lthc
hcar
aree
providers, policymakers, public health departments, and community leaders. Circulation.
2013;127:1342-1350.
34. Herlitz J, Ekstrom L, Wennerblom B, Axelsson A, Bang A, Holmberg S. Effect of bystander
initiated cardiopulmonary resuscitation on ventricular fibrillation and survival after witnessed
cardiac arrest outside hospital. Br Heart J. 1994;72:408-412.
35. Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB.
Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital
cardiac arrest. JAMA. 2008;299:1158-1165.
36. Drezner JA, Rao AL, Heistand J, Bloomingdale MK, Harmon KG. Effectiveness of
emergency response planning for sudden cardiac arrest in United States high schools with
automated external defibrillators. Circulation. 2009;120:518-525.
37. Drezner JA. Preparing for sudden cardiac arrest--the essential role of automated external
19
DOI: 10.1161/CIRCULATIONAHA.114.011988
defibrillators in athletic medicine: a critical review. Br J Sports Med. 2009;43:702-707.
38. Drezner JA, Rogers KJ. Sudden cardiac arrest in intercollegiate athletes: detailed analysis
and outcomes of resuscitation in nine cases. Heart Rhythm. 2006;3:755-759.
39. Drezner JA, Chun JSDY, Harmon KG, Derminer L. Survival trends in the United States
following exercise-related sudden cardiac arrest in the youth: 2000-2006. Heart Rhythm.
2008;5:794-799.
40. American College of Sports Medicine and American Heart Association joint position
statement: automated external defibrillators in health/fitness facilities. Med Sci Sports Exerc.
2002;34:561-564.
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
41. Drezner JA, Courson RW, Roberts WO, Mosesso VN, Jr., Link MS, Maron BJ. Interassociation task force recommendations on emergency preparedness and management of sudden
cardiac arrest in high school and college athletic programs: a consensus statement. Heart
Rhythm. 2007;4:549-565.
42. Drezner JA, Asif IM, Harmon KG. Automated external defibrillators in healt
health
lthh an
aand
d fi
ffitness
tnes
tn
esss
es
facilities. Phys Sportsmed. 2011;39:114-118.
43. Ainsworth BE,, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, O'Brien WL,
Bassett
KH, Emplaincourt PO, Jacobs
Bass
Ba
sset
ss
ettt DR,
et
DR, Jr.,
Jr., Schmitz
Schmitz
ch
Jacobs DR, Jr., Leon
L onn AS.
Le
AS. Compendium of
physical
activities:
MET
Sci
Sports
Exerc.
phhyssic
i al act
ctiv
ivittie
iv
ies:
s an
s:
an update
upda
up
date
da
te of
of activity
acti
ac
tivi
vity
ty
y ccodes
odes
od
es aand
ndd M
ET
T iintensities.
nten
nt
e siiti
tiees. Med
Meed Sc
ci Sp
Spor
orts
or
ts E
xeerc
r .
2000;32:S498-504.
2000;32:S498
00
8-5
-504
04.
04
44.
Mittleman
Maclure
Tofler
Sherwood
Goldberg
RJ,
Muller
Triggering
444. Mi
Mitt
t le
tt
lema
mann MA
ma
MA,, M
acclur
clu e M, T
ofle
of
lerr GH
GH,, Sh
her
e wood
ood JB
JB,, Go
Gold
l berg
ld
berg R
J, M
ulleer JE
ulle
JE.. Tr
rig
igge
g riing
ge
g oof
acute
myocardial
physical
exertion.
Protection
triggering
regular
acut
utee my
m
ocar
oc
a di
d al
a iinfarction
nfar
nf
arctio
ionn by hheavy
eavy phy
ea
hysi
sica
call ex
exertion
on. Pr
Prot
otec
ection
on aagainst
gainst
ga
st tr
rig
gge
gering
g bby
y re
regu
gulaar
exertion. Determinants
Med.
Dete
teerm
rmin
in
nan
ants
ts of
of Myocardial
Myoccar
My
ardi
diial
a Infarction
Infa
In
farc
fa
rcti
rc
tion
ti
on
n Onset
Onsset
e Study
Stu
tudy
dy Investigators.
Inv
nvessti
t ga
gato
tors
to
rs.. N En
rs
Engl
gl J M
ed.
1993;329:1677-1683.
1993
19
93;3
;329
29:1
:167
6777-16
1683
83
20
DOI: 10.1161/CIRCULATIONAHA.114.011988
Table 1. Patient Characteristics for SCA Associated With Sports Versus Not Associated With
Sports.
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
Demographic data
Age — yr
Mean±SD
35–50
50–65
Timing — no. (%)
Weekend
Timing
Morning (6:00 am to 12:00 pm)
Afternoon (12:00 pm to 6:00 pm)
Night (6:00 pm to 06:00 am)
Unknown
Seasons
Summer
Autumn
Winter
Sppri
ring
ng
Spring
Nu
umber
mb off ca
card
rdio
iova
io
vasc
sccul
ular
ar risk
ris
isk
k factor
f ct
fa
ctor
or
Number
cardiovascular
no (%)
— no.
Non
None
One
One
More than
tha
hann one
on
ne
More
Type of cardiovascular
card
dio
iova
vasc
va
scul
sc
ular
ul
ar ris
risk
isk
is
k fa
factor
act
ctor
orr —
no.
no (%)
(%)
Diabetes mellitus
Dyslipidemia
Systemic hypertension
Body mass index (Kg/m2)
Smoking
Known heart disease — no. (%)*
Coronary artery disease
Atrial fibrillation
Heart failure
Pacemaker
Implantable Cardioverter Defibrillator
Sports-Associated
SCA
N=63
Non SportsAssociated SCA
N=1,184
P Value
51.1±9
39 (62)
24 (38)
53.1±8
648 (55)
536 (45)
0.08
0.26
28 (44)
314 (27)
0.002
<0.001
16 (25)
23 (37)
7 (11)
17 (27)
358 (30)
268 (23)
234 (20)
324 (27)
00.24
0.
24
19 (30)
14 (22)
12 (19)
188 (29)
258 (22)
288 (24)
340 (29)
298 (25)
298
0.
.38
0.38
18
8 ((43)
43
3)
9 ((19)
199)
(38
38))
18 (38)
3544 ((33)
35
33)
3
3)
15
59 (1
(15)
5)
159
5 9 (48)
50
(4
48)
509
4 (8)
16 (33)
19 (40)
29±6
10 (31)
10 (16)
5 (8)
3 (5)
3 (5)
3 (5)
0 (0)
315 (28)
290 (26)
528 (47)
30±8
451 (61)
358 (30)
220 (19)
64 (5)
185 (16)
56 (5)
2 (0)
0.002
0.27
0.28
0.21
0.001
0.01
0.03
0.82
0.02
0.95
1
SD denotes Standard Deviation. Percentages were calculated on the basis of the total number of known events.
* Among consent survivors or deceased patients with medical records available (N=583, including 45 sportsassociated SCA).
21
DOI: 10.1161/CIRCULATIONAHA.114.011988
Table 2. Setting and Outcomes of SCA Associated With Sports Versus Not Associated With
Sports.
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
Public occurrence — no. (%)
Sudden death witnessed — no. (%)
Bystander CPR — no. (%)
First rhythm recorded on preadmission
electrocardiogram — no. (%)
Ventricular fibrillation
Asystole
Pulseless electrical activity
Undetermined
Call-to-EMS arrival — no. (%)
Mean±SD
”8min
ROSC — no. (%)
Survival to hospital discharge — %
(95%
95%
% cconfidence
onfide
on
dencce in
de
interval)
Sports-Associated
SCA
N=63
55 (90)
55 (87)
28 (44)
Non SportsAssociated SCA
N=1,184
242 (22)
614 (52)
300 (25)
42 (84)
4 (8)
4 (8)
0 (0)
437 (51)
180 (21)
228 (27)
9 (1)
6.79±4
34 (77)
24 (39)
23.2 (11.8-34.6)
6.80±4
631 (79)
9)
241 (29))
13.6 (11.6-15.5)
EM
EMS
MS de
deno
denotes
n tees Em
Emer
Emergency
rge
genccy Medical Services; ROSC, Return
rn O
Off Spontaneous Ci
Circulation
irculat
atio
i n
io
Percentages
erceentages
en
were
were ccalculated
alcu
al
cula
cu
late
teed on tthe
h bbasis
he
asis
as
is ooff th
thee to
ttotal
taal nu
numb
number
mbeer ooff known
kn
now
ownn events.
even
ev
nts
ts.
22
P Value
<0.001
<0.001
0.001
<0.001
0.99
0.99
00.44
.444
.4
0.11
11
0.11
0.04
DOI: 10.1161/CIRCULATIONAHA.114.011988
Table 3. Coronary Artery Disease Associated With Sudden Cardiac Arrest: Sports Versus Not
Associated With Sports.
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
Sports-Associated
SCA
N=63
SCA with cause assessed — no. (%)
43 (68)
Frequency of CAD — no. (%)
36 (84)
Coronary presentation
Acute MI — no. (%)
12 (33)
History of CAD — no. (%)
3 (25)
No history — no. (%)
9 (75)
No Acute MI — no. (%)
24 (66)
History of CAD — no. (%)
17 (71)
No history — no. (%)
7 (29)
History of CAD — no. (%)
20 (56)
Prior revascularization
2 (10)
Surgical
1 (5)
PCI
1 (5)
History of angina
0 (0)
History
Hist
Hi
sttor
oryy of MI
MI
122 (60)
(60
6 )
Mean
48.1±18
Mean EF
F
48.1
48
.11±18
Non Sports-Associated P Value
SCA
N=1,184
786 (66)
0.89
717 (91)
0.10
0.23
169 (24)
69 (41)
100 (59)
548 (76)
428 (78)
120 (22)
497 (69)
0.08
138 (28)
0.12
0.1
.12
74 (15)
64 (13)
22 (4)
0.99
246
24 (49)
0.37
47.1±16
0.84
47.1±1
47
±166
0 84
0.
8
CAD denotes coronary
CAD
co
oro
ona
n ry
y aartery
rter
rt
eryy di
dis
disease;
seas
seas
asee;
e; EF,
EF, ejection
eje
ject
ctiion fr
frac
fraction
ction
n off thee le
left
eft vventricle;
en
ntr
tric
icle
le; MI
MI,, my
myocardial
yocar
ardi
ar
dial
di
al iinfarction;
nfar
nf
a ct
ar
ctio
i n;; P
io
PCI,
C,
CI
percutaneous
pee cutaneous coronary
perc
coronaaryy intervention.
intterv
ventioon..
Percentages
Peerc
r en
entages were
weere ca
calculated
alcculateed oon
n tthe
he bbasis
a is ooff th
as
thee total
to nu
number
umbeer ooff known
knoown
kn
own events.
ev
ventss.
23
DOI: 10.1161/CIRCULATIONAHA.114.011988
Figure Legends:
Figure 1. Panel A – Proportion of patients with return of spontaneous circulation and survival to
hospital discharge, according to sudden cardiac arrest (SCA) occurring during sports or not
during sports; Panel B – Odds ratio for survival to hospital discharge of Sports SCA compared to
Non-Sports SCA (crude and adjusted for age, sex, initial rhythm, response time, presence of
witness, bystander cardiopulmonary resuscitation, ventricular fibrillation). Error bars indicate
upper 95% confidence interval.
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Figure 2. Distribution of Cardiovascular Abnormalities Associated With Suddenn Cardiac
Car
a di
diac
acc Arrest
Arr
r es
et
SCA) in the 1,247 Subjects, According to Sports SCA (Upper Pie, N=63) and Non-Sports SCA
(SCA)
Low
ower
er Pie,
Pie
ie,, N=1,184).
N 1,
N=
1,1184).
18
(Lower
24
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Figure 1A
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3
2.5
2
1.5
1.5
1
0.5
0.5
5
0
Crude OR for
Survival
Figure 1B
Adjusted OR for
Survival
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Figure 2
Sudden Cardiac Arrest During Sports Activity in Middle Age
Eloi Marijon, Audrey Uy-Evanado, Kyndaron Reinier, Carmen Teodorescu, Kumar Narayanan,
Xavier Jouven, Karen Gunson, Jonathan Jui and Sumeet S. Chugh
Circulation. published online April 6, 2015;
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