Merije Chukumerije, MD, FACC

Although rare, a sports-related sudden cardiac arrest (SrSCA) and/or sudden cardiac death (SCD) in an athlete is a devastating, heartbreaking event with significant emotional and societal impact. Male athletes appear to have an incidence of SCD up to fivefold higher than their female counterparts,² more than observed in the general population.³ There is also clear evidence demonstrating an increased risk with higher level of competition, particularly from high school to collegiate athletics as first studied by Van Camp et al.² Data from the National Collegiate Athletic Association has shown higher event rates in Division I athletes compared to Division II and III athletes,^4,5 and also highlighted that amongst the most at-risk of all athletes were Black male Division I basketball players.^4,5

Given the growing pool of data, prudent efforts focusing on education and prevention have been implemented over the past decade, such as preparticipation screening of athletes to identify clinically relevant preexisting cardiovascular conditions. Although controversial and without universal standardization, this screening typically includes a comprehensive history and physical examination with the addition of downstream cardiovascular testing, if necessary. The presence of high-risk findings allows the clinician to appropriately counsel the athlete and their family, coach, team and organization regarding management or potential disqualification from play.

Emergency Action Plan

Recognizing that SrSCA may still occur despite our best efforts at prevention via screening, training facilities, sporting venues, and schools are encouraged to publish and prepare an emergency action plan (EAP) for the unfortunate moment when it is needed. There are multiple parts to an effective plan. The American Heart Association (AHA) has underscored a chain of survival which emphasizes an immediate recognition of the SCA, activation of emergency medical services, early cardiopulmonary resuscitation (CPR), rapid automated external defibrillator (AED) use, adequate advanced cardiac life support, and appropriate post-cardiac arrest care.¹⁰ The effectiveness of all parts of the EAP is only as good as the knowledge, understanding, and ability of those tasked with implementing it. For this reason, athletic trainers and team medical personnel, including team physicians, have been intimately apprised to the resuscitation strategy and frequently recertify to validate their competency. But what about the most important members of the response team? The athlete.

The Athlete's Role

As the hard-to-watch videos often illustrate, typically the first and closest witnesses to a fallen player are their fellow athletes. Understandably, the initial reaction is often one of fear, shock and dismay; rarely one of action. But the ability to quickly recognize a fallen player, check for a pulse, and immediately start CPR before and during the arrival of the trained staff may be a crucial addition to a successful resuscitation. Multiple studies demonstrate that immediate resuscitation efforts with CPR and early defibrillation with an AED significantly improve the chance of survival in out-of-hospital cardiac arrest, with survival rates declining by 7% to 10% for every minute that defibrillation is delayed.^11-13 As such, the athletic training team and medical personnel should have immediate access to AEDs, and participating athletes and spectators should also be aware of the locations of these devices and how to use them.

The world saw the perfect example of this at the 2020 UEFA European Football Championship Soccer tournament when a teammate provided immediate CPR to a fallen player. This was further supported in a French study that demonstrated how major improvements in on-field resuscitation led to a 3-fold increase in survival.¹⁸

As the common denominator and central figure in sports, the athlete may also play a significant role in sporting events that occur away from formal play. Organized sporting events have on-site emergency teams trained and prepared to implement a rehearsed EAP during games, dramatically reducing the SCA mortality rate.^11-15 However, there is limited data highlighting the incidence of SrSCA when not in the presence of trained medical professionals (i.e., when the athletes are training only amongst themselves). As practice and reactional play occur more frequently than formal games, increasing opportunities for cardiac events to occur, it is essential athletes understand the basics of SCD and how to implement an EAP. For this reason, athletes should consider practicing SCA resuscitation alongside other drills. Furthermore, given the rate of SCD in the general population, athletes equipped with CPR and emergency cardiovascular care are valuable members to their community and family. There are many ways to encourage the athlete to embrace this new responsibility, all of which starts with education, especially given the efforts to simplify CPR.⁹

Conclusion

Despite advances in screening and preparation, SCD – though extremely rare – will continue to occur. As we continue to learn more about SCD in athletes, provide more effective preparticipation screening, and improve response plans, an all-hands-on-deck approach is necessary to prevent every causality possible, both in the presence and absence of the medical staff. Training athletes to recognize and immediately respond to a witnessed collapse by a fellow athlete or spectator may be the one play in the playbook they will forever remember.

References

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This article was authored by Merije Chukumerije, MD, FACC, member of ACC's Sports and Exercise Section.

Additional ACC SCA resources include:

• ACC Joins Smart Heart Sports Coalition to Support Nationwide CPR Education, AED Access
• CardioSmart Patient Hub on SCA
• Exercising With HCM Infographic For Clinicians Working With Student Athletes
• AHA/ACC/HRS Guideline For Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (See Section 10.1 on athletes)
• ACC.org Expert Analysis Outlining the "How To" of Emergency Action Planning