Sudden death in athletes reduced three-fold with bystander training

Sudden cardiac death in athletes was reduced three-fold over a 13-year period as public education programs were introduced and more defibrillators were distributed in Parisian districts, even as incidence of heart attacks stayed the same. A study in the Journal of the American College of Cardiology tracked how the incidence, management and outcomes of sudden cardiac arrest (SCA) changed over time in sections of Paris, France as bystander cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use both increased. Researchers used data from the Paris-Sudden Death Expertise Center (Paris-SDEC) Sports-related Sudden Cardiac Arrest (SrSCA) dataset. A registry was deployed in more than 60 districts in Paris, most starting in 2005. Read: No increased risk of congenital anomalies from statin use during pregnancy “SCA was defined as a sudden and unexpected pulseless event without obvious extra-cardiac cause. SrSCA was defined as SCA occurring during sports, both competitive and recreational, or within 1 hour of sports cessation,” the study said. Researchers analyzed data for a 13-year period, during which time efforts evolved to reduce the burden of SCA, and of SrSCA in particular—including promoting basic life support via CPR and AEDs use by bystanders, as well as systematic screening of sports participants. Starting in March 1999, medical assessments became mandatory to participate in competitive sports or to get a sports license. In 2009, the French Society of Cardiology published pre-participation screening guidance. Read: QUIZ: Test your dyslipidemia knowledge Researchers looked at the number of new cases and management of SrSCA over a series of six successive two-year periods between 2005 and 2018. Results showed a steady increase in the frequency of bystander CPR initiation (reaching 94.7%, compared with 34.9% in the first study period) and public AED use (28.8% compared to 1.6%). This represented a nearly three-fold increase in survival rate, jumping from 23.8% in the first study period to 66.7% in the last period. However, sports-related SCA incidence remained stable with about 50 cases in the area each year. Most cases were middle-aged men participating in leisure activities. The authors emphasized this was an observational study suggesting an association rather than a causal relationship, but still strongly suggesting the importance of bystander CPR and AED use. Similarly, a Canadian-led meta-analysis of 29 studies published in the BMJ in 2021 also found that bystander CPR and AED use were related to favourable survival outcomes after exercise-related SCA. Its authors concluded “there is an imminent need for strategies that prioritise layperson education in CPR and basic life support, the availability of AEDs in physical activity spaces, and the development of emergency action plans to provide rapid cardiac care after these unexpected events.” Read: Study finds 15-fold increase in maternal deaths related to chronic hypertension Overall, a median of 71% of exercise-related SCA received bystander CPR, but only a median of 31% of arrests had bystanders use an AED. The median rate of survival to hospital discharge after exercise-related SCA was a low 32%. The study also found most cases of sudden cardiac death were in males who had a shockable ventricular arrhythmia. The French study results are encouraging and in line with the 2019 Canadian guidelines, said guideline chair and cardiologist Dr. Amer Johri, associate professor of medicine at Queen’s University. While there's been a general improvement in availability of defibrillators and CPR courses in Canada over about 20 years, their use and effectiveness remains patchy in many instances. Gaps include issues such as AEDs not being regularly maintained, bystanders not knowing where they may be located or how to use them. There is varying awareness about the need for CPR and AED training. And yet, studies show having these pieces in place is associated with saving lives, noted Dr. Johri. Read: Women with vascular issues at higher risk of cognitive decline than men Canada needs a national strategy There are jurisdictional differences, and no consistency in terms of launching programs or keeping them active, suggesting the need for a national strategy. “There is no overall mandate or legislation for bystander training,” said Dr. Johri. Many sport and exercise settings lack sufficient plans to effectively respond to a cardiac event. Sudden cardiac death, especially in young athletes, is devastating for those around them because they occur in otherwise healthy, active people. The Canadian guidelines have a tiered approach for prevention of sudden cardiac death in athletes, the first being a foundation of high-quality emergency protocols. This includes bystander CPR training, awareness and CPR training in leadership, safety protocols, education and greater community awareness. The more people with CPR training and access to AED implementation, the better. The guidelines also discuss screening—a controversial topic—especially around electrocardiograms (ECGs) because of the cost, the fact that SCA is rare and the potential to generate false positive results. This approach would depend on the resources and expertise that are available by an organization wishing to implement a comprehensive screening program. Dr. Johri added that Queen’s University screens all of its incoming varsity competitive athletes as per the Canadian guidelines. Read: Guidance on titrating therapy for heart failure with reduced ejection fraction The guideline states that “history and physical examination components are a reasonable initial aspect of screening in a stepwise program or incremental approach (tier 1 and 2). Abnormal findings on history and physical exam require further investigation, such as with ECG.” They also recommend “an institution-centred or regionalized approach to CV (cardiovascular) screening of athletes.” The extent of athlete screening and the importance of bystander CPR and AED training are o interest to everyone, said Dr. Johri. Medical costs are weighed against the devastating societal costs of sudden cardiac death, fueling this often passionate discussion. Dr. Johri is part of the Community & Athlete Cardiovascular Health Network (CATCH), an expert-led group of physicians, community partners and others to bring awareness to Canada's first recommendations for the cardiovascular screening of competitive athletes. Its website offers resources such as position statements, ongoing research that can be of use to doctors, and the development of teaching resources centered around bystander CPR and AED training. Read: Opsynvi, first fixed-dose combination product for pulmonary arterial hypertension

Sudden death in athletes reduced three-fold with bystander training

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