N. A. Mark Estes, III, MD University of Pittsburgh

1. Cardiac Emergencies in Sports
N. A. Mark Estes III, M. D.
Director, Cardiac Arrhythmia Center
Tufts Medical Center
Professor of Medicine
9th Annual Duke Sports Cardiology Symposium
April 12, 2024

2.  Historical Perspective
 Epidemiology
 Screening
 Structural Heart Disease
 Emergency Action Plans
 Conclusions
Cardiac Emergencies in Sports

3. Cardiac Emergencies in Sports
Historical Perspective
•Pheidippides
Ran from Marathon to Athens
to announce victory over the Persians.
After running 24 miles (40 km) he
he dropped dead.
Martin, Ann NY Acad Science, 1977

4. To an athlete dying young
A. E. Hausman 1895
Towns man of
a
stiller town.

5. Sudden Cardiac Death Athletes
Epidemiology
High school and college women 1/769,000
High school and college men 1/133,000
High school men 0.66/100,000
College men 1.45/100,000
Males> age 40 1/15,000
Risk of SCD increases 8-56X with exercise
Estes NAM, Wang PJ, Salem D, Sudden Death in the Athlete, Futura, 1997

6. 0
5
10
15
20
25
30
35
40
45
50
Sport
Football
Basket-
ball
Track Base-
ball
Swim-
ming
Volley-
ball
Ice
Hocke
y
Boxing Crew
Ice
Skating
TennisWrestling
Soccer
No.
of
Athletes
Sudden Cardiac Death in the Athlete
Deaths by Sport
Maron BJ, et al. JAMA. 2000.

7. 0
10
20
30
40
50
Black
HC
M
Possible
HCM
Other
Coronary
Anomaly
Aortic
Dis.
Cor.
Bridge
ARVD AVS
Anoma
lous
Cor.
%
of
Athletes
Sudden Cardiac Death in the Athlete
Cardiac Condition and Race
Maron BJ, et al. JAMA. 2000.
White

8. (http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html)
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
Accident Homicide SCD Suicide Cancer Athletic SCD
Causes of Death in US Population Age 1-21 (CDC)
79,000,000

9. Sudden Cardiac Death in the Athlete
Preparticipation Screening
 AHA/ACC/HRS has recommended screening young
athletes every 2 to 4 years
 Aspects of cardiovascular screening:
 History should include:
 1. Prior exertional CP, syncope, excessive SOB.
 2. PMH of heart murmur or HTN.
 3. FMH of early death, or HCM, LQTS, Marfans, IDCM.
 Examination should include:
 1. Cardiac auscultation.
 2. Assessment of femoral arteries.
 3. Recognition of stigmata of Marfan’s syndrome.
 4. Blood pressure.
 No recommendation for an EKG
Maron BJ et al. Circulation; Estes et al. JCE 2001

10. Gaps in Knowledge
 Precise frequency of SCD in athletes and non-athletes
 Numerator/Demoninator
 Pre-participating screening strategies
 Effectiveness, Predictive Accuracy, Cost
 Athletic restriction
 Effectiveness, Predictive Accuracy, Cost
 The ongoing debate related to an international protocol for
sports eligibility persists because of:
 Knowledge gaps
 Absence of RCTs

11. Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A 20-Year Study
Circulation. 2024;149:80–90

12. Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A 20-Year Study
Circulation. 2024;149:80–90
Causes of sudden cardiac death or findings on cardiac autopsy
among National Collegiate Athletic Association athletes (n=118)

13. Sudden Cardiac Death in National Collegiate Athletic Association Athletes: A 20-Year Study
Circulation. 2024;149:80–90
Exertional status at time of death by common causes of sudden cardiac death

14. State and Federal Polices
Legal Protection for Owners, Users,
Medical Directors
Court Opinions
As evidence-based medicine has defined
the clinical benefits of AED use, public
policy, laws, funding programs, and court
decisions have served the societal interest
of promoting use of AEDs by minimizing
legal liability.
AED-Public Policy, Legislation and Legal Liability
England, H Weinberg P, Estes N JAMA 2006

15. AEDs
Link et al
JACC 2002

16. Sequential Steps in SCA
1. Recognize SCA
2. Call for help / Call 9-1-1
3. Begin chest compressions (CPR)
4. Send bystander to retrieve AED
5. Apply and use the AED as soon as possible
6. Continue CPR until EMS arrives

17. Early
Recognition
Early
CPR
Early
AED
Chain of Survival
Improved
Survival

18. Emergency Planning
Written Emergency Action Plan for
SCA
Emergency communication system
Trained responders in CPR/AED
AED locations – all staff awareness
Access to early defibrillation (<3-5
min collapse to shock)
Practice and review of the response
plan at least annually
Integrate AEDS into local EMS system

19. AEDs in the NCAA

20. AEDs in Sport
 Provide a means of early defibrillation and the
potential for effective secondary prevention of
SCD
 Athletes
 Students
 Staff
 Spectators
 Coaches
 Officials
 Visitors

21. Studies of Rapid Defibrillation
 Use of AEDs by first responders and trained or
untrained laypersons have demonstrated survival
rates from 41% to 74% if bystander CPR is
provided and defibrillation occurs within
3 to 5 minutes of collapse

22. Results
Report Design STD Rx AED P Value Benefit
RCT
RCT
OBS
OBS
RCT
OBS
OBS
OBS
OBS
OBS
OBS
Evidence Based Medicine AEDs
15 *
21
28
8
22
18
42 46
38
36 <.001
<.001
<.02
26 <.01
30 NS
44
29 * <0.04
44 <.01
48
44
*# of survivors
White
Weaver
Smith
Mossenco
Weaver
Page
Myerburg
Valenzuela
Caffrey
Capucci
PAD
X
X
X
X
X
X
X
X
X
X
X
28
11 <0.05
<.01
<.01
<.01

23. 0
10
20
30
PAD Trial Location of Cardiac Arrest
PAD Investigators The Public Access to Defibrillation Study NEJM 2004;637-645

24. Survival trends in the U.S. following exercise-
related SCA in the youth: 2000-2006
p =
0.035
p = 0.018
Drezner; Heart Rhythm 2008
[N=486; average survival 11%; range 4-21% per year]
Low survival rate demands
re-evaluation of emergency
response planning for SCA in
sport

25. The Collapsed and Unresponsive Athlete
Management of SCA
 Suspect SCA in any
collapsed and
unresponsive athlete
 An AED should be
applied as soon as
possible for rhythm
analysis and
defibrillation if
indicated
Drezner; Heart Rhythm 2007

26. Availability of AEDs
 The single greatest factor affecting survival is
the time from cardiac arrest to defibrillation
(shock)
 AEDs improve survival through early
defibrillation
 Survival rate decreases by 10 % for ever minute
an AED is not being used

27. Is there evidence that AEDs
are effective in young
athletes with SCA?

28.  Cross-sectional survey
 Comprehensive survey on emergency response
planning and details of SCA cases
 1,710 high schools with on-site AEDs
 (July 2006 – July 2007)
Circulation,
2009

29. AED Use for SCA
 36 cases (22 adults, 14 student-athletes)
 35/36 (97%) SCA cases witnessed
 Brief seizure-like activity reported in 7/14 (50%)
student-athletes after collapse
 34/36 (94%) received bystander CPR
 AED deployed a shock in 30/36 (83%) cases

30. Survival to Hospital Discharge after SCA in
U.S. High Schools with AEDs [N=36]
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Student athletes
(9/14)
Non-students
(14/22)
Overall
(23/36)
64% 64% 64%
9/14 14/22 23/36
Survival
to hospital
discharge

31. Limitations
 Cross-sectional survey
 Responder/Non-responder bias
 Self-reported data
 Undetected cases
 No comparison group

32.  2-year prospective observational study
 2,149 high schools
 Primary outcome measure:
 Survival to hospital discharge BJSM

33. Cases of SCA
 2,149 high schools
 87% with AED program
 95% 2-year follow-up
 59 cases of SCA on
campus
79%
male

34. Resuscitation Details
 93% witnessed
 92% prompt CPR
 AEDs applied in 85% of cases
 Provided by school: 41 (69%)
 Provided by off-site EMS: 15 (23%)
 Provided by on-site EMS: 3 (5%)
 66% shock deployed

35. Survival Following SCA
Onsite AED vs. EMS
Unadjusted odds ratio
4.0, [1.14; 14.02], p-
value 0.03

36. Significance
 School-based AED programs demonstrate a
high survival rate for victims of SCA
occurring on school campus
 SCA in students and student-athletes is largely
a survivable event through prompt treatment
and access to an AED

37.  Schools and other organizations hosting athletic events or providing
training facilities for organized competitive athletic programs should have
an emergency action plan that incorporates basic life support and AED use
within a broader plan to activate EMS(Class I; Level of Evidence B).
 Coaches and athletic trainers should be trained to recognize cardiacarrests
and to implement timely and AHA guideline–directedCPR (100 to120
beats per minute and compression depth of 2 inches) along with AED
deployment.(Class I; Level of Evidence B).
 AEDs should be available to all cardiac arrest victims within 5 minutes, in
all settings, including competition, training, and practice (Class I; Level of
Evidence B).
 Advanced post–cardiac arrest care, including tar- geted temperature
management, should be available at sites to which patients are taken by
EMS (Class I; Level of Evidence A).

38. Strategies for Prevention of SCD
Complementary Strategies
Primary Prevention
Secondary Prevention
H&P ECG
AED

39. Emergency Action Plan
Written Emergency Action Plan for SCA
Emergency communication system
Trained responders in CPR/AED
AED locations – all staff awareness
Access to early defibrillation (<3-5 min
collapse to shock)
Practice and review of the response plan at
least annually
Integrate AEDS into local EMS system

40.  Almost all young athletes dying suddenly have underlying heart
disease-males are at greater risk than females. In older patients
underlying CAD is the most common cause.
 Current screening techniques lack sensitivity and specificity for
detecting athletes at risk for sudden death. Evaluation of
standardized screening programs with tracking of long-term
outcomes is needed.
Sudden Cardiac Death in Athlete
Conclusions

41.  AEDs are effective in acute treatment of ventricular arrhythmias in
athletes. Further studies are needed to assess the efficacy and cost of
making AEDs available at all athletic events.
 Further basic, clinical and epidemiologic research is needed to
develop cost-effective strategies to predict and prevent SCD in the
athlete.
Sudden Cardiac Death in Athlete
Conclusions

42. Cardiac Emergencies in Sports
N. A. Mark Estes III, M. D.
Director, Cardiac Arrhythmia Center
Tufts Medical Center
Professor of Medicine
9th Annual Duke Sports Cardiology Symposium
April 12, 2024