Fast CPR Doesn't Stop Sudden Cardiac Death in Young Athletes

SEATTLE, June 20 - Sudden cardiac arrest was fatal in eight of nine college athletes who had witnessed events, despite the rapid efforts of athletic trainers, EMS personnel, and the ready availability of automated external defibrillators.

This finding suggested that more "information is needed regarding early defibrillation in young athletes," Jonathan A. Drezner, M.D. and Kenneth J. Rogers, Ph.D., A.T.C., reported in the July issue of Heart Rhythm.

Timely treatment was not an issue, said Dr. Drezner of the department of family medicine at the University of Washington and Dr. Rogers of the department of orthopedic surgery at the University of Pennsylvania.

Cardiopulmonary resuscitation was initiated within 30 seconds of arrest in six patients and in less than one minute after arrest in two others. In five of the nine young athletes, the automated external defibrillator was provided by the athletic trainer and in four cases it was supplied by EMS. In seven of the nine patients shock was deployed, and the average time from arrest to defibrillation was 3.1 minutes (range one minute to 7.5 minutes).

The most common cause of arrest was hypertrophic cardiomyopathy, which led to five of the eight deaths. Two lacrosse players suffered arrest caused by the deadly blow to the chest known as commotio cordis and a 30-year-old African-American basketball player suffered sudden cardiac death triggered by a myocardial infarction.

The basketball player who died had the longest interval from arrest to initiation of CPR-eight minutes.

The single surviving athlete was a 20-year-old African-American basketball player who had a history of hypertension that was controlled with an angiotensin receptor blocker. The time from arrest to first shock was 2.5 minutes and his initial rhythm was ventricular fibrillation. Rhythm after first shock was asystole.

This basketball player received a total of five shocks. He remained unconscious for 3.5 weeks "but made a remarkable recovery, with only short-term memory deficits and no motor deficits." This survivor received an implantable cardioverter defibrillator but "no underlying structure heart disease or precise cause of arrest was identified."

Dr. Drezner and Dr. Rogers said the nine witnessed sudden cardiac arrest among college athletes were from 1999 through 2005. All involved men and the average age of athletes was 21 (range 18 to 30). Five of the athletes were African American.

There were four basketball players, two football players, two lacrosse players, and one swimmer. In each case a detailed questionnaire was completed by the athletic trainer directly involved in the resuscitation and was followed up with telephone interviews by Dr. Drezner.

In seven athletes the initial rhythm was ventricular fibrillation, pulseless idioventricular rhythm in one case, and unknown in one case, so no shock was recommended.

The authors noted that studies citing the benefit of public automated external defibrillators have generally shown a benefit for the devices in older populations, such as devices in airplanes, airports, and casinos that have been shown to improve survival by 36% to 52% among patients with mean ages of 58 to 68.

The study was limited by its small sample size and its retrospective design, which relied on self-reported data, which is subject to potential recall bias. Selection bias-relying on data from the National Collegiate Athletic Association-is another limitation because it may underestimate the true incidence of sudden cardiac arrhythmias in young athletes.

Better data may be available with use of the National Registry for Automated External Defibrillator Use in Sports, which has been developed to "prospectively monitor arrhythmias and automated external defibrillator utilization in the athletic setting," they wrote.

Finally, the authors concluded, "Structured and practiced emergency response plans are needed at university and public sporting venues. With increased public and rescuer education in the recognition of cardiac arrest, new guidelines for CPR and emergency cardiovascular care, and increasing availability of automated external defibrillators, the potential for limiting these catastrophic events in young athletes remains promising."