I'd like to spend the next 10 minutes talking about on-field management of acute cardiac events. I have no relevant conflicts of interest or disclosures. As a point of background, unfortunately, sudden cardiac arrest is the leading cause of athletes in exercise-reduced death. 75% of all exercise deaths are associated with sudden cardiac arrest. And while the prevalence is low, due to the sheer number of people who are competing in athletics, still 1 to 50,000 or 1 to 80,000 athletes will suffer a sudden cardiac arrest. I think, unfortunately, all of us can go to our recent memory and think of a professional athlete, a college athlete, a high school athlete, or an international athlete who had a cardiac arrest during practice, after the game, or during the game. Our Italian colleagues have had a lot of success preventing cardiac arrest through screening. Here in the United States, we haven't been quite as successful, again, due to the sheer number of athletes competing and our heterogeneity genetic makeup. As such, we don't typically perform ECGs as part of screening. We defer to the American Heart Association's 14-point cardiovascular screening tool that looks at personal history, family history, and physical exam to try to uncover underlying cardiac diseases. You can see that some of the professional organizations use the same plan, but mix in ECGs and echocardiograms. And despite this higher level of screening, we still see international and professional athletes suffering cardiac arrest, despite relatively benign evaluations at various stages of their athletic career. If you look at deaths among NCAA athletes over a 10-year period, the vast majority of them are off the field in accidents. But the second leading cause of death, and the number one cause of death during competition is sudden cardiac arrest. If you draw your attention to the pie chart on the right, you'll see that the greatest proportion of sudden cardiac arrest, 25%, is despite genetic and autopsy data, we don't know. It becomes challenging to screen for a disease that I can't explain after the actual disease phenotype presented. Moreover, if you look at the three silos of how the heart can result in sudden cardiac arrest, you have things like structural heart problems, like hypertrophic cardiomyopathy. You have electrical problems, like Wolff-Parkinson-White or Brugada syndrome. And then you have acquired things, like toxins, environmental exposures, or trauma. Well, our screening tests are pretty good catching structural stuff. They're not so great catching electrical stuff, and quite frankly, acquired things won't be caught on my annual screen unless they happen within the 48 hours prior to that screening. So there's a lot of leeway here for patients with underlying cardiac issues to present on the field. If you couple that with a paradigm shift in sports cardiology, 10 years ago, we performed the same screening. If we got a positive screening test, we'd confirm the diagnosis with appropriate testing. And in all likelihood, we'd disqualify that athlete from competition. But over the course of the last 10 years, we've moved to a much more progressive system, where in addition to making the diagnosis and confirming it with appropriate testing, we attempt to risk stratify those patients, and through shared care decision with the athlete, the university, the club, medical personnel, and any other family involved, come with a risk assessment that often leads to that athlete being able to compete either fully or under certain pretenses. As a result, you guys as team physicians are going to see more and more athletes competing with underlying cardiovascular illness. Now, the key to being prepared for an on-the-field cardiac event is an emergency action plan. So a coordinator needs to develop this plan. That could be anybody, from your team doc, to your athletic trainer, to a coach, to administrator. You have to make sure all the assets from the entire American Heart Association chain of care, first responder, EMS, all the way to receiving a hospital, are prepared to care for an athlete with sudden cardiac arrest. That EAP coordinator is going to develop a plan, they're going to write it, they're going to implement it, and they're going to practice it. A couple of important points from this plan. Number one, all first responders have to be aware of sudden cardiac arrest. If you see an athlete go down without contact, if when you arrive at that athlete's side they are unconscious despite no physical trauma prior to their syncopal episode, and if they have seizure-like activity, or if they have seizure-like activity, that has a high suspicion for sudden cardiac arrest. And much like in the hospital, you have to check for a pulse, initiate CPR, and activate an AED as soon as possible. We know that the most profound benefit you can provide to this patient in this unfortunate situation is accurate and quick defibrillation. For every one minute between syncopal episode, cardiac arrest, and defibrillation, your survival goes down by 10%. So if you're thinking about a sudden cardiac arrest for the first time as you're approaching an athlete on the field or on the court, you're behind the eight ball. Once an EAP has been established, you want to ensure that your AEDs are not only there, but they're accessible. They do no good locked in the training office. And they've been checked by Biomed or some equivalent periodically through the year. The American College of Cardiology, my home section, has come up with guidelines on how to write an emergency action plan involving the key personnel, the communication necessary, the necessary equipment, medical transportation, venue-specific issues, and the role of each member of that chain in caring for the patient. Again, the more you establish these roles and practice them up front, in the event that this unlikely situation occurs, you are prepared to render the most appropriate and timely care to that athlete. From a liability standpoint, we're all protected by the Federal Cardiac Arrest Survival Act and good Samaritan state legislation for no liability, even if you're practicing outside of your scope and rendering this level of care. And many of you as team docs in this room might know this better than I. The most famous emergency action plan is that with the NFL. They have more resources than I think any of our individual clinics have to render. And every match, before every game, they have a 60-minute meeting where they go over the particulars of brain trauma, spinal cord trauma, heat injury, cardiac arrest, and massive bleeding from internal rupture. Every relevant stakeholder from away and home teams, medical personnel, game day officials, event staff, local EMS are at this meeting, and they run each one of these scenarios to ensure every member of the team is aware of their role and responsibility. It is probably because of this plan and the rapid recognition of what was happening that saved Mr. Hamlin's life and probably the most famous sudden cardiac event during sport. Now all this seems like common sense because it is, but that you'd be surprised how limited this has gotten into the community. This is a study involving AAU basketball teams, boys and men's basketball teams. 450 teams were surveyed. Only about 50 or 60 responded. You'll see that 66% of AAU coaches receive CPR and AED training. That's pretty good, but that's far from 100%. Only 31% of clubs have an emergency action plan, and only 6% of them have ever practiced that plan. And lastly, less than a third of those clubs has an AED. As a result, more than 50% of the athletes competing in AAU either practice and or play in a scenario where nobody's been trained in CPR and an AED is not available. Does that translate to poor outcomes? Shockingly, it does. If you look at this study of over six years, there were 60 sudden cardiac arrests during sport. And if you go back and do an autopsy of each one of these events, you'll find that school-sponsored events where CPR-trained medical personnel are available and AEDs are available, their survival rate is 67%. As compared to the club-sponsored events where CPR and AEDs are far less common and survival is much lower. Over the course of two years in the mid-2000s, this group of physicians looked at prospective all-sudden cardiac arrests. There were 132 of them in this two-year period. You'll see on the bar graph on the right that the highest survival to discharge was Division I athletes. That was 75%. That is likely a function of resources, athletic trainers who could perform CPR, AEDs that are available and utilized in a timely fashion. If you look at all 132 of these, the overall survival was somewhere in the 50% range, which is much better than the out-of-hospital arrest for all non-athletes, which is somewhere between 10% and 12%. Now if you have a CPR-trained athletic trainer who's present at the time of that arrest, your survival goes from 50% up to 63%. If you couple in an AED in the gym or on the field with that athletic trainer who's CPR-trained at the time of the arrest, the survival went to 89%. So a few simple initiatives prior to competition with practice directly results in improved outcomes. Now, in the interest of time, I'm not going to show you the video that I'm sure all of you have seen before, but I want to highlight a few things. If you watch this video again, you'll notice that Bill's medical staff is by Mr. Hamlin's side within 15 seconds. Less than 10 seconds after their arrival, they've made the acquisition that this is a sudden cardiac arrest. And you can see one of the medical personnel using a walkie-talkie to communicate with off-the-field personnel. There's a second medical personnel who runs off the field conceivably to get an AED. It then goes to commercial, and I don't have access to any video after that. But it's, I think, relatively assured that that recognition couldn't have been quicker, and the institution of the appropriate therapies, ultimately defibrillation, led to Mr. Hamlin's survival. So in conclusion, this isn't rocket science. We should keep cardiac arrest as part of the differential diagnosis for an athlete who goes down. We need to recognize it quickly, institute AEDs that work at the patient's side on the field, and have a chain of survival through EMS and local hospitals that can care for that patient all the way through. Thank you for your time. Thank you.

sudden cardiac arrest

emergency action plan

CPR

AED use

survival rates