Abstract and Introduction
Mass gathering events in sports arenas create challenges regarding the cardiovascular safety of both athletes and spectators. A comprehensive medical action plan, to ensure properly applied cardiopulmonary resuscitation, and wide availability and use of automated external defibrillators (AEDs), is essential to improving survival from sudden cardiac arrest at sporting events. This paper outlines minimum standards for cardiovascular care to assist in the planning of mass gathering sports events across Europe with the intention of local adaptation at individual sports arenas, to ensure the full implementation of the chain of survival.
Mass gathering events in sports arenas create challenges regarding the cardiovascular safety of both athletes and spectators.
The most feared acute cardiovascular event is the occurrence of sudden cardiac arrest (SCA), which could result in sudden death. Sudden cardiac death (SCD) is defined as a 'natural death due to cardiac causes, heralded by abrupt loss of consciousness within 1 h of the onset of acute symptoms; pre-existing heart disease may have been known to be present, but the time and mode of death are unexpected'. The incidence of SCD in the general population (adults >35 years) is estimated to be 1 in 1000 persons per year, while in young people (<35 years of age) the incidence of SCD is 0.3–3.6 per 100 000 persons per year.
Intense physical activity, also in athletes, will carry a higher risk for acute cardiac events, especially in subjects with an underlying cardiovascular disease. On the basis of earlier studies, cardiac screening is recommended in competitive athletes by the European Society of Cardiology, as well as by major sporting bodies such as FIFA and UEFA. The catastrophic consequences and public nature of these events provide compelling reasons to implement effective strategies for emergency management in case of SCA. The assistance to players is potentially rapid and readily accessible.
However, spectators also may have an increased risk for SCA during a sports event due to emotional excitation with increased catecholamine-levels during a game that could trigger a coronary event. The viewing of a stressful sports event has been shown to substantially increase the risk of an acute cardiovascular event, although this increased risk has been questioned. Recent studies suggest an incidence of SCA of 1 per 5–600 000 spectators in major European soccer arenas and in one study as high as 1 per 260 000. In addition, at the Barcelona FC Stadium (capacity of 98 260 spectators), a total of seven episodes of acute coronary syndromes were recorded during a single-season (2000–01). For spectators, more barriers to access may exist to provide a rapid response in case of SCA.
At the time of the first heart rhythm analysis, ~40% of overall SCA victims have ventricular fibrillation (VF). It is likely that many more have VF or rapid ventricular tachycardia at the time of collapse but, when the first electrocardiogram is recorded, their rhythm has deteriorated to asystole. Many SCA victims could survive if bystanders act immediately while VF is present, but successful resuscitation is unlikely once the rhythm has deteriorated to asystole. The optimum treatment for VF cardiac arrest is immediate bystander cardiopulmonary resuscitation (CPR) plus electrical defibrillation, as outlined in the latest Guidelines for Resuscitation, by the European Resuscitation Council. The 'chain of survival' includes four vital steps needed for successful resuscitation:
early recognition of the emergency and calling for help, activating the local emergency medical services (EMS) or response system;
early bystander CPR;
early advanced cardiac life support (ACLS) and post-resuscitation care.
The major determinant of survival is ultimately the time to defibrillation and should be CPR adequately applied to bridge the gap to defibrillation, with the critical time from onset of a life-threatening arrhythmia to shock delivery being ~3–5 min. Historical survival rates from out-of-hospital cardiac arrest are <5%. Survival following SCA has been greatly improved by public access defibrillation programmes designed to shorten the time interval from SCA to shock delivery. By introducing the 'chain of survival', having trained rescuers in CPR and providing access to early defibrillation, survival from out-of hospital VFs can be considerably increased to >60%.
Rationale for Automated External Defibrillators in the Public Settings
Scientific evidence support the placement of automated external defibrillators (AEDs) as part of a strategic emergency plan in public places hosting large mass events, including sports arenas.
Specifically, public access defibrillation and first responder AED programmes increase the number of victims who receive bystander CPR and early defibrillation, thus improving survival from out of hospital SCA. Lay rescuer AED programmes with very rapid response times in airports, on airplanes, or in casinos, and uncontrolled studies using police officers as first responders, have reported survival rates up to 70%.
Public access defibrillation programmes are most likely to improve survival from cardiac arrest if they are established in locations where witnessed cardiac arrest is likely to occur. Suitable sites have been suggested to include those who by their size carry the probability of cardiac arrest occurring at least once every 2 years. The role of early on-site defibrillation in large public venues is also supported by recent studies.
Thirteen witnessed SCAs occurred in the Fritz-Walter Stadium, Germany (capacity of 46 600 spectators) in a 80-month period, all in males with documented VF. Basic life support was usually provided within 2 min and defibrillation and advanced life support within 4 min. Of the victims, 77% regained spontaneous circulation and 62% survived without neurological deficits. Another recent retrospective analysis of 36 cases of SCA in US High Schools with on-site AED programmes showed a survival benefit for young athletes comparable with adult non-athletes (spectators, coaches, officials) with over 60% of victims surviving.
The Present Situation in Europe
The actual availability of AEDs in major soccer arenas in Europe is suboptimal. A recent study from the section of Sports Cardiology, showed inadequacies concerning a written medical action plan (MAP) for delivery of emergency care, availability of AEDs as well as basic 'CPR training' for stadium personnel in a substantial number of (n = 190 examined) European soccer sports arenas. Only 64% of arenas reported having a written MAP, 72% had an external defibrillator available, and 65% had a basic CPR training programme. Even in the 79 arenas where the transportation time to hospital exceeded the critical 5 min, 20 of 79 arenas (25%) did not have an AED available to ensure prompt defibrillation, should an SCA occur. This observation emphasizes the urgency for action to ensure an appropriate level of cardiovascular safety at sports arenas in Europe.
Limited recognized standards and/or uniform legislation exist regarding cardiovascular EMS at public mass gatherings in sports events. Most of the articles found in the literature are case reports describing the care at a few large facilities or events. Regarding care to spectators, the National Association of Emergency Medical Services Physicians (NAEMSP) issued a comprehensive document to assist physicians with planning emergency medical care at mass gatherings. The goal was to define minimum standards for delivery of EMS to all mass gathering events. In this check-list a MAP defining the responsibilities of a medical director, number of personnel, medical equipment including AEDs, transportation, and communication, were included.
In the USA, an Inter-Association Task Force led by the National Athletic Trainers' Association (NATA) published a consensus statement providing recommendations on emergency preparedness and management of SCA in high school and college athletic programmes. Moreover, AEDs are already recommended in large US health and fitness facilities when the time of access to defibrillation exceeds the critical threshold of 5 min. On the contrary, no recommendations regarding acute cardiovascular care at sports arenas exist at present in Europe. As 67 cases of SCA were observed in the 190 European arenas of the Arena study in one season only, the potential for saving lives with a proper level of cardiovascular arena care is evident.