“Pheidippides was a legend in ancient Greece. He ran 250 kms in 2 days to request help from the Spartans when Athens was being invaded. However, after helping defeat the Persians in Marathon, he ran 35 kms to declare victory, collapsed and died. The greatest physical specimen of super-compensated physiology became the first documented case of sudden death in an endurance athlete.”1

The role of regular exercise as a means of preventing, managing and treating disease in all ages is well described.2 ,3 Participating in sport is thus considered to be of benefit to the health of an individual and competitive athletes are often regarded as the healthiest facet of our society: “mens sana in corpore sano—a sound mind in a healthy body.”3 ,4

Sudden cardiac arrest (SCA) in sport was a rare, yet regular event. Recently, with international media coverage5 and committed medical research,6 its rarity has come under scrutiny. Whatever its prevalence, if the end result is an unsuccessful cardiac resuscitation, the ensuing sudden cardiac death (SCD) has ramifications that extend to the victim's family, often to the local community and possibly to the sporting environment generally, because this unfortunate event in a young, healthy and fit sportsperson is contrary to all expectations and beliefs.

The management of SCA is dependent on two specific life-saving activities: expeditious start of effective and efficient cardiopulmonary resuscitation (CPR) on site and swift retrieval, application and use of an automated external defibrillator (AED) to the victim's chest.7–9 Drezner et al10 have conclusively demonstrated, in a 2-year prospective study of 2149 high schools participating in the National Registry for AED Use in Sports in the USA , that the availability and use of an AED during SCA, on the participating schools’ campuses, contributed to an overall successful survival rate of 71% to hospital discharge.

Also in this issue, Cronin et al11 in their retrospective review of 171 amateur sports clubs in Cork City and County, Ireland, analysed not only the availability and use of AEDs, but also reviewed the maintenance and accessibility of the AEDs on site. They revealed that only 76.3% of participating clubs with an AED on site undertake regular maintenance, which potentially leaves almost an astonishing quarter of all AEDs reviewed in a state of malfunction at a time of acute lifesaving need. Additionally, their study also indicated that 59.7% of the clubs kept their AEDs under lock and key, a practical consideration that may have a critical influence on the speed with which the AED arrives at the SCA victim's side.

With these two important studies indicating the mandatory requirement for a fully functional, well-maintained and easily accessible AED in the sport environment, during training and competition, Dvorak et al have provided a succinct practical global solution, particularly in football, by representing the Fédération Internationale de Football Association's (FIFA) endorsement of the officially launched FIFA Medical Emergency Bag (FMEB) and accompanying FIFA 11 Steps to Prevent Sudden Cardiac Death, which is intended for use during all football training and competition matches. One of the main features of the FMEB is a fully functional AED which is located in a fully transparent, highly visible outer compartment. The advanced life support equipped FMEB, with its five language instructional training manual and digital video disc on the provision of CPR and AED use, are recommendations intended to create a global standard for emergency preparedness and medical response to life-threatening, on-field injuries and illnesses.

The FIFA 11 Steps to Prevent SCD provides a practical protocol, whose implementation is meant to address all the critical issues thus far discussed in this issue, to prevent where possible and treat when necessary SCA, at all times ensuring that there is always an effective on-site emergency medical plan, skilled healthcare personnel and a fully functional, visible, easily accessible, mobile emergency bag including AED.

SCA remains the leading cause of death in sports. Whenever its prevention has failed, for whatever reason, its immediate medical management becomes paramount if the life under acute threat is to be saved. In many circumstances, this can only be effectively and efficiently achieved by the presence of a fully functional AED which is activated while CPR is being undertaken. It is no longer a question of whether an AED is necessary in any mass gathering sport environment but how many are necessary and where they should be located. The FIFA endorsed slogan of the ABC of Football, namely: A = AED, B = Blow the whistle, C = Commence the game, always in that order, is the future challenge for the sport medical fraternity. Sadly, Pheidippides had neither CPR undertaken nor functional AED activated. “Those who do not learn from history are doomed to repeat it.”12