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Bystander interventions and survival after exercise-related sudden cardiac arrest: a systematic review
  1. Nicholas Grubic1,2,
  2. Braeden Hill2,
  3. Dermot Phelan3,
  4. Aaron Baggish4,
  5. Paul Dorian5,
  6. Amer M Johri2
  1. 1 Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
  2. 2 Department of Medicine, Queen's University, Kingston, Ontario, Canada
  3. 3 Sports Cardiology Center, Atrium Health Sanger Heart and Vascular Institute, Charlotte, North Carolina, USA
  4. 4 Cardiovascular Performance Program, Massachusetts General Hospital, Boston, Massachusetts, USA
  5. 5 Department of Medicine, Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Nicholas Grubic, Department of Public Health Sciences, Queen's University, Kingston, Canada; nicholas.grubic{at}


Objective To evaluate the provision of bystander interventions and rates of survival after exercise-related sudden cardiac arrest (SCA).

Design Systematic review.

Data sources MEDLINE, EMBASE, PubMed, CINAHL, SPORTDiscus, Cochrane Library and grey literature sources were searched from inception to November/December 2020.

Study eligibility criteria Observational studies assessing a population of exercise-related SCA (out-of-hospital cardiac arrests that occurred during exercise or within 1 hour of cessation of activity), where bystander cardiopulmonary resuscitation (CPR) and/or automated external defibrillator (AED) use were reported, and survival outcomes were ascertained.

Methods Among all included studies, the median (IQR) proportions of bystander CPR and bystander AED use, as well as median (IQR) rate of survival to hospital discharge, were calculated.

Results A total of 29 studies were included in this review, with a median study duration of 78.7 months and a median sample size of 91. Most exercise-related SCA patients were male (median: 92%, IQR: 86%–96%), middle-aged (median: 51, IQR: 39–56 years), and presented with a shockable arrest rhythm (median: 78%, IQR: 62%–86%). Bystander CPR was initiated in a median of 71% (IQR: 59%–87%) of arrests, whereas bystander AED use occurred in a median of 31% (IQR: 19%–42%) of arrests. Among the 19 studies that reported survival to hospital discharge, the median rate of survival was 32% (IQR: 24%–49%). Studies which evaluated the relationship between bystander interventions and survival outcomes reported that both bystander CPR and AED use were associated with survival after exercise-related SCA.

Conclusion Exercise-related SCA occurs predominantly in males and presents with a shockable ventricular arrhythmia in most cases, emphasising the importance of rapid access to defibrillation. Further efforts are needed to promote early recognition and a rapid bystander response to exercise-related SCA.

  • exercise
  • athletes
  • resuscitation
  • survival
  • heart

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  • Twitter @nickgrubic, @DermotphelanMD

  • Contributors All authors contributed to the conception and design of this systematic review. Data collection was performed by NG and BH. Data analysis and interpretation was performed by NG, BH and AMJ. The first draft of the manuscript was written by NG, BH and AMJ. Key edits and critical revision of the manuscript were provided by DP, AB and PD. All authors approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests NG is supported by a Canadian Institutes of Health Research (CIHR) Charles Best and Frederick Banting Canada Graduate Scholarship to study the impact of bystander interventions on survival after out-of-hospital cardiac arrests. All other authors report no competing interests.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.