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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}queensu.ca

Abstract

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

https://doi.org/10.1136/bjsports-2021-104623

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    Introduction

    Sudden cardiac arrest (SCA) is the leading medical cause of death among competitive athletes and a common cause of sudden death in the general population during exercise.1–3 The risk of SCA is known to increase during sport or physical activity among all age groups with underlying cardiovascular disorders or conditions.4–6 As the occurrence of these unexpected events in otherwise healthy, active individuals has a traumatic societal impact,7 further public health efforts are needed to prevent tragic outcomes after exercise-related SCA.

    Current recommendations suggest the development of emergency action plans to ensure a rapid and coordinated response to SCA within athletic environments. Fundamental components of these plans include cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) training of potential lay responders, publicly accessible AEDs in key activity spaces, and the creation, dissemination, and practice of emergency response protocols.8–10 Despite strong recommendations from athletic organisations and medical societies across the globe,8 9 11–14 many sport organisations, exercise facilities and institutions continue to have variable or poorly coordinated emergency response plans,15–21 limiting their ability to efficiently respond to cardiac events. Time and cost considerations required to train lay responders in basic life support and acquire emergency equipment, such as AEDs, for on-site use also contribute to inadequate emergency preparations.15 22

    While some studies have reported survival rates for athletes who experience exercise-related SCA,23–27 the survival benefits associated with bystander interventions after exercise-related SCA have not been comprehensively examined. Further evaluation of the bystander response to exercise-related SCA may strengthen policies, planning and recommendations for on-site cardiac care in athletic environments. Accordingly, the objective of this systematic review was to evaluate the provision of bystander interventions (bystander CPR and AED use) and rates of survival after exercise-related SCA.

    Methods

    Protocol and registration

    The methodology for this systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, ensuring a uniform, systematic and transparent approach to study inclusion, data synthesis and review structure.28 The PRISMA checklist for this systematic review is shown in the online supplemental material. The review protocol was registered in the PROSPERO international systematic review database prior to commencing the search process (registration number: CRD42020219328).

    Supplemental material

    Eligibility criteria

    Observational research studies published in English were included in this review. The study question was defined using the PICOS (Population, Intervention, Comparison, Outcome, Study Design) framework. We identified studies of exercise-related SCA (P) where bystander-initiated CPR and/or AED use was reported (I). Exercise-related SCA was defined as an out-of-hospital cardiac arrest occurring during physical activity, sport or exercise, or within 1 hour of cessation of activity.3 29 30 Bystander CPR was defined as the provision of CPR (compressions with or without ventilations). Bystander AED use was defined as the application of an AED (with or without defibrillation), which included public access defibrillation. A bystander was considered to be any individual responding to the medical emergency but not involved in the organised emergency medical response system. For example, members of the general public and on-site healthcare professionals (eg, team physicians, athletic therapists, etc) were considered as bystanders, whereas responding emergency medical services (EMS) personnel and professional first responders (eg, fire and police) were not considered as bystanders. To be included, studies had to report either bystander CPR alone, bystander AED use alone or both bystander CPR and AED use.

    Although a comparator group was not required for study inclusion, where reported, the comparator group consisted of exercise-related SCA where bystander CPR and/or AED use were not performed, but were attended/treated by a professional responder or EMS personnel (C). Only studies reporting survival outcomes, including prehospital return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge or survival at ≥1 month were included (O). This included studies that reported survival to hospital discharge or survival at ≥1 month with good neurological outcome, defined as a Cerebral Performance Category (CPC) score of 1 or 2.31 To allow for acceptable comparisons between studies, only observational studies with a patient population of n>10 were included. Abstracts or conference papers were excluded (S).

    Information sources and search strategies

    We conducted literature searches in MEDLINE (1946 to present), EMBASE (1947 to present), PubMed (1966 to present), CINAHL (1937 to present), SPORTDiscus (1892 to present) and Cochrane Library (1991 to present) electronic databases on 9 November 2020. Focused grey literature searches of Google Scholar (first 300 results, sorted by relevance), as previously suggested,32 and CADTH Grey Matters were performed throughout November and December 2020. Our electronic search strategies, specific for each database, are shown in the online supplemental material.

    Study selection process

    Study selection was performed using the electronic systematic review management platform Covidence, which has shown high accuracy in the identification of duplicate records.33 Any duplicate records were identified and removed automatically. Title and abstract screening were performed by two independent reviewers (NG and BH). Any conflicts regarding the inclusion or exclusion of articles were discussed until consensus was reached. If consensus was not reached, a third reviewer (AMJ) provided an independent decision to resolve any conflicts. Full-text review was conducted by the same two independent reviewers, with any disagreements resolved by discussion until consensus was reached. A Cohen’s kappa (κ) statistic and 95% CI for inter-rater reliability was calculated at the abstract screening stage. A ‘backward snowballing’ process34 was performed by reviewing the reference lists of included articles for additional articles that may be relevant. Any additional articles identified at this stage were judged for inclusion using the same process outlined above. Studies that had overlapping patient data were considered as duplicate publications; the article capturing the longest time period or larger sample size was included, whereas the other(s) were excluded.

    Data collection and data items

    Data extraction of included articles was performed in duplicate by two independent reviewers (NG and BH) using a standardised data collection form. All results were reviewed for relevance and confirmed by a medical professional involved in cardiovascular care of athletes and exercisers (AMJ). The variables extracted from each study included first author’s name, year of publication, study design, study period, geographical location, sample size, data source/registry, patient characteristics (age, sex, arrest rhythm, arrest aetiology), bystander CPR, bystander AED use and survival outcomes (prehospital ROSC, survival to hospital admission, survival to hospital discharge, survival at ≥1 month). Any arrests with missing data for patient characteristics, bystander interventions or survival outcomes were excluded from the measures reported in this review. If the study population was divided into distinct subgroups, these groups were combined to compute a single measure, following the formula for combining summary statistics across subgroups from the Cochrane Handbook.35

    Risk of bias in individual studies

    The risk of bias in included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale, which was developed to evaluate the quality of non-randomised studies.36 This scale uses a ‘star system’ to award cohort studies a maximum of 9 (highest quality) and a minimum of 0 stars (lowest quality) based on the selection of the study groups, comparability of the groups, and ascertainment of the exposure and outcome of interest. Stars are awarded based on the representativeness of the exposed cohort (maximum one star), selection of the non-exposed cohort (maximum one star), ascertainment of the exposure (maximum one star), demonstration that the outcome of interest was not present at the start of the study (maximum one star), comparability of the cohorts (maximum two stars), assessment of the outcome (maximum one star), length of the follow-up (maximum one star) and adequacy of the follow-up (maximum one stars). On the basis of the analyses of included studies, we were unable to award stars for the comparability of the cohorts. Thus, all included studies were scored out of a total of seven stars. The minimum acceptable follow-up threshold used in this assessment was 80%.37 All included cohort studies were evaluated using this scale by two independent reviewers (NG and BH), and the score (or range if scores differed between reviewers) was presented. Modified versions of this assessment scale were used to assess the risk of bias in included cross-sectional studies and case series. The Newcastle-Ottawa Scales are shown in online supplemental tables S1–S3.

    Statistical analysis

    Given the heterogeneity in reported outcomes and methodological diversity of included studies, we were unable to perform a formal meta-analysis.38 In lieu of a meta-analysis, we synthesised the results of included studies by calculating: (1) the median proportion (range and IQR) of arrests that received bystander CPR, (2) the median (range and IQR) proportion of arrests that received bystander AED use and (3) the median (range and IQR) rate of survival at various endpoints (prehospital ROSC, survival to hospital admission, survival to hospital discharge and survival at ≥1 month). The summary measures for each survival outcome were only calculated from studies explicitly ascertaining the specified outcome (ie, rates of survival at ≥1 month were not included in the summary measure for survival to hospital discharge). Summary measures for survival to hospital discharge and survival at ≥1 month included all studies that reported these outcomes, regardless of whether or not they were ascertained with good neurological status (ie, CPC 1 or 2). Any studies that reported measures from a hospital-based sample (ie, only patients who survived to hospital admission) were excluded from summary measure calculations due to the potential for more favourable outcomes in this group.

    Two post-hoc analyses were conducted with the final selection of included studies. First, a sensitivity analysis was performed by including only cohort studies in the summary measure calculations. Second, a subgroup analysis was performed by stratifying included studies into two groups based on the setting of where most exercise-related SCA occurred: (1) organised settings (eg, competitions, sporting events, school-sanctioned sport or exercise) and (2) non-organised settings (eg, recreational locations, fitness/exercise facilities, home-based activities). All analyses were performed using SAS V.9.4 software (SAS Institute).

    Results

    Study selection

    Following electronic literature searches, we identified 3711 records from databases, 6 records from grey literature sources and 1 record from the reference lists of included studies. After the removal of duplicates, 2850 records were assessed for inclusion through title and abstract screening. A total of 176 studies were selected for full-text review, with a Cohen’s κ of 0.78 (95% CI 0.73 to 0.83), indicating excellent agreement.39 Following the full-text review to assess for eligibility, 147 studies were excluded, leaving 29 eligible studies in our systematic review for qualitative synthesis (figure 1).

    Figure 1
    Figure 1

    Preferred Reporting Items for Systematic Reviews and Meta-Analyses study selection flowchart.

    Study characteristics and risk of bias

    The characteristics of included studies are shown in table 1. Among the 29 included articles, 25 were cohort studies, 2 were cross-sectional studies and 2 were case series. The median study duration was 78.7 months (IQR 60–122.5) and the median sample size was 91 (IQR 35–186). In general, the study samples were comprised mostly male (median: 92%, IQR: 86%–96%) and middle-aged patients (median: 51, IQR: 39–56 years). The aetiologies of exercise-related SCA from each study (if reported) are shown in online supplemental table S4. The risk of bias for included studies, as assessed through the Newcastle-Ottawa Scale, ranged from 2/7 to 7/7 stars. Most studies achieved a high score (6/7 or 7/7), indicating no to minimal bias, whereas some studies, particularly the cross-sectional studies and case series, were prone to potential biases. The Newcastle-Ottawa Scale scores for each included study, as evaluated by both reviewers, are reported in online supplemental tables S5–S7.

    View this table:
    Table 1

    Characteristics of included studies

    Results of individual studies and summary measures

    For each included study, the proportion of arrests that received bystander interventions (CPR and AED use) and survived at various endpoints are reported in table 2. The majority of patients presented with a shockable arrest rhythm on analysis (median: 78%, IQR: 62%–86%). The provision of bystander CPR was reported in 25 studies, whereas bystander AED use was reported in 18 studies. Survival to hospital discharge was the most commonly reported outcome in 20 studies, whereas prehospital ROSC, survival to hospital admission and survival at ≥1 month were reported by 10, 8 and 9 studies, respectively.

    View this table:
    Table 2

    Bystander interventions and survival outcomes reported among included studies

    The summary measures for bystander interventions and survival outcomes among all included studies are shown in table 3. Among 22 studies, the median proportion of bystander CPR was 71% (IQR: 59%–87%). Among 16 studies, the median proportion of bystander AED use was 31% (IQR: 19%–42%). Among 19 studies that reported survival to hospital discharge, the rate of survival to hospital discharge ranged from 11% to 77%, with a median of 32% (IQR: 24%–49%). The median proportion of arrests that achieved prehospital ROSC (9 studies) was 63% (IQR: 39%–72%), whereas the median rates of survival to hospital admission (8 studies) and survival at ≥1 month (7 studies) were 40% (IQR: 31%–57%) and 53% (IQR: 46%–65%), respectively.

    View this table:
    Table 3

    Summary measures among studies reporting bystander interventions and survival outcomes

    Association between bystander interventions and survival

    Five studies included in this review performed a statistical comparison to evaluate the association between bystander interventions and survival after exercise-related SCA. The main findings from these studies are summarised in table 4. Four of five studies demonstrated a significant association between bystander CPR and survival after exercise-related SCA. A total of eight studies included in this review provided sufficient data to report the proportion of arrests that received bystander CPR (five studies) and AED use (six studies) by survival to hospital discharge status, which are summarised in figure 2. Among patients who survived to hospital discharge, the median proportion of patients who received bystander CPR and AED use was 93% (IQR: 82%–100%) and 56% (IQR: 52%–66%), respectively. Among patients who died before hospital discharge, the median proportion of patients who received bystander CPR and AED use was 54% (IQR: 44%–80%) and 13% (IQR: 11%–20%), respectively.

    View this table:
    Table 4

    Summary of included studies which evaluated the association between bystander interventions and survival outcomes

    Figure 2
    Figure 2

    Bystander CPR (A) and AED use (B) according to survival to hospital discharge among eight included studies. A total of five studies reported bystander CPR according to survival to hospital discharge status, whereas a total of six studies reported bystander AED use according to survival to hospital discharge status. Patients with missing information for bystander interventions or survival were not included when calculating these measures. Fisher’s exact test was used to compare the provision of bystander CPR or AED use between survival groups for each study (*p<0.05). AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; NR; not reported.

    Post-hoc analyses

    The results of the post-hoc analyses are presented in the online supplemental material. After excluding the case series and cross-sectional studies, all of which scored low in our risk of bias assessment, similar summary measures for bystander interventions and survival outcomes were noted (online supplemental table S8). In the subgroup analysis of exercise-related SCA by setting, the median rate of survival to hospital discharge was 37% (IQR: 22%–60%) in organised settings and 32% (IQR: 25%–49%) in non-organised settings (online supplemental table S9). The median proportions of bystander CPR and AED use in organised settings were 89% (IQR: 74%–93%) and 54% (IQR: 33%–79%), respectively. The median proportions of bystander CPR and AED use in non-organised settings were 68% (IQR: 55%–81%) and 20% (IQR: 4%–35%), respectively (online supplemental table S9).

    Discussion

    Summary of evidence

    To the best of our knowledge, this was the first systematic review to evaluate bystander interventions and survival outcomes after exercise-related SCA. Our review noted that a median of 71% of exercise-related SCA received bystander CPR, whereas only a median of 31% of arrests had an AED applied by a bystander. The median rate of survival to hospital discharge after exercise-related SCA was 32%. Among studies which evaluated the impact of bystander interventions on survival to hospital discharge, strong associations between the provision of bystander CPR and AED use, and survival after exercise-related SCA, were noted. Collectively, our findings suggest that bystander CPR and AED use are crucial to maximising survival after exercise-related SCA (figure 3).

    Figure 3
    Figure 3

    Bystander interventions and survival after exercise-related sudden cardiac arrest. AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; ROSC, return of spontaneous circulation; SCA, sudden cardiac arrest.

    In comparison to SCA in the general population,40–42 both the provision of bystander interventions and overall survival outcomes were markedly higher for exercise-related SCA. However, when comparing public arrests in the general population43–45 to exercise-related arrests (the majority of which also occur in public settings), only a moderate difference was noted. Interestingly, the median proportion of exercise-related SCA that received bystander interventions and survived to hospital discharge were consistent with estimates for arrests occurring in densely populated public settings, such as airports, which have high foot traffic, trained responders on-site and a coordinated response to emergencies.46 Similar to the rapid bystander response observed in these settings, a short time delay from collapse to initiation of bystander CPR or application of an AED was noted for exercise-related SCA.3 24 47–54 In general, the average time delay was well under 3 min, which has been suggested as the threshold to allow for neurologically intact survival after SCA in public settings.55 56 Given the opportunities for timely resuscitation and favourable outcomes after SCA in athletic settings, particularly due to the closed environment, frequent presence of bystanders, organised personnel and potential for coordinated emergency planning, there is still substantial room to improve the provision of bystander interventions and survival outcomes after exercise-related SCA.

    Another key finding from this review was that in comparison to non-exercise-related SCA, exercise-related arrests more often had a bystander witness the event and presented with a shockable arrest rhythm (ventricular fibrillation or ventricular tachycardia). This finding was observed in all studies that had a comparator group of non-exercise-related SCA.29 57–63 Given that these factors are well-known predictors of survival from out-of-hospital cardiac arrest,41 64 it is likely that they contributed to improved outcomes after exercise-related SCA. Importantly, with a strong bystander presence and high proportion of shockable arrests, there is a high likelihood that a promptly deployed AED would be effective in resuscitating a patient with exercise-related SCA.

    Patient-related factors may also play a role in survival outcomes after exercise-related SCA. Younger patients with fewer comorbidities have demonstrated more favourable outcomes after a cardiac arrest.65 66 Thus, the relatively young median age for exercise-related SCA noted in our review may predispose patients to a greater probability of surviving an event. Similarly, patients who experience exercise-related SCA may be healthier than the general population due to the well-documented benefits of physical activity on cardiovascular health.67 68 Substantial gender differences in exercise-related SCA were also noted in our review, with an overwhelming majority of male patients comprising all study samples. Possible explanations include differences in atherosclerotic plaque morphology, ventricular electrical activity and autonomic factors.69 The earlier onset and predominance of atherosclerosis, coronary artery disease and other genetic heart diseases in men may also help to explain gender differences in exercise-related SCA.70–74

    Clinical implications

    The frequent presence of multiple lay rescuers at organised sporting events or within exercise facilities presents the opportunity to maximise the provision of bystander interventions, increasing the probability of survival after exercise-related SCA. Evidence has shown that in many sport and exercise settings, satisfactory plans are not in place to effectively respond to a cardiac event.15–21 24 75–77 Our review strengthens the need to further reduce the chance of a catastrophic outcome after exercise-related SCA through the development and rehearsal of emergency action plans at institutions, exercise facilities and during organised sporting events.9 11 12 With ideal protocols, well-coordinated procedures and ample resources, high survival rates are possible, especially in mass participation events.48 To strengthen the bystander response to exercise-related SCA, efforts should be aimed at procuring AEDs for sport and exercise facilities, as well as offering basic life support training to athletes, spectators, event support staff and all other individuals involved in the training, coordination or care of the physically active population. Education of the general public in the recognition of SCA, provision of CPR, and use of an AED may also impact the response and outcomes for exercise-related SCA occurring in the public sector. Additionally, legislative mandates for AED placement and the implementation of emergency action plans at institutions, exercise facilities and organised sporting events is a reasonable policy consideration.

    Limitations

    There are some important limitations at the study and outcome level that should be noted. First, the time threshold after exercise used to define an exercise-related SCA varied across included studies, ranging from 5 min to 1 hour after exercise. Second, due to reporting differences among included studies, we were unable to meaningfully differentiate between the application of an AED with or without defibrillation. Thus, our summary measure for bystander AED use may be underestimated. Third, the time from collapse to initiation of CPR or AED use was not examined, both of which have been shown to influence survival outcomes.78 79 Fourth, there was heterogeneity among study samples included in our review. However, to prevent potential overestimation in our summary measures, any studies of hospital-based cohorts were excluded from the analyses. Finally, there is a small possibility that misclassification may have been introduced into our results due to the differing interpretations of a ‘bystander’ among international EMS personnel and reporting systems.80

    The findings of this systematic review should also be interpreted in the context of limitations at the review level. To ensure consistency within the intended target population, some studies that only reported arrests that occurred in exercise or sports facilities were excluded on the basis that the exercise-related nature of the arrest was not specified. However, these excluded studies did note similar conclusions, with high rates of bystander CPR, AED use and survival after SCA observed in these facilities.81–83 Additionally, only studies written in English were included, and studies with a patient population of ≤10 were excluded to weaken potential publication biases. Finally, the results of this review are based on observational studies which may be subject to confounding and other biases, thus causality between bystander interventions and survival cannot be inferred.

    Conclusions

    Our review supports that the provision of bystander CPR and AED use are related to favourable survival outcomes after exercise-related SCA. To improve resuscitation outcomes after exercise-related SCA, there is an imminent need for strategies that prioritise layperson education in CPR and basic life support, the availability of AEDs in physical activity spaces, and the development of emergency action plans to provide rapid cardiac care after these unexpected events.

    Summary box

    What is already known?

    • Sudden cardiac arrest (SCA) is the leading cause of sudden death among competitive athletes during exercise.

    • Bystander interventions, including cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, are associated with favourable outcomes after SCA.

    • Sport organisations, exercise facilities and institutions may have variable or poorly coordinated emergency response plans and resources, limiting their ability to efficiently respond to exercise-related SCA.

    • The survival benefits associated with bystander interventions after exercise-related SCA have not been comprehensively examined.

    What are the new findings?

    • Exercise-related SCA occurs most commonly in males (92%) and presents with a shockable arrest rhythm (78%), emphasising the importance of access to AEDs and rapid defibrillation.

    • On average, 71% of exercise-related SCA cases received bystander CPR and 31% had an AED applied by a bystander.

    • The median rate of survival to hospital discharge among exercise-related SCA was 32%.

    • Both bystander CPR and AED use were significantly associated with survival after exercise-related SCA.

    Ethics statements

    Patient consent for publication

    Acknowledgments

    The authors would like to thank the Community and Athletic Cardiovascular Health (CATCH) Network (https://catchnet.ca/) for their support in public knowledge translation.

    References

    1. ↵
      2. Harmon KG ,
      3. Drezner JA ,
      4. Wilson MG , et al
      . Incidence of sudden cardiac death in athletes: a state-of-the-art review. Br J Sports Med 2014;48:1185–92.doi:10.1136/bjsports-2014-093872 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24963027
      OpenUrlAbstract/FREE Full Text
    2. ↵
      2. Peterson DF ,
      3. Kucera K ,
      4. Thomas LC , et al
      . Aetiology and incidence of sudden cardiac arrest and death in young competitive athletes in the USA: a 4-year prospective study. Br J Sports Med 2021;55:1196–203.doi:10.1136/bjsports-2020-102666 pmid:http://www.ncbi.nlm.nih.gov/pubmed/33184114
      OpenUrlAbstract/FREE Full Text
    3. ↵
      2. Marijon E ,
      3. Tafflet M ,
      4. Celermajer DS , et al
      . Sports-Related sudden death in the general population. Circulation 2011;124:672–81.doi:10.1161/CIRCULATIONAHA.110.008979 pmid:http://www.ncbi.nlm.nih.gov/pubmed/21788587
      OpenUrlAbstract/FREE Full Text
    4. ↵
      2. Tutarel O ,
      3. Gabriel H ,
      4. Diller G-P
      . Exercise: friend or foe in adult congenital heart disease? Curr Cardiol Rep 2013;15:416.doi:10.1007/s11886-013-0416-9 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24057770
      OpenUrlCrossRefPubMed
    5. ↵
      2. Corrado D ,
      3. Basso C ,
      4. Schiavon M , et al
      . Does sports activity enhance the risk of sudden cardiac death? J Cardiovasc Med 2006;7:228–33.doi:10.2459/01.JCM.0000219313.89633.45 pmid:http://www.ncbi.nlm.nih.gov/pubmed/16645394
      OpenUrlCrossRefPubMed
    6. ↵
      2. Goodman JM ,
      3. Burr JF ,
      4. Banks L , et al
      . The acute risks of exercise in apparently healthy adults and relevance for prevention of cardiovascular events. Can J Cardiol 2016;32:523–32.doi:10.1016/j.cjca.2016.01.019 pmid:http://www.ncbi.nlm.nih.gov/pubmed/27017149
      OpenUrlCrossRefPubMed
    7. ↵
      2. Grubic N ,
      3. Puskas J ,
      4. Phelan D , et al
      . Shock to the heart: psychosocial implications and applications of sudden cardiac death in the young. Curr Cardiol Rep 2020;22:168.doi:10.1007/s11886-020-01419-6 pmid:http://www.ncbi.nlm.nih.gov/pubmed/33040200
      OpenUrlPubMed
    8. ↵
      2. Johri AM ,
      3. Poirier P ,
      4. Dorian P , et al
      . Canadian cardiovascular society/canadian heart rhythm Society joint position statement on the cardiovascular screening of competitive athletes. Can J Cardiol 2019;35:1–11.doi:10.1016/j.cjca.2018.10.016 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30595170
      OpenUrlPubMed
    9. ↵
      2. Drezner JA ,
      3. Courson RW ,
      4. Roberts WO , et al
      . Inter-association Task force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement. J Athl Train 2007;42:143–58.pmid:http://www.ncbi.nlm.nih.gov/pubmed/17597956
      OpenUrlPubMedWeb of Science
    10. ↵
      2. Toresdahl B ,
      3. Courson R ,
      4. Börjesson M , et al
      . Emergency cardiac care in the athletic setting: from schools to the Olympics. Br J Sports Med 2012;46 Suppl 1:i85–9.doi:10.1136/bjsports-2012-091447 pmid:http://www.ncbi.nlm.nih.gov/pubmed/23097485
      OpenUrlPubMed
    11. ↵
      2. Thompson PD ,
      3. Baggish AL ,
      4. Franklin B , et al
      . American college of sports medicine expert consensus statement to update recommendations for screening, staffing, and emergency policies to prevent cardiovascular events at health fitness facilities. Curr Sports Med Rep 2020;19:223–31.doi:10.1249/JSR.0000000000000721 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32516193
      OpenUrlPubMed
    12. ↵
      2. Hainline B ,
      3. Drezner JA ,
      4. Baggish A , et al
      . Interassociation consensus statement oncardiovascular care of collegestudent-athletes. J Am Coll Cardiol 2016;67:2981–95.doi:10.1016/j.jacc.2016.03.527 pmid:http://www.ncbi.nlm.nih.gov/pubmed/27090220
      OpenUrlFREE Full Text
    13. ↵
      2. Thompson PD ,
      3. Franklin BA ,
      4. Balady GJ
      . Exercise and acute cardiovascular events. Circulation 2007;115:2358–68.doi:10.1161/CIRCULATIONAHA.107.181485
      OpenUrlAbstract/FREE Full Text
    14. ↵
      2. Borjesson M ,
      3. Serratosa L ,
      4. Carre F , et al
      . Consensus document regarding cardiovascular safety at sports arenas: position stand from the European association of cardiovascular prevention and rehabilitation (EACPR), section of sports cardiology. Eur Heart J 2011;32:2119–24.doi:10.1093/eurheartj/ehr178 pmid:http://www.ncbi.nlm.nih.gov/pubmed/21672932
      OpenUrlCrossRefPubMedWeb of Science
    15. ↵
      2. Sherrid MV ,
      3. Aagaard P ,
      4. Serrato S , et al
      . State requirements for automated external defibrillators in American schools: framing the debate about legislative action. J Am Coll Cardiol 2017;69:1735–43.doi:10.1016/j.jacc.2017.01.033 pmid:http://www.ncbi.nlm.nih.gov/pubmed/28359520
      OpenUrlFREE Full Text
    16. ↵
      2. Drezner JA ,
      3. Asif IM ,
      4. Harmon KG
      . Automated external defibrillators in health and fitness facilities. Phys Sportsmed 2011;39:114–8.doi:10.3810/psm.2011.05.1901 pmid:http://www.ncbi.nlm.nih.gov/pubmed/21673491
      OpenUrlCrossRefPubMed
    17. ↵
      2. Nishiuchi T ,
      3. Kinoshita R ,
      4. Kubota Y , et al
      . The current status of development and implementation of medical emergency response plan in schools. Pediatr Emerg Care 2018;34:189–92.doi:10.1097/PEC.0000000000000689 pmid:http://www.ncbi.nlm.nih.gov/pubmed/27077997
      OpenUrlPubMed
    18. ↵
      2. Post EG ,
      3. Schaefer DA ,
      4. Biese KM , et al
      . A comparison of emergency preparedness between high school coaches and Club sport coaches. J Athl Train 2019;54:1074–82.doi:10.4085/1062-6050-207-18 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31633408
      OpenUrlPubMed
    19. ↵
      2. Malhotra A ,
      3. Dhutia H ,
      4. Gati S , et al
      . Emergency response facilities including primary and secondary prevention strategies across 79 professional football clubs in England. Br J Sports Med 2019;53:813–7.doi:10.1136/bjsports-2016-097440 pmid:http://www.ncbi.nlm.nih.gov/pubmed/28615216
      OpenUrlAbstract/FREE Full Text
    20. ↵
      2. Sekendiz B ,
      3. Gass G ,
      4. Norton K , et al
      . Cardiac emergency preparedness in health/fitness facilities in Australia. Phys Sportsmed 2014;42:14–19.doi:10.3810/psm.2014.11.2087 pmid:http://www.ncbi.nlm.nih.gov/pubmed/25419884
      OpenUrlPubMed
    21. ↵
      2. Reagan J ,
      3. Moulson N ,
      4. Velghe J , et al
      . Automated external defibrillator and emergency action plan preparedness amongst Canadian university athletics. Can J Cardiol 2019;35:92–5.doi:10.1016/j.cjca.2018.10.012 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30595187
      OpenUrlPubMed
    22. ↵
      2. Smith CM ,
      3. Lim Choi Keung SN ,
      4. Khan MO , et al
      . Barriers and facilitators to public access defibrillation in out-of-hospital cardiac arrest: a systematic review. Eur Heart J Qual Care Clin Outcomes 2017;3:264–73.doi:10.1093/ehjqcco/qcx023 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29044399
      OpenUrlPubMed
    23. ↵
      2. Drezner JA ,
      3. Chun JSDY ,
      4. Harmon KG , et al
      . Survival trends in the United States following exercise-related sudden cardiac arrest in the youth: 2000-2006. Heart Rhythm 2008;5:794–9.doi:10.1016/j.hrthm.2008.03.001 pmid:http://www.ncbi.nlm.nih.gov/pubmed/18486566
      OpenUrlCrossRefPubMedWeb of Science
    24. ↵
      2. Drezner JA ,
      3. Rao AL ,
      4. Heistand J , et al
      . Effectiveness of emergency response planning for sudden cardiac arrest in United States high schools with automated external defibrillators. Circulation 2009;120:518–25.doi:10.1161/CIRCULATIONAHA.109.855890 pmid:http://www.ncbi.nlm.nih.gov/pubmed/19635968
      OpenUrlAbstract/FREE Full Text
    25. ↵
      2. Drezner JA ,
      3. Peterson DF ,
      4. Siebert DM , et al
      . Survival after exercise-related sudden cardiac arrest in young athletes: can we do better? Sports Health 2019;11:91–8.doi:10.1177/1941738118799084 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30204540
      OpenUrlPubMed
    26. ↵
      2. Drezner JA ,
      3. Toresdahl BG ,
      4. Rao AL , et al
      . Outcomes from sudden cardiac arrest in US high schools: a 2-year prospective study from the National Registry for AED use in sports. Br J Sports Med 2013;47:1179–83.doi:10.1136/bjsports-2013-092786 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24124037
      OpenUrlAbstract/FREE Full Text
    27. ↵
      2. Drezner JA ,
      3. Rogers KJ
      . Sudden cardiac arrest in intercollegiate athletes: detailed analysis and outcomes of resuscitation in nine cases. Heart Rhythm 2006;3:755–9.doi:10.1016/j.hrthm.2006.03.023 pmid:http://www.ncbi.nlm.nih.gov/pubmed/16818200
      OpenUrlCrossRefPubMedWeb of Science
    28. ↵
      2. Moher D ,
      3. Liberati A ,
      4. Tetzlaff J , et al
      . Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097.doi:10.1371/journal.pmed.1000097 pmid:http://www.ncbi.nlm.nih.gov/pubmed/19621072
      OpenUrlCrossRefPubMed
    29. ↵
      2. Berdowski J ,
      3. de Beus MF ,
      4. Blom M , et al
      . Exercise-related out-of-hospital cardiac arrest in the general population: incidence and prognosis. Eur Heart J 2013;34:3616–23.doi:10.1093/eurheartj/eht401 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24096330
      OpenUrlCrossRefPubMedWeb of Science
    30. ↵
      2. Rai M ,
      3. Thompson PD
      . The definition of exertion-related cardiac events. Br J Sports Med 2011;45:130–1.doi:10.1136/bjsm.2009.057653 pmid:http://www.ncbi.nlm.nih.gov/pubmed/20404002
      OpenUrlAbstract/FREE Full Text
    31. ↵
      2. Safar P
      . Resuscitation after brain ischemia. In: Grenvik A , Safar P , eds. Brain Failure and Resuscitation. Net York: Churchill Livingstone, 1981: 155–84.
    32. ↵
      2. Haddaway NR ,
      3. Collins AM ,
      4. Coughlin D , et al
      . The role of Google Scholar in evidence reviews and its applicability to grey literature searching. PLoS One 2015;10:e0138237.doi:10.1371/journal.pone.0138237 pmid:http://www.ncbi.nlm.nih.gov/pubmed/26379270
      OpenUrlCrossRefPubMed
    33. ↵
      2. McKeown S ,
      3. Mir ZM
      . Considerations for conducting systematic reviews: evaluating the performance of different methods for de-duplicating references. Syst Rev 2021;10:1–8.doi:10.1186/s13643-021-01583-y
      OpenUrlCrossRef
    34. ↵
      2. Wohlin C
      . Guidelines for snowballing in systematic literature studies and a replication in software engineering. In: Proceedings of the 18th International Conference on Evaluation and Assessment in Software Engineering - EASE ’14. New York, USA: ACM Press, 2014: 1–10.
    35. ↵
      2. Li T ,
      3. Higgins J ,
      4. Deeks J
      . Chapter 6: Choosing effect measures and computing estimates of effect. In: Thomas J , Chandler J , eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020. Cochrane, 2020. www.training.cochrane.org/handbook
    36. ↵
      2. Wells G ,
      3. Shea B ,
      4. O’Connell D
      . The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp [Accessed 7 Jan 2021].
    37. ↵
      2. Altman DG
      . Statistics in medical journals: some recent trends. Stat Med 2000;19:3275–89.doi:10.1002/1097-0258(20001215)19:23<3275::AID-SIM626>3.0.CO;2-M pmid:http://www.ncbi.nlm.nih.gov/pubmed/11113959
      OpenUrlCrossRefPubMedWeb of Science
    38. ↵
      2. McKenzie J ,
      3. Brennan S , et al
      . Chapter 12: Synthesizing and presenting findings using other methods. In: Higgins J , Thomas J , Chandler J , eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020. Cochrane, 2020. www.training.cochrane.org/handbook
    39. ↵
      2. Fleiss JL ,
      3. Levin B ,
      4. Paik MC
      . The Measurement of Interrater Agreement. In: Statistical Methods for Rates and Proportions. Hoboken, NJ: John Wiley & Sons, Inc, 2004: 598–626.
    40. ↵
      2. Berdowski J ,
      3. Berg RA ,
      4. Tijssen JGP , et al
      . Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2010;81:1479–87.doi:10.1016/j.resuscitation.2010.08.006 pmid:http://www.ncbi.nlm.nih.gov/pubmed/20828914
      OpenUrlCrossRefPubMedWeb of Science
    41. ↵
      2. Sasson C ,
      3. Rogers MAM ,
      4. Dahl J
      . Predictors of survival from out-of-hospital cardiac arrest. Circulation 2010;3:63–81.doi:10.1161/CIRCOUTCOMES.109.889576
      OpenUrl
    42. ↵
      2. Kiguchi T ,
      3. Okubo M ,
      4. Nishiyama C , et al
      . Out-of-hospital cardiac arrest across the world: first report from the International Liaison Committee on Resuscitation (ILCOR). Resuscitation 2020;152:39–49.doi:10.1016/j.resuscitation.2020.02.044 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32272235
      OpenUrlPubMed
    43. ↵
      2. Weisfeldt ML ,
      3. Sitlani CM ,
      4. Ornato JP , et al
      . Survival after application of automatic external defibrillators before arrival of the emergency medical system. J Am Coll Cardiol 2010;55:1713–20.doi:10.1016/j.jacc.2009.11.077
      OpenUrlFREE Full Text
    44. ↵
      2. Hansen SM ,
      3. Hansen CM ,
      4. Folke F , et al
      . Bystander defibrillation for out-of-hospital cardiac arrest in public vs residential locations. JAMA Cardiol 2017;2:507.doi:10.1001/jamacardio.2017.0008 pmid:http://www.ncbi.nlm.nih.gov/pubmed/28297003
      OpenUrlPubMed
    45. ↵
      2. Kobayashi D ,
      3. Sado J ,
      4. Kiyohara K , et al
      . Public location and survival from out-of-hospital cardiac arrest in the public-access defibrillation era in Japan. J Cardiol 2020;75:97–104.doi:10.1016/j.jjcc.2019.06.005 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31350130
      OpenUrlPubMed
    46. ↵
      2. Masterson S ,
      3. McNally B ,
      4. Cullinan J , et al
      . Out-of-hospital cardiac arrest survival in international airports. Resuscitation 2018;127:58–62.doi:10.1016/j.resuscitation.2018.03.024 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29550496
      OpenUrlPubMed
    47. ↵
      2. Kim JH ,
      3. Malhotra R ,
      4. Chiampas G , et al
      . Cardiac arrest during long-distance running races. N Engl J Med 2012;366:130–40.doi:10.1056/NEJMoa1106468 pmid:http://www.ncbi.nlm.nih.gov/pubmed/22236223
      OpenUrlCrossRefPubMedWeb of Science
    48. ↵
      2. Kinoshi T ,
      3. Tanaka S ,
      4. Sagisaka R , et al
      . Mobile automated external defibrillator response system during road races. N Engl J Med 2018;379:488–9.doi:10.1056/NEJMc1803218 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30067927
      OpenUrlPubMed
    49. ↵
      2. Ko SY ,
      3. Ro YS ,
      4. Shin SD , et al
      . Effect of a first responder on survival outcomes after out-of-hospital cardiac arrest occurs during a period of exercise in a public place. PLoS One 2018;13:e0193361.doi:10.1371/journal.pone.0193361 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29489877
      OpenUrlPubMed
    50. ↵
      2. Kuroki N ,
      3. Abe D ,
      4. Suzuki K , et al
      . Exercise-related resuscitated out-of-hospital cardiac arrest due to presumed myocardial ischemia: result from coronary angiography and intravascular ultrasound. Resuscitation 2018;133:40–6.doi:10.1016/j.resuscitation.2018.09.023 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30273611
      OpenUrlPubMed
    51. ↵
      2. Steinskog DM ,
      3. Solberg EE
      . Sudden cardiac arrest in sports: a video analysis. Br J Sports Med 2019;53:1293–8.doi:10.1136/bjsports-2018-099578 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30425046
      OpenUrlAbstract/FREE Full Text
    52. ↵
      2. Stratil P ,
      3. Sterz F ,
      4. Haugk M , et al
      . Exercise related cardiac arrest in amateur athletes on the tennis court. Resuscitation 2011;82:1004–7.doi:10.1016/j.resuscitation.2011.03.017 pmid:http://www.ncbi.nlm.nih.gov/pubmed/21481515
      OpenUrlPubMed
    53. ↵
      2. Torell MF ,
      3. Strömsöe A ,
      4. Zagerholm E , et al
      . Higher survival rates in exercise-related out-of-hospital cardiac arrests, compared to non-exercise-related - a study from the Swedish Register of Cardiopulmonary Resuscitation. Eur J Prev Cardiol 2017;24:1673–9.doi:10.1177/2047487317729251 pmid:http://www.ncbi.nlm.nih.gov/pubmed/28870144
      OpenUrlPubMed
    54. ↵
      2. Vicent L ,
      3. Ariza-Solé A ,
      4. González-Juanatey JR , et al
      . Exercise-related severe cardiac events. Scand J Med Sci Sports 2018;28:1404–11.doi:10.1111/sms.13037 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29237243
      OpenUrlPubMed
    55. ↵
      2. Siebert DM ,
      3. Drezner JA
      . Sudden cardiac arrest on the field of play: turning tragedy into a survivable event. Neth Heart J 2018;26:115–9.doi:10.1007/s12471-018-1084-6 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29411289
      OpenUrlPubMed
    56. ↵
      1. American Heart Association
      . Implementing an AED program, 2012. Available: https://cpr.heart.org/idc/groups/ahaecc-public/@wcm/@ecc/documents/downloadable/ucm_501521.pdf
    57. ↵
      2. Eastwood D ,
      3. Andrew E ,
      4. Smith K , et al
      . Exercise-related out-of-hospital cardiac arrest in Victoria, Australia. Resuscitation 2019;139:57–64.doi:10.1016/j.resuscitation.2019.03.043 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30981883
      OpenUrlPubMed
    58. ↵
      2. Jayaraman R ,
      3. Reinier K ,
      4. Nair S , et al
      . Risk factors of sudden cardiac death in the young. Circulation 2018;137:1561–70.doi:10.1161/CIRCULATIONAHA.117.031262
      OpenUrlAbstract/FREE Full Text
    59. ↵
      2. Kiyohara K ,
      3. Nishiyama C ,
      4. Kiguchi T , et al
      . Exercise‐Related out‐of‐hospital cardiac arrest among the general population in the era of public‐access defibrillation: a population‐based observation in Japan. J Am Heart Assoc 2017;6:1–10.doi:10.1161/JAHA.117.005786
      OpenUrlCrossRefPubMed
    60. ↵
      2. Marijon E ,
      3. Uy-Evanado A ,
      4. Reinier K , et al
      . Sudden cardiac arrest during sports activity in middle age. Circulation 2015;131:1384–91.doi:10.1161/CIRCULATIONAHA.114.011988 pmid:http://www.ncbi.nlm.nih.gov/pubmed/25847988
      OpenUrlAbstract/FREE Full Text
    61. ↵
      2. Pechmajou L ,
      3. Sharifzadehgan A ,
      4. Bougouin W , et al
      . Does occurrence during sports affect sudden cardiac arrest survival? Resuscitation 2019;141:121–7.doi:10.1016/j.resuscitation.2019.06.277 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31238153
      OpenUrlPubMed
    62. ↵
      2. Søholm H ,
      3. Kjaergaard J ,
      4. Thomsen JH , et al
      . Myocardial infarction is a frequent cause of exercise-related resuscitated out-of-hospital cardiac arrest in a general non-athletic population. Resuscitation 2014;85:1612–8.doi:10.1016/j.resuscitation.2014.06.033 pmid:http://www.ncbi.nlm.nih.gov/pubmed/25047569
      OpenUrlPubMed
    63. ↵
      2. Toukola TM ,
      3. Kauppila JP ,
      4. Pakanen L , et al
      . Characteristics and prognosis of exercise-related sudden cardiac arrest. Front Cardiovasc Med 2018;5:102.doi:10.3389/fcvm.2018.00102 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30094241
      OpenUrlPubMed
    64. ↵
      2. Myat A ,
      3. Song K-J ,
      4. Rea T
      . Out-of-hospital cardiac arrest: current concepts. Lancet 2018;391:970–9.doi:10.1016/S0140-6736(18)30472-0 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29536861
      OpenUrlCrossRefPubMed
    65. ↵
      2. Majewski D ,
      3. Ball S ,
      4. Finn J
      . Systematic review of the relationship between comorbidity and out-of-hospital cardiac arrest outcomes. BMJ Open 2019;9:e031655.doi:10.1136/bmjopen-2019-031655 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31740470
      OpenUrlAbstract/FREE Full Text
    66. ↵
      2. Swor RA ,
      3. Jackson RE ,
      4. Tintinalli JE , et al
      . Does advanced age matter in outcomes after out-of-hospital cardiac arrest in community-dwelling adults? Acad Emerg Med 2000;7:762–8.doi:10.1111/j.1553-2712.2000.tb02266.x pmid:http://www.ncbi.nlm.nih.gov/pubmed/10917325
      OpenUrlCrossRefPubMedWeb of Science
    67. ↵
      2. Cheng S-J ,
      3. Yu H-K ,
      4. Chen Y-C , et al
      . Physical activity and risk of cardiovascular disease among older adults. Int J Gerontol 2013;7:133–6.doi:10.1016/j.ijge.2013.03.001
      OpenUrl
    68. ↵
      2. Pinckard K ,
      3. Baskin KK ,
      4. Stanford KI
      . Effects of exercise to improve cardiovascular health. Front Cardiovasc Med 2019;6:69.doi:10.3389/fcvm.2019.00069 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31214598
      OpenUrlPubMed
    69. ↵
      2. Bougouin W ,
      3. Mustafic H ,
      4. Marijon E , et al
      . Gender and survival after sudden cardiac arrest: a systematic review and meta-analysis. Resuscitation 2015;94:55–60.doi:10.1016/j.resuscitation.2015.06.018 pmid:http://www.ncbi.nlm.nih.gov/pubmed/26143159
      OpenUrlCrossRefPubMed
    70. ↵
      2. Olivotto I ,
      3. Maron MS ,
      4. Adabag AS , et al
      . Gender-Related differences in the clinical presentation and outcome of hypertrophic cardiomyopathy. J Am Coll Cardiol 2005;46:480–7.doi:10.1016/j.jacc.2005.04.043 pmid:http://www.ncbi.nlm.nih.gov/pubmed/16053962
      OpenUrlFREE Full Text
    71. ↵
      2. Mosca L ,
      3. Barrett-Connor E ,
      4. Wenger NK
      . Sex/Gender differences in cardiovascular what a difference a decade makes gender differences in the burden of CVD. Circulation 2011;124:2145–54.doi:10.1161/CIRCULATIONAHA.110.968792
      OpenUrlFREE Full Text
    72. ↵
      2. Siontis KC ,
      3. Ommen SR ,
      4. Geske JB
      . Sex, survival, and cardiomyopathy: differences between men and women with hypertrophic cardiomyopathy. J Am Heart Assoc 2019;8:e014448.doi:10.1161/JAHA.119.014448 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31663428
      OpenUrlPubMed
    73. ↵
      2. Gordon T ,
      3. Kannel WB
      . Predisposition to atherosclerosis in the head, heart, and legs. The Framingham study. JAMA 1972;221:661–6.pmid:http://www.ncbi.nlm.nih.gov/pubmed/4261853
      OpenUrlCrossRefPubMedWeb of Science
    74. ↵
      2. Bergström G ,
      3. Persson M ,
      4. Adiels M , et al
      . Prevalence of subclinical coronary artery atherosclerosis in the general population. Circulation 2021;144:916–29.doi:10.1161/CIRCULATIONAHA.121.055340 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34543072
      OpenUrlCrossRefPubMed
    75. ↵
      2. Allan KS ,
      3. Jefkins TT ,
      4. O'Neil E , et al
      . Mandating training is not enough: the state of cardiopulmonaryresuscitation and automated external deiibrillator training in Ontario schools. CJC Open 2021;3:822–6.doi:10.1016/j.cjco.2021.02.008 pmid:http://www.ncbi.nlm.nih.gov/pubmed/34169261
      OpenUrlPubMed
    76. ↵
      2. O'Connor S ,
      3. Whyte E ,
      4. Fortington L
      . Are Irish Gaelic athletic association clubs prepared to use an AED following a sudden cardiac arrest? A cross-sectional survey. Phys Sportsmed 2020;48:320–6.doi:10.1080/00913847.2019.1704666 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31829067
      OpenUrlPubMed
    77. ↵
      2. Takamura A ,
      3. Ito S ,
      4. Maruyama K , et al
      . Quality of basic life support education and automated external defibrillator setting in schools in Ishikawa, Japan. Pediatr Int 2017;59:352–6.doi:10.1111/ped.13155 pmid:http://www.ncbi.nlm.nih.gov/pubmed/27589486
      OpenUrlPubMed
    78. ↵
      2. Hara M ,
      3. Hayashi K ,
      4. Hikoso S , et al
      . Different impacts of time from collapse to first cardiopulmonary resuscitation on outcomes after witnessed out-of-hospital cardiac arrest in adults. Circ Cardiovasc Qual Outcomes 2015;8:277–84.doi:10.1161/CIRCOUTCOMES.115.001864 pmid:http://www.ncbi.nlm.nih.gov/pubmed/25925373
      OpenUrlAbstract/FREE Full Text
    79. ↵
      2. Dorian P ,
      3. Allan KS ,
      4. Grant K
      . Retrieving AEDs to save a life: more complicated than it seems. Resuscitation 2020;151:213–4.doi:10.1016/j.resuscitation.2020.04.025 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32360425
      OpenUrlPubMed
    80. ↵
      2. Maurer H ,
      3. Masterson S ,
      4. Tjelmeland IB , et al
      . When is a bystander not a bystander any more? A European survey. Resuscitation 2019;136:78–84.doi:10.1016/j.resuscitation.2018.12.009 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30572073
      OpenUrlPubMed
    81. ↵
      2. Murakami Y ,
      3. Iwami T ,
      4. Kitamura T , et al
      . Outcomes of out-of-hospital cardiac arrest by public location in the public-access defibrillation era. J Am Heart Assoc 2014;3:e000533.doi:10.1161/JAHA.113.000533 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24755149
      OpenUrlAbstract/FREE Full Text
    82. ↵
      2. Matsui S ,
      3. Kitamura T ,
      4. Sado J , et al
      . Location of arrest and survival from out-of-hospital cardiac arrest among children in the public-access defibrillation era in Japan. Resuscitation 2019;140:150–8.doi:10.1016/j.resuscitation.2019.04.045 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31075289
      OpenUrlPubMed
    83. ↵
      2. Page RL ,
      3. Husain S ,
      4. White LY , et al
      . Cardiac arrest at exercise facilities. J Am Coll Cardiol 2013;62:2102–9.doi:10.1016/j.jacc.2013.06.048
      OpenUrlFREE Full Text
      2. Aschieri D ,
      3. Penela D ,
      4. Pelizzoni V , et al
      . Outcomes after sudden cardiac arrest in sports centres with and without on-site external defibrillators. Heart 2018;104:1344–9.doi:10.1136/heartjnl-2017-312441 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29463609
      OpenUrlAbstract/FREE Full Text
      2. Bohm P ,
      3. Scharhag J ,
      4. Egger F , et al
      . Sports-Related sudden cardiac arrest in Germany. Can J Cardiol 2021;37:105–12.doi:10.1016/j.cjca.2020.03.021 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32464107
      OpenUrlPubMed
      2. Cheah SO ,
      3. Ong MEH ,
      4. Chuah MBF
      . An eight year review of exercise-related cardiac arrests. Ann Acad Med Singap 2010;39:542–6.pmid:http://www.ncbi.nlm.nih.gov/pubmed/20697672
      OpenUrlPubMed
      2. Edwards MJ ,
      3. Fothergill RT
      . Exercise-related sudden cardiac arrest in London: incidence, survival and bystander response. Open Heart 2015;2:e000281.doi:10.1136/openhrt-2015-000281 pmid:http://www.ncbi.nlm.nih.gov/pubmed/26468401
      OpenUrlAbstract/FREE Full Text
      2. Jung E ,
      3. Park JH ,
      4. Kong SY , et al
      . Cardiac arrest while exercising on mountains in national or provincial parks: a national observational study from 2012 to 2015. Am J Emerg Med 2018;36:1350–5.doi:10.1016/j.ajem.2017.12.040 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29287617
      OpenUrlPubMed
      2. Landry CH ,
      3. Allan KS ,
      4. Connelly KA , et al
      . Sudden cardiac arrest during participation in competitive sports. N Engl J Med 2017;377:1943–53.doi:10.1056/NEJMoa1615710 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29141175
      OpenUrlCrossRefPubMed
      2. Nishiuchi T ,
      3. Hayashino Y ,
      4. Iwami T , et al
      . Epidemiological characteristics of sudden cardiac arrest in schools. Resuscitation 2014;85:1001–6.doi:10.1016/j.resuscitation.2014.04.027 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24820224
      OpenUrlPubMed
      2. Sado J ,
      3. Kiyohara K ,
      4. Kitamura T , et al
      . Sports activity and paediatric out-of-hospital cardiac arrest at schools in Japan. Resuscitation 2019;139:33–40.doi:10.1016/j.resuscitation.2019.03.041 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30953710
      OpenUrlPubMed
      2. Schmied C ,
      3. Drezner J ,
      4. Kramer E , et al
      . Cardiac events in football and strategies for first-responder treatment on the field. Br J Sports Med 2013;47:1175–8.doi:10.1136/bjsports-2012-091918 pmid:http://www.ncbi.nlm.nih.gov/pubmed/23613518
      OpenUrlAbstract/FREE Full Text

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    Footnotes

    • 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.