Publish in this journal
Journal Information
Vol. 53. Num. 197.January - March 2018Pages 1-42
Download PDF
More article options
Vol. 53. Num. 197.January - March 2018Pages 1-42
DOI: 10.1016/j.apunts.2017.07.003
Cardiopulmonary resuscitation and use of the automatic external defibrillator in sport
Reanimación cardiopulmonar y uso del desfibrilador externo automático en el deporte
Gonzalo Graziolia,
Corresponding author

Corresponding author.
, Xavier Escaladab, Luis Serratosac, Jordi Medallod, Josep Gutierreze, Marta Sitgesa, Josep Brugadaa
a Cardiovascular Institut Clínic, Hospital Clínic, University of Barcelona, Institute for Biomedical Research August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
b Sistema d’Emergències Mèdiques de Catalunya, Barcelona, Catalonia, Spain
c Hospital Universitario Quironsalud, Madrid, Spain
d Institut de Medicina Legal i Ciències Forenses de Catalunya, Barcelona, Catalonia, Spain
e Consell Català de l’Esport, Barcelona, Catalonia, Spain
This item has received
Article information
Full Text
Download PDF

Cardiac arrest during sport practice is a low-incidence event, however, as it is commonly seen witnessed to have a high survival rate compared to general non-hospital cardiac arrest. The objective of this review is to analyze the special characteristics, give recommendations for the installation of automatic external defibrillators and the elaboration of an adequate medical action plan for each sports center.

Cardiopulmonary resuscitation
Sudden death
Automatic external defibrillator

La parada cardiaca durante la práctica de deporte es un evento de baja incidencia, sin embargo, al ser habitualmente presenciado presenta una tasa de supervivencia elevada si se compara con el paro cardiaco extra-hospitalario en general. El objetivo de esta revisión es analizar las características especiales, dar recomendaciones para la instalación de desfibriladores externos automáticos y elaboración de un plan de acción médica adecuado a cada centro deportivo.

Palabras clave:
Reanimación cardiopulmonar
Muerte súbita
Desfibrilador externo automático
Full Text

Sudden cardiac death (SCD) during sports is a rare event, with an estimated 1–2 cases per 100,000 athletes year incidence1 however, it has a large impact on media and society in general.

In a practical approach to this problem of public health, it described the “rule of 5” of the SCD in sport; because it represents 5% of the total incidence in the general population SCD,2 occurs in 5% in females,3 5% occurs in competitive athletes,4 however, the competitive athletes have a relative risk 5 times higher than those practicing sport recreationally.4

The incidence of SCD in sport increases with age,5 and from the age of 35 the main cause is atherosclerotic coronary disease, which multiplies by 4 times its incidence, in relation to the youngest.6 In individuals under 35 years of age, the causes of SCD during sports are mainly congenital and hereditary heart diseases that affect heart morphology and electrical impulse conduction disorders.7 In both cases the alterations can generate complex arrhythmias triggered during the physical exercise, that finally are causes of the cardiac arrest during the sport practice.

For the prevention of SCD in sport, pre-participation screening has been proposed with the medical history, physical examination and ECG of the athlete, however, in some cases there may be false negatives, in congenital diseases such as incomplete forms of expression of cardiomyopathy, anomalies of the origin of the coronary arteries, early coronary disease; and other acquired diseases such as commotio cordis, myocarditis or hydroelectrolytic disorders.8

According to the studies of Marijon et al.2,4 in more than 90% of the cases of cardiac arrest (CA) during sports were witnessed,2 being the early onset of cardiopulmonary resuscitation (CPR) maneuvers, which was carried out in one third of the cases, the main determinant of a better survival rate and better neurological status at hospital discharge.4

The survival rate after a CA can be up to about three times higher when it occurs during sports practice compared to those in which CA occurs outside the sports field, although according to results of the same study9 the highest survival is only seen in those over 35 years. In athletes under 35 years of age, the low incidence of SCD makes it difficult to find evidence to support prevention strategies, however, in a study conducted in a total of 2149 secondary education institutes in the United States with 39 cases of CA during the sports practice, 89% survival rates were found in both young and adult patients in relation to early CPR and the use of automatic external defibrillator (AED).10

A good communication system to the local medical emergency services is also essential to increase the chances of survival of the athlete, and in its simplest form must include at least one mobile phone and know the location of the sports facility to facilitate the access. It is expected that in the coming years there will be a greater number of organizers, referees, coaches, physical trainers, athletes and even spectators who have received training in CPR and use of the DEA. Currently, we have simple tools such as the CPR11 mobile phone application, which is part of FIFA F-MARC's emergency prevention and management strategies, which can be downloaded free of charge and with videos, sound and text is intended to teach anyone without previous medical training how to act before a CA of an athlete.11

In this context, the purpose of this document is to offer recommendations based on the scientific evidence available for the development and implementation of medical action plans (MAP) that include the installation of a DEA in sports centers in order to guarantee an adequate and early response to a CA.

Priori et al.12 make no mention of the special situation of cardiac arrest during sports practice; however, in the year 2015 the guidelines of the European Resuscitation Council include this paragraph for the first time as a special situation,13 and reaffirm the importance of prior organization of the response to a PC and immediate defibrillation.

The guidelines recommendation in 2004 year, for the use of the AED by the European Society of Cardiology and the European Resuscitation Council12 makes no mention of the special situation of cardiac arrest during sports practice, however, in the year 2015 the guidelines of the European Resuscitation Council include this paragraph for the first time as a special situation,13 and reaffirm the importance of prior organization of the response to a CA and immediate defibrillation.

In relation to large sports facilities where sports competitions (stadiums, halls, etc.), the European Society of Preventive Cardiology held, recommended in a consensus document the existence of a MAP and installation of a DEA to ensure then one response from a CA, the presence of at least a nurse and a physician if the capacity exceeds 1000 spectators and athletes.14 The plan must be tailored to each facility, so that human resources (doctors, nurses, emergency medical technicians), clinics or attention stations, mobile units of life support and defibrillators, should be required to meet response times suitable to a CA (1min. to begin CPR and 3–5min. to use the defibrillator).8

In Catalonia there is legislation relating to the installation and use of AEDs,15 and self-protection measures by different centers.16 While not a sports centers referred to in Annex III, one can extrapolate the requirement of an AED for each establishment with more than 1000 people capacity. However, the MSC mentioned above in the context of sport is a particular situation; with a low incidence in relation to total extra-hospital cardiac arrest, but with a higher relative risk if we assume the exposure time, and in turn it represents the PC with greater possibility of effective resuscitation by habitual presence of witnesses.2

When a CA is witnessed, the hospital survival rate and the neurological status are significantly better,17,18 so the recommendations suggest the existence of a MAP in the stadiums with capacity above 1000 spectators14 With personnel with the appropriate training and experience in life support (basic and/or advanced), and a coordinator to be a physician trained in extra-hospital must lead the emergency device, unusual but essential condition emergencies.

In Catalonia, the legislation allows anyone to use an AED19 and there is a decree regulating CPR training,15 which must be obtained by at least one responsible for coordinating the MAP in each sports center, in order to improve the operation of the chain of survival. There are four basic elements for the success of a CPR program in the extra-hospital setting: (1) planned and practiced response, (2) training in CPR and AED use, (3) Automatic system of medical emergency notice, and (4) maintenance DEA.20

The studies that have evaluated the cost-effectiveness of the DEA installation in public places, in turn performing an analysis by the type of place in which cardiac arrest occurs and using the Markov analysis model, estimate a cost for Sports facilities and gyms of between US $ 45,00021 and US $ 136,00022; however, in these studies it is not detailed the number of athletes that attended each sport center analyzed.

In conclusion, due to the higher relative risk of having an SCD during sports practice, the higher survival rate in CA cases witnessed, and cost-effectiveness analyzes with theoretical models; we consider useful the preparation of a MAP that includes the training in CPR of first responders and the access to a DEA with connection to the local medical emergency system, in each sports center and stadiums with a capacity of more than 1000 people.

Conflicts of interest

The authors did not report any conflicts of interest in this article.


To the Mémora Group for supporting research on prevention of sport-related death.

K.G. Harmon,I.M. Asif,J.J. Maleszewski,D.S. Owens,J.M. Prutkin,J.C. Salerno
Incidence etiology, and comparative frequency of sudden cardiac death in NCAA athletes. A decade in review
Circulation [Internet], 132 (2015), pp. 10-19
Available from:
E. Marijon,A. Uy-Evanado,K. Reinier,C. Teodorescu,K. Narayanan,X. Jouven
Sudden cardiac arrest during sports activity in middle age
Circulation, 131 (2015), pp. 1384-1391
P. Bohm,J. Scharhag,T. Meyer
Data from a nationwide registry on sports-related sudden cardiac deaths in Germany
Eur J Prev Cardiol, 23 (2016), pp. 649-656
E. Marijon,M. Tafflet,D.S. Celermajer,F. Dumas,M.C. Perier,H. Mustafic
Sports-related sudden death in the general population
Circulation [Internet], 124 (2011), pp. 672-681
Available from:
E. Marijon,W. Bougouin,D.S. Celermajer,M.C. Périer,F. Dumas,N. Benameur
Characteristics and outcomes of sudden cardiac arrest during sports in women
Circ Arrhythmia Electrophysiol, 6 (2013), pp. 1185-1191
A. La Gerche,A.L. Baggish,J. Knuuti,D.L. Prior,S. Sharma,H. Heidbuchel
Cardiac imaging and stress testing asymptomatic athletes to identify those at risk of sudden cardiac death
JACC Cardiovasc Imaging [Internet], 6 (2013), pp. 993-1007
Available from: [cited 6.05.14]
G. Grazioli,D. Brotons,F. Pifarré,M. Sanz de la Garza,S. Montserrat,B. Vidal
Cardiological contraindications in sports
Apunt Med Esport, 52 (2017), pp. 3-9
A. Malhotra,H. Dhutia,S. Gati,T.-J. Yeo,G. Finnochiaro,T. Keteepe-Arachi
Emergency response facilities including primary and secondary prevention strategies across 79 professional football clubs in England
Br J Sports Med [Internet], (2017),
Available from:
J. Berdowski,M.F. De Beus,M. Blom,A. Bardai,M.L. Bots,P.A. Doevendans
Exercise-related out-of-hospital cardiac arrest in the general population: incidence and prognosis
Eur Heart J, 34 (2013), pp. 3616-3623
J.A. Drezner,B.G. Toresdahl,A.L. Rao,E. Huszti,K.G. Harmon
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 [Internet], 47 (2013), pp. 1179-1183
Available from:
L.J. Serratosa,E.B. Kramer,H.D. Pereira,J. Dvorak,P.L. Ripoll
CPR 11 a mobile application that can help in saving lives (Mobile App User Guide)
Br J Sports Med [Internet], 50 (2016), pp. 823-824
S.G. Priori,L.L. Bossaert,D.A. Chamberlain,C. Napolitano,H.R. Arntz,R.W. Koster
ESC-ERC recommendations for the use of automated external defibrillators (AEDs) in Europe
Eur Heart J, 25 (2004), pp. 437-445
A. Truhlar,C.D. Deakin,J. Soar,G.E.A. Khalifa,A. Alfonzo,J.J.L.M. Bierens
European Resuscitation Council Guidelines for Resuscitation 2015. Section 4. Cardiac arrest in special circumstances
M. Borjesson,L. Serratosa,F. Carre,D. Corrado,J. Drezner,D.L. Dugmore
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 [Internet], 32 (2011), pp. 2119-2124
Available from: [cited 7.08.14]
DECRET 151/2012, de 20 de novembre, pel qual s’estableixen els requisits per a la instal-lació i l’ús de desibril ladors externs fora de l’àmbit sanitari i per a l’autorització d’entitats formadores en aquest ús
D Of la General Catalunya, 6259 (2012), pp. 57848-57859
Decret 30/2015, de 3 de març, pel qual s’aprova el catàleg d’activitats i centres obligats a adoptar mesures d’autoprotecció i es fixa el contingut d’aquestes mesures
D Of la General Catalunya, 6824 (2015), pp. 1-45
G. Nichol,E. Huszti,A. Birnbaum,B. Mahoney,M. Weisfeldt,A. Travers
Cost-effectiveness of lay responder defibrillation for out-of-hospital cardiac arrest
Ann Emerg Med [Internet], 54 (2009),
G.D. Perkins,I.G. Jacobs,V.M. Nadkarni,R.A. Berg,F. Bhanji,D. Biarent
Cardiac arrest and cardiopulmonary resuscitation outcome reports: update of the Utstein resuscitation registry templates for out-of-hospital cardiac arrest
Resuscitation [Internet], 96 (2015), pp. 328-340
M. Sitges,J.A. Gutiérrez,J. Brugada,R. Balius,M. Bellver,D. Brotons
Consensus for the prevention of sudden cardiac death in athletes
Apunt Med Esport, 48 (2013), pp. 35-41
N.F. Garritano,M. Willmarth-Stec
Student athletes, sudden cardiac death, and lifesaving legislation: a review of the literature
J Pediatr Heal Care [Internet], 29 (2015), pp. 233-242
P. Cram,S. Vijan,A.M. Fendrick
Cost-effectiveness of automated external defibrillator deployment in selected public locations
J Gen Intern Med, 18 (2003), pp. 745-754
G. Nichol,T. Valenzuela,D. Roe,L. Clark,E. Huszti,G.A. Wells
Cost effectiveness of defibrillation by targeted responders in public settings
Copyright © 2018. FC Barcelona
Apunts Medicina de l'Esport (English Edition)

Subscribe to our Newsletter

Article options
Cookies policy
To improve our services and products, we use cookies (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.