Sports-Related Sudden Cardiac Arrest 'Extremely' Rare in Women

"Our study shows that cardiac arrest during sports activities is up to 13 times less frequent in women, which means that the risk of sports-related cardiac arrest is substantially lower in women than in men. This tighter risk is consistent across all age subgroups and registries," Orianne Weizman, MD, MPH, Université Paris CitéFrance, told | Medscape Cardiology.

"Even if it is a nonconsensual suggestion, the question of risk-adapted screening in women must be asked," Weizman and colleagues propose.

Annual Incidence

Among 34,826 cases of SCA in the registries that occurred in adults between 2006 and 2017, 760 (2.2%) were related to sports and the vast majority occurred in men (706, 92.9%). Only 54 (7.1%) occurred in women.

Overall, the average annual incidence of Sr-SCA in women was 0.19 per million compared with 2.63 per million in men (< .0001).

When extrapolating to the total European population and accounting for age and sex, this translates into 98 expected cases of Sr-SCA each year in women versus 1350 cases annually in men.

The average age of Sr-SCA was similar in women and men (59 years). Most cases occurred during moderate-vigorous physical activity, although data on the types of sports and time spent on sports per week or month were not defined.

However, the investigators note that women with Sr-SCA were more likely than men to be engaged in light or moderate physical activity at the time of arrest (17.5% vs 4.2%) — suggesting a potential higher propensity for women to present with SCA at moderate workloads.

The incidence of Sr-SCA increased only slightly in postmenopausal women, while there was an 8-fold increase in men aged 60 to 74 years, relative to peers younger than 40 years.

History of heart disease was relatively uncommon in both men and women. Previous myocardial infarction (MI) was the most frequent preexisting condition in men (26.8%), whereas nonischemic heart disease (cardiomyopathy and valvular heart disease) was more frequent among women (29.0%).

Cardiovascular risk factors were frequently present in both men and women, with at least one factor present in two-thirds of the patients, regardless of sex.

Pulseless electrical activity and asystole were more common in women than in men (40.7% vs 19.1%), as has been shown in previous studies of resuscitation from SCA in the general population. Ventricular tachycardia or fibrillation was the initial rhythm in 80.9% of men and 59.3% of women.

The cause of SCA was MI in 31.4% of women and 29.0% of men. Other cases were related to dilated cardiomyopathy (5.6% in women, 1.8% in men) or hypertrophic cardiomyopathy (1.9% in women, 1.3% in men). Electrical heart disease was found in two women (3.7%) and 15 men (2.1%).

In most cases (86%), one or more witnesses were present and assisted after the collapse. There was no significant difference between men and women in bystander response, time to defibrillation, and survival, which approached 60% at hospital discharge with early bystander cardiorespiratory resuscitation and automatic external defibrillator use.

A limitation of the study is a predominantly White European population, meaning that the findings may not be extrapolated to other populations.

Tailored Screening?

"These findings raise questions about the causes of this extremely low risk, which are not yet clear, and the extent to which we should revise our pre-sport screening methods," Weizman told | Medscape Cardiology.

"We suggest that extensive, routinely conducted screening in women would not be cost-effective because of the extremely rare incidence of serious events," Weizman said.

What's lacking, however, is sport-specific data on whether specific activities (endurance or resistance) would be more risky for women. Further information, particularly on the sports at highest risk for Sr-SCA in women, is needed to propose tailor-made screening algorithms, Weizman noted.

The value of preparticipation screening for occult heart disease beyond the history and physical examination has been debated, with some organizations recommending electrocardiogram (ECG) in addition to baseline assessments.

But this can lead to false-positives, "with the anxiety and cost associated with additional testing," Anne Curtis, MD, University at Buffalo, Buffalo General Medical Center, New York, and Jan Tijssen, PhD, University of Amsterdam, the Netherlands, write in a linked editorial.

Currently, the American Heart Association recommends screening before sports participation, with a focused personal and family history and physical examination.

Curtis told | Medscape Cardiology that the US guidelines "should stay as they are, but if one were to change them, it would be important to recognize that male athletes are much more likely to suffer arrhythmic events during sports than female athletes."

"That to me means that female athletes in particular should not need to have ECGs prior to sports participation unless the history and physical examination detects a potential problem that needs further investigation," Curtis said.

"Both women and men should be screened for cardiovascular risk factors during routine primary care, with appropriate interventions for hypertension, hyperlipidemia, smoking, and other risk factors," Curtis and Tijssen advise in their editorial.

"In asymptomatic individuals who wish to become more active, in most cases they should be given the green light to proceed, starting slow and increasing intensity/duration over time, without specific additional testing. This advice is particularly relevant for women, given the findings of the current and prior studies," they add.