Author + information
- Alejandro Santos-Lozano, PhD∗ (, )
- Juan Martín-Hernández, PhD,
- Carlos Baladrón, PhD,
- María Ángeles Turrado-Sevilla, PhD,
- Ángel Arrarás-Flores, MSc,
- Julián P. Villacastín, MD, PhD,
- Araceli Boraita, MD, PhD,
- Héctor Bueno, MD, PhD and
- Alejandro Lucia, MD, PhD
- ↵∗European University Miguel de Cervantes, Padre Julio Chevalier, 2, 47012 Valladolid, Spain
Sudden cardiac death (SCD) in professional athletes has a considerable impact on society. This visibility is amplified in soccer, as it is the most popular sport worldwide, with approximately 250 million registered players (∼113,000 professionals) (1). Soccer is a demanding sport: during a 90-min game, professional players run about 10 km at high average intensities (close to the anaerobic threshold, at 80% to 90% of maximal heart rate) and with numerous explosive bursts (e.g., jumping, sprinting) (2). Thus, active players with undetected cardiovascular abnormalities may be at risk for exertional SCD. The Fédération Internationale de Football Association has developed standards for medical planning and procedures to prevent SCD in soccer (including pre-participation screening), which remain to be implemented worldwide, especially in competitions other than the 5 major European leagues (France, Germany, Italy, Spain, and the United Kingdom).
We adapted a previously defined methodology (3) to identify cardiac events that occurred during games and training among professional soccer players worldwide in the present century (January 2000 to June 2017). The following terms were used to search LexisNexis and Google: “soccer death,” “soccer fatality,” “sudden cardiac death, soccer,” “cardiac arrest, soccer,” “cardiovascular event, soccer,” “football death,” “football fatality,” “sudden cardiac death, football,” “cardiac arrest, football,” “heart attack, football,” and “cardiovascular event, football” (and combinations of more than 1 of these terms). For cases with unknown or uncertain data, we corresponded with the relevant football federations via the Spanish National Sports Council in an effort to contact next of kin or someone with legal authority to report the autopsy results. To be considered an SCD, each death had to fully comply with 3 stringent definition criteria (4): 1) unexpected as a result of natural causes; 2) post-mortem confirmation of the primary cause in the heart or great vessels (noncardiac causes excluded); and 3) occurring ≤1 h of the onset of collapse symptoms.
Eighty-nine documented deaths related to games and training were registered. Of these, 59 were due to cardiovascular events (all men; mean age at death 25 ± 5 years; incidence of 3.07 cardiovascular deaths/100,000 person-years; 95% confidence interval [CI]: 2.34 to 3.96), and 20 fully complied with the criteria of SCD, yielding an estimated worldwide incidence of 1.04 SCDs/100,000 person-years (95% CI: 0.85 to 1.26; mean age at death 24 ± 5 years) (Table 1). One methodological limitation of these findings is the lack of reliable information on underlying cardiac disease, autopsy data, and time from symptom onset to actual death for 21 of the 59 identified cardiovascular deaths (the vast majority in Asian and African countries), some of which might have fulfilled SCD criteria. If the aforementioned 21 cases were classified as SCDs, the incidence would have been 2.13 suspected SCDs/100,000 person-years (95% CI: 1.53 to 2.90). In the major European leagues (data on 45,506 players and 26,208 matches), only 1 cardiovascular death (occurring after resuscitated exertional cardiac arrest) was registered, yielding an incidence of 0 SCDs/100,000 person-years.
Our study indicates that although the global incidence of SCD in modern professional soccer is relatively low at 1.04 SCD/100,000 person-years, it is in fact higher than the average global incidence of sports-related SCD reported in a recent meta-analysis including 21 studies and >437 million individuals: 0.72 (95% CI: 0.58 to 0.86) (5). Of note, we report a null incidence of SCD among players who underwent pre-participation screening, that is, those playing in the major European competitions. Further research is needed to determine the effectiveness of pre-participation screening in preventing SCD among professional soccer players from all continents and ethnicities. While recognizing the stringent nature of the commonly adopted definition of SCD (especially the short time window between symptom onset and death), it appears that the exhaustive media coverage may be contributing to amplify the perception of SCD risk associated with sports participation, particularly when considering global data from soccer players. Although important in the light of mass media coverage, these data should not detract from participation in soccer in individuals without known heart disease.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose. P.K. Shah, MD, served as Guest Editor-in-Chief for this paper.
- 2017 American College of Cardiology Foundation