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Mobile Automated External Defibrillator Response System during Road Races



In Japan, an automated external defibrillator (AED) response system for runners included paramedics on bicycles who carried AEDs, on-foot teams, and a central dispatch system. During 251 races, 28 of 30 runners who had a cardiac arrest were successfully resuscitated.
Cor responde nce
The new england journal of medicine
n engl j med 379;5 August 2, 2018
Cor responde nce
Mobile Automated External Defibrillator Response System
during Road Races
To the Editor: The number of marathon races
and other road races has rapidly increased in
as have the number of sudden cardiac
arrests during these races.
We developed a rapid
mobile automated external defibrillator (AED)
system to provide early cardiopulmonary resus-
citation (CPR) and AED intervention for runners
who have cardiac arrest during road races.
The system consists of mobile teams (pairs of
paramedics who ride bicycles and carr y AEDs
and emergency medical kits) and on-foot teams
(pairs of paramedic trainees who carry AEDs and
can provide basic life support). The system also
includes medical communications dispatchers,
staff at a first-aid station, and physician volun-
teers who run the race and are available by a
global positioning system–enabled telephone to
assist if needed. Details of the system and the
method of data collection are provided in the
Supplementary Appendix, available with the full
text of this letter at
Between January 1, 2005, and March 7, 2017,
we used the system to support 1,965,265 runners
in 251 road races of a distance of 10.0 to 42.2 km,
and during that period we responded to 30 runners
with cardiac arrest (Table 1). There was 1 cardiac
arrest per 65,509 runners (1.53 cardiac arrests per
100,000 runners). Regardless of the length of the
race, a total of 21 of the cardiac arrests (70%)
occurred in the last quarter of the distance run or
near the finish line of the race. Gasping was noted
in 26 of the runners with cardiac arrest (87%).
Two runners had unwitnessed cardiac arrest.
The initial rhythm was pulseless electrical activ-
ity in one runner and asystole in the other, and
neither of the two runners was successfully re-
In the 28 runners with witnessed cardiac arrest,
the median interval bet ween collapse and the
initiation of basic CPR was 0.8 minutes (inter-
quartile range, 0.5 to 1.0) and the median inter-
val between collapse and delivery of the first
AED shock was 2.2 minutes (interquartile range,
1.6 to 4.4). Shocks were delivered to 23 runners
who had ventricular f ibrillation, and another 5 run-
ners (4 with pulseless electrical activity and 1 with
ventricular fibrillation) recovered with basic CPR
only. The median interval between collapse and
the return of spontaneous circulation was 5.5 min-
utes (interquartile range, 3.2 to 7.0); all these
runners had return of spontaneous circulation
in the f ield, and all had a favorable neurologic
outcome (Cerebral Performance Categor y of 1 or 2,
on a scale from 1 [good cerebral performance]
to 5 [death or brain death]) at 1 month and 1 year.
The median length of hospitalization was 5 days
(interquartile range, 3 to 8 days).
Tomoya Kinoshi, M.S.Sc.
Shota Tanaka, B.S.
Ryo Sagisaka, Ph.D.
Takahiro Hara, Ph.D.
Toru Shirakawa, M.E.M.
Etsuko Sone, M.E.M.
Hiroyuki Takahashi, Ph.D.
Masaru Sakurai, M.D., Ph.D.
Akira Maki, M.D., Ph.D.
this week’s letters
488 Mobile Automated External Def ibrillator
Response System during Road Races
490 Catheter Ablation for Atrial Fibrillation with
Heart Failure
493 Genetics of Diffuse Large B-Cell Lymphoma
494 Diagnostic Use of Base Excess in Acid–Base
The New England Journal of Medicine
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Copyright © 2018 Massachusetts Medical Society. All rights reserved.
Cor re spondence
n engl j med 379;5 August 2, 2018
Hiroshi Takyu, Ph.D.
Hideharu Tanaka, M.D., Ph.D.
Kokushikan University
Tokyo, Japan
Disclosure forms provided by the authors are avail able wit h
the fu ll text of th is letter at
1. Sasakawa Sport s Foundation. Spor ts li fe dat a. (htt ps:/ / ww w
.ssf .or .jp/ research/ sldata/ tabid/ 381/ Default .aspx). (I n Japa nese.)
2. Shirakawa T, Tanaka H, Kinoshi T, Tanaka S, Taky u H.
Analysis of sudden cardiac arrest cases during marathon races
in Japan. I nt J Clin Med 2017; 8: 472-80.
3. Maezumi T, Tana ka H, Hosokawa T, et al. Importa nce of
bicycle mobi le tea m (Mobile AED team) in citizen marathon.
Journa l of Clinical Spor ts Medicine 2009; 26: 329-34. (In Japanese.)
4. Tanaka H, Tokunaga T, Maezumi T, Hosokawa T. A develop-
ment of an ef fect ive emergency med ical support in the cit izens’
marat hon events. The An nual Reports of Healt h, Physical Edu-
cation and Sport Science 2008; 27: 115-22. (In Japanese.)
DOI: 10.1056/NEJMc1803218
All Runners with
Cardiac Arrest
(N = 30)
Runners with
Cardiac Arrest
(N = 28)
Runners with
Cardiac Arrest
(N = 2)
Distance of race — no. (%)
>21.1 to full marathon, 42.2 km 19 (63) 19 (68) 0
Half-marathon, 21.1 km 7 (23) 6 (21) 1 (50)
10.0 to <21.1 km 4 (13) 3 (11) 1 (50)
Demographic characteristics of runners
Median age (IQR) — yr 51 (35–59) 52 (36–59) 28 (27–29)
Male sex — no. (%) 27 (90) 25 (89) 2 (100)
Cardiac arrests
Median time from start of race to cardiac arrest (IQR) — min 159 (121–192) 161 (134–195) Unknown
Gasping — no. (%) 26 (87) 25 (89) 1 (50)
Median time from collapse to contact with rapid mobile AED system
team (IQR) — min
0.8 (0.5–1.1) 0.8 (0.5–1.0) Unknown
Median time from witnessed cardiac arrest to initiation of CPR (IQR)
— min
Unknown 0.8 (0.5–1.0) Unknown
Person who initially performed CPR — no. (%)
Rapid mobile AED system team member 23 (77) 21 (75) 2 (100)
Another runner 7 (23) 7 (25) 0
AED analysis
Defibrillation performed — shocks delivered/patients with ventricular
fibrillation (%)
23/24 (96) 23/24 (96) 0
Median time from collapse to delivery of AED shock (IQR) — sec 131 (99–263) 131 (99–263) Unknown
Documented ECG waveform according to initial AED data — no. (%)
Ventricular fibrillation 24 (80) 24 (86) 0
Pulseless electrical activity 5 (17) 4 (14) 1 (50)
Asystole 1 (3) 01 (50)
Return of spontaneous circulation in field — no. (%) 28 (93) 28 (100) 0
CPC 1 or 2 — no. (%)†
At 1 mo 28 (93) 28 (100) 0
At 1 yr 28 (93) 28 (100) 0
Median hospital stay (IQR) — day 5 (3–8) 5 (3–8) Unknown
* AED denotes automated external defibrillator, ECG electrocardiographic, and IQR interquartile range.
The Cerebral Performance Category (CPC) is graded on a scale from 1 (good cerebral performance) to 5 (death or brain death).
Table 1. Characteristics of Races, Runners, and Sudden Cardiac Arrests.*
The New England Journal of Medicine
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Copyright © 2018 Massachusetts Medical Society. All rights reserved.
... 1 In marathons, research indicates the SCD rate ranges from 0.24 to 0.39 per 100 000 runners. 3 4 A study reported the incidence of SCA as 0.54 per 100 000 runners and found 42 cases of SCD among 59 total SCAs in 10.9 million runners. 4 In a Japanese study, the incidence of SCA was 0.46 per 100 000 runners. 5 The London marathon had the same incidence, 6 while marathons in the Tokyo area had a higher rate of 0.65 per 100 000 runners. 7 Death occurred in 1 in 80 000 runners in 26 London marathons. To increase the survival rate ...
... of SCA during marathons, the early initiation of cardiopulmonary resuscitation (CPR) and defibrillation is vital. 7 The cerebral performance category (CPC) score, which ranges from 1 to 5 (1 indicates normal consciousness and 5 indicates brain death), is generally used to evaluate neurological outcomes post-cardiac arrest. 8 Favourable neurological outcomes (CPC 1-2) were found in 51.8% of public access defibrillation (PAD) cases and 25.5% of non-PAD cases in public locations. ...
... [10][11][12] In our previous study, a 100% survival rate was achieved by the initiation of immediate chest compressions and defibrillation for witnessed SCA cases during road races. 7 However, details of the resuscitation and long-term neurological outcomes were not reported. ...
Objective: To describe neurological outcomes after sudden cardiac arrests (SCAs) in road and long-distance races using a rapid mobile automated external defibrillator system (RMAEDS) intervention. Methods: A total of 42 SCAs from 3 214 701 runners in 334 road and long-distance races from 1 February 2007 to 29 February 2020 were examined. Demographics, SCA interventions, EMS-related data and SCA-related outcomes were measured. Primary endpoints were favourable neurological outcomes (Cerebral Performance Categories 1-2) at 1-month and 1-year post-SCA. Secondary endpoints were factors related to the field return of spontaneous circulation (ROSC) and resuscitation characteristics, including the initial ECG waveform classification and resuscitation sequence times according to the initial ECG rhythm. Results: The SCA incidence rate was 1.31 per 100 000 runners (age: median (IQR), 51 (36.5, 58.3) years). Field ROSC and full neurological recovery at 1-month post-SCA was achieved 90.4% and 92.9% of cases, respectively. In 22 cases in which bystander cardiopulmonary resuscitation was initiated within 1 min and defibrillation performed within 3 min, full neurological recovery was achieved at 1-month and 1-year post-SCA in 95.5.% and 95.5% of cases, respectively. Conclusions: The RMAEDS successfully treated patients with SCA during road and long-distance races yielding a high survival rate and favourable neurological outcomes. These findings support rapid intervention and the proper placement of healthcare teams along the race course to initiate chest compressions within 1 min and perform defibrillation within 3 min.
... [92] Moreover, the availability of automated external defibrillators in all fitness facilities has been strongly emphasized. [93][94][95] In addition, health-fitness facilities should perform pre-entry screening, have written emergency policies, conduct regular emergency drills and cardiopulmonary resuscitation, as well as establish a "hotline" for immediate use in case of medical emergencies. [20] Unfortunately, it seems that there is a significant gap between international guidelines and everyday practice. ...
... P = 0.002), with rates of survival to hospital discharge highest in recreational areas (49%). AED availability during a sporting event, education of trainers and bystanders, and systematic emergency response methods all contribute to high survival rates in settings with systematic emergency response methods and timely deployment of AEDs [7,[48][49][50] [ Tables 4 and 5]. ...
Arrhythmias, which are fatal in some patients, can be triggered by sports in vulnerable people. It is estimated that 1:40,000–1:250,000 athletes will suffer a sudden cardiac death (SCD). However, female athletes appear to have some level of cardiac protection, since suffering from SCD considerably less than male athletes during sports. Athletes with underlying coronary, valvular or myocardial disease, as well as channelopathies, may be particularly prone to SCD from exercise- and sports-related physical activity. There are three main causes of SCD in young athletes: Sudden Arrhythmic Death Syndrome (56%), congenital anomalous coronary arteries (7%–14%), and hypertrophic cardiomyopathy (36%–48%). In the context of exercise, acute ischemia, myocardial infarction, and stroke risk are increased by catecholamine surge and exercise-induced stress. In middle-aged athletes, excessive cardiovascular activity is associated with a higher risk of mortality related to cardiovascular disease. It is possible to detect at-risk athletes by conducting cardiac screening, which involves a family history, physical examination, and a resting electrocardiogram. Consequently, efforts have been made to better understand the causes of SCD in athletes and to develop appropriate prevention methods.
... Coaches and athletes should be made aware of potential warning signs and symptoms (e.g., syncope, lightheadedness, perceived palpitations, or arrhythmias). Regular emergency drills, bystander cardiopulmonary resuscitation, and the use of automated external defibrillators have all been shown to improve overall and athletic population survival rates [67,68]. ...
Full-text available
Primary prevention of sudden cardiac arrest (SCA) refers to the use of pharmacological or interventional therapy and healthy lifestyle modifications to prevent sudden cardiac death (SCD) in patients who have not experienced symptomatic, life-threatening persistent ventricular tachycardia or ventricular fibrillation or SCA but are considered to be at a higher risk. This review provides an overview of the physiological heart changes and distinct electrical manifestations, the etiology of SCA, and screening methods and interventions for the prevention of SCA in athletes. The American College of Cardiology and the American Heart Association (AHA) Guidelines recommend screening with a 14-point history and physical examination. In most cases, a thorough clinical evaluation along with an ECG is sufficient for screening. Athletes with heart diseases leading to SCD are urged not to compete. Further decisions are taken following the European Society of Cardiology and the AHA's current workout recommendations. Early detection of cardiac disease allows for individualized risk evaluation and treatment, which has been shown to reduce mortality rates in athletes.
... This is extremely important, given that early AED use was the strongest determinant of survival, with ≥90% of survival at hospital discharge in the subgroup of subjects who benefited from both early CPR and defibrillation, in line with a previous report on SCA using mobile AED response system during road races marathon in Japan. 13 Very high survival in both young and older sports participants is possible in the setting of SrSCA when AED use and early CPR are provided, 14 SrSCA in young adults in the community with the higher survival of SrSCA compared with non-SrSCA, and of SrSCA occurring in sports facilities compared with those occurred outside, mostly explained by increased rates of AED use and early CPR. 17,18 Thus, understanding the reasons for low AED use by lay responders is crucial. ...
Full-text available
Aims: Data on sports-related sudden cardiac arrest (SrSCA) among young adults in the general population are scarce. We aimed to determine the overall SrSCA incidence, characteristics, and outcomes in young adults. Methods and results: Prospective cohort study of all cases of SrSCA between 2012 and 2019 in Germany and Paris area, France, involving subjects aged 18-35 years. Detection of SrSCA was achieved via multiple sources, including emergency medical services (EMS) reporting and web-based screening of media releases. Cases and aetiologies were centrally adjudicated. Overall, a total of 147 SrSCA (mean age 28.1 ± 4.8 years, 95.2% males) occurred, with an overall burden of 4.77 [95% confidence interval (CI) 2.85-6.68] cases per million-year, including 12 (8.2%) cases in young competitive athletes. While bystander cardiopulmonary resuscitation (CPR) was initiated in 114 (82.6%), automated external defibrillator (AED) use by bystanders occurred only in a minority (7.5%). Public AED use prior to EMS arrival (odds ratio 6.25, 95% CI 1.48-43.20, P = 0.02) was the strongest independent predictor of survival at hospital discharge (38.1%). Among cases that benefited from both immediate bystander CPR and AED use, survival rate was 90.9%. Coronary artery disease was the most frequent aetiology (25.8%), mainly through acute coronary syndrome (86.9%). Conclusion: Sports-related sudden cardiac arrest in the young occurs mainly in recreational male sports participants. Public AED use remains disappointingly low, although survival may reach 90% among those who benefit from both bystander CPR and early defibrillation. Coronary artery disease is the most prevalent cause of SrSCA in young adults.
... Approximately 1 in 70 high schools had a SCA on campus each year, nearly half of these events in students or student-athletes and survival rates were higher in schools with an emergency action plan for SCA versus those without (79% vs 44%; OR 4.6), and if an onsite AED was used versus an offsite AED provided by emergency services (80% vs 50%; OR 4.0) [91]. A 2019 investigation of mobile responders equipped with AEDs during road races in Japan reported 100% survival in 28 participants with witnessed SCA in which the mean time to CPR was 0.8 min and the mean time to AED shock was 2.2 min [92]. AEDs are safe to use and come with simple instructions including voice and visual prompts that can be followed by any trained or untrained responder. ...
Sudden death in young athletes is a rare but always dramatic condition. Unlike all other rare diseases, the estimate of its real incidence is made complex not only because of the uncertain number of correctly identified cases (numerator) but also because of the uncertain estimation of the real number of the reference population, the athletes (denominator). New elements of complexity are also emerging with regard to prevention. The current two pillars of prevention are pre-participation screening (proactive strategy) and promoting use / access to the automated external defibrillator (reactive strategy). The standardization of procedures implemented over the past two decades for pre-participation screening can now allow us to assess the impact of this approach. The result is complex to evaluate. While screening may allow the identification of conditions potentially associated with SDA, and therefore the adoption of specific treatments, in about 0.4% of screened subjects, a single study investigated the yield in terms of mortality showing a positive predictive value of 4.7% with 25% sensitivity. Conversely, the reactive strategy appears considerably effective, due to the widespread use of the automated external defibrillators in sports facilities, calling for a homogeneous implementation worldwide. On a broader perspective, the vast attention devoted to SDA prevention in the world of sports represents a major driver for transfer of a reactive prevention strategy to the general population.
... The system is made up of mobile teams (paramedics riding bicycles while carrying AEDs and emergency medical equipment) and on-foot groups (paramedic trainees carrying AEDs and providing assistance for daily living). Medical communications emergency responders, personnel at a first-aid stop, and doctor participants who run the marathon and are ready to help if required through a global positioning system-enabled cellphone are all part of the system [31]. Furthermore, through the study of device data, new potential for estimating participant medical requirements throughout these events arise with consumer activity monitor devices. ...
Full-text available
The majority of marathon deaths are caused by sudden cardia arrest which occurs in approximately 1 in 100,000 runners around the world. In such cases, sudden resuscitation of first aid, including an early use of automated external defibrillator (AED) on runners by medical staff is immediately necessary. However, in some cases patient information of the runner is required to support the clinical decision-making of the medical staff, including the admission to hospital with certain symptoms. To make marathon events safer, we developed a mobile-healthcare emergency assistance application for safety and prevention in marathon events. Our project covers three phases: registration, data analytics and running phases. In the registration phase, we designed and developed a form containing the runner’s electronic personal health record filled in during the registration of the runner at the event. For the analytics and running phases, we analyze the data from the registration phase in order to prepare the capacity of resource and medical staff necessary to prevent and treat injuries and accidents including a sufficient number of AED devices. Finally, for the running phase, we developed a mobile application Medic and Track based on the qr code scanning in BIB for patient information that allows to locate the runner's emergency aid point and bring the patient to that rescue point or hospital. We also tested the application on a large number of runners participating in the CMU marathon 2020 with 9721 runners. The results of this study suggest that the purpose of our application can be generally accepted for the medical staff, and it also proved to be a suitable technology to prevent serious accidents in future marathon 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 ...
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.
Aims To evaluate the association of basic life support with survival after sports-related sudden cardiac arrest (SR-SCA). Methods and results In this systematic review and meta-analysis, a search of several databases from each database inception to 31 July 2021 without language restrictions was conducted. Studies were considered eligible if they evaluated one of three scenarios in patients with SR-SCA: (i) bystander presence, (ii) bystander cardiopulmonary resuscitation (CPR), or (iii) bystander automated external defibrillator (AED) use and provided information on survival. Risk of bias was evaluated using Risk of Bias in Non-randomized Studies of Interventions. The primary outcome was survival at the longest follow up. The meta-analysis was conducted using the random-effects model. The Grading of Recommendations Assessment, Development, and Evaluations (GRADE) approach was used to rate certainty in the evidence. In total, 28 non-randomized studies were included. The meta-analysis showed significant benefit on survival in all three groups: bystander presence [odds ratio (OR) 2.55, 95% confidence interval (CI) 1.48–4.37; I2 = 25%; 9 studies—988 patients], bystander CPR (OR 3.84, 95% CI 2.36–6.25; I2 = 54%; 23 studies—2523 patients), and bystander AED use (OR 5.25, 95% CI 3.58–7.70; I2 = 16%; 19 studies—1227 patients). The GRADE certainty of evidence was judged to be moderate. Conclusion In patients with SR-SCA, bystander presence, bystander CPR, and bystander AED use were significantly associated with survival. These results highlight the importance of witness intervention and encourage countries to develop their first aid training policy and AED installation in sport settings.
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