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Incidence of ventricular arrhythmias during World Cup football 2014 in patients with implantable cardioverter defibrillator
International Journal of Cardiology 187 (2015) 307–308
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Incidence of ventricular arrhythmias during World Cup football 2014 in patients with implantable cardioverter defibrillator Yusuke Kondo ⁎, Markus Linhart, Joerg O. Schwab, René P. Andrié Department of Medicine-Cardiology, University of Bonn, Sigmund-Freud Str. 25, 53127 Bonn, Germany
a r t i c l e
i n f o
Article history: Received 3 March 2015 Accepted 19 March 2015 Available online 20 March 2015 Keywords: Ventricular arrhythmia Implantable cardioverter defibrillator Emotional stress Football World Cup
Sporting events, such as football and rugby matches in World Cup, may increase the risk of cardiovascular events and mortality rates [1–4]. Such emotional stress has been proposed as a trigger for acute coronary syndrome [5]. However, little is known about the relation between sporting events and incidence of ventricular arrhythmias in patients with implantable cardiac defibrillator (ICD) patients. The Fédération Internationale de Football Association (FIFA) World Cup was held in Brazil from June 12 to July 13, 2014. It provided the opportunity to examine the relation between the football games and the incidence of ventricular arrhythmic events in patients with ICD in the World Cup champion nation. We analyzed the database of ICD clinic at our center and retrospectively compared incidence of antitachycardia pacing therapies (ATPs) and appropriate shock therapies during World Cup with all events occurred during the control period from June 12 to July 13 in 2012 and 2013. All variables are reported as means ± standard deviations. Categorical variables were expressed as percentages, using the Chi-square test for differences between groups. Continuous variables were compared with two-sided Student's t-test. Statistical significance was established at a P b 0.05. A total of 410 patients were included in this survey. One hundred forty three patients and 267 patients were seen during World cup in 2014 and the control period in 2013 and 2012 respectively.
⁎ Corresponding author. E-mail address: [email protected] (Y. Kondo).
http://dx.doi.org/10.1016/j.ijcard.2015.03.279 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Table 1 demonstrates the clinical characteristics of this population. There were no significant differences between two groups, except for the length of the follow-up period. Table 2 demonstrates incidence of ventricular arrhythmic events. During World Cup, 12 (9.7%) of 143 patients had ATPs and 5 patients (3.5%) shock therapies. During the control period, 15 (5.6%) of 267 patients had ATPs and 6 patients (2.2%) shock therapies. Incidence of ventricular arrhythmias increased during the period of World Cup football games in this population (incidence rate ratio (IRR) for ATPs, 1.49 [95% CI, 0.72–3.10]; IRR for shock, 1.56 [95% CI, 0.48–5.01]). Previous studies reported a causal relation between emotions and cardiovascular emergencies [1–6]). A study by Lampert R et al. described life-threatening ventricular arrhythmia that was triggered by emotions of anger in patients with ICD [7]. European Guidelines on cardiovascular disease prevention also indicate that anger and hostility are associated with an increased risk of cardiovascular events in both healthy and cardiovascular disease populations [8]. Incidence of out-of-hospital cardiac arrest is increased inside large football stadium when compared with the general population, and the absolute probability of suffering such an event remains low [5]. This is the first investigation to show a relationship between ICD therapies and major sporting events. Although the relationship was not statistically significant, presumably owing to the small absolute number of events, we suggest that in a country such as Germany where football is particular popular, World Cup matches involving the German team could be a trigger strong enough to increase incidence of ventricular tachyarrhythmias in patients with ICD. A possible explanation for this finding is that major sporting events lead to emotional triggers and behavioral change such as increase of non-compliance with medical routines or excessive food and alcohol intake. These factors seem to contribute to changes in physiological parameters such as heart rate and blood pressure. Nonmedical strategies, such as behavioral therapy for coping with stress, could be useful. In addition, remote monitoring of ICD is a rapidly evolving new technology that enables timely detection of high rate, reduced heart rate variability, non-sustained ventricular tachycardia or recent ATPs [9]. Interventions that should be considered include the administration or the increase in dose of beta-adrenergic-blocking drugs and antiarrhythmic drugs. During World Cup, incidence of ventricular arrhythmias increased in ICD patients of the champion nation Germany. This may be emotional stress caused by the major sporting games.
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Y. Kondo et al. / International Journal of Cardiology 187 (2015) 307–308
Table 1 Values indicate number of patients (%) or the mean ± SD. SCD, sudden cardiac death; CAD, coronary artery disease; AF, atrial fibrillation; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association. Year
2014 (n = 143)
2013 and 2012 (n = 267)
P value
Age (years) Sex (male, %) Secondary prevention of SCD (%) CAD (%) AF (%) LVEF (%) NYHA class Follow-up period (months)
66 ± 13 79 54 63 51 38 ± 13 2.2 ± 0.7 78 ± 58
67 ± 13 76 50 56 50 41 ± 16 2.3 ± 0.7 95 ± 82
0.327 0.536 0.379 0.136 0.733 0.062 0.891 0.034
Table 2 ATPs, antitachycardia pacing therapies. (a) ATPs Year Number of patients Incidence of therapies Relative rate ratio (95% confidential index)
2014 (n = 143)
2013 and 2012 (n = 267)
12 15 9.7% 5.6% 1.49 (0.72–3.10)
(b) Shock therapies Year Number of patients Incidence of therapies Relative rate ratio (95% confidential index)
2014 (n = 143)
2013 and 2012 (n = 267)
5 6 3.5% 2.2% 1.56 (0.48–5.01)
Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
References [1] D. Carroll, S. Ebrahim, K. Tilling, J. Macleod, G.D. Smith, Admissions for myocardial infarction and World Cup football: database survey, BMJ 325 (2002) 1439–1442. [2] U. Wilbert-Lampen, D. Leistner, S. Greven, et al., Cardiovascular events during World Cup Soccer, NEJM 358 (2008) 475–483. [3] E. Katz, J.T. Metzger, A. Marazzi, L. Kappenberger, Increase of sudden cardiac deaths in Switzerland during the 2002 FIFA World Cup, Int. J. Cardiol. 107 (2006) 132–133. [4] P. Olsen, J. Elliott, C. Frampton, et al., Winning or losing does matter: acute cardiac admissions in New Zealand during Rugby World Cup tournaments, Eur. J. Prev. Cardiol. (2014 Jun 12) pii: 2047487314539433. [Epub ahead of print]. [5] F. van de Sandt, V. Umans, Acute cardiac events and deployment of emergency medical teams and automated external defibrillators in large football stadiums in the Netherlands, Eur. J. Cardiovasc. Prev. Rehabil. 16 (2009) 571–575. [6] M. Reppel, K. Franzen, F. Bode, et al., Central hemodynamics and arterial stiffness during the finals of the world cup soccer championship 2010, Int. J. Cardiol. 166 (2013) 627–632. [7] R. Lampert, T. Joska, M.M. Burg, et al., Emotional and physical precipitants of ventricular arrhythmia, Circulation 106 (2002) 1800–1805. [8] J. Perk, G. De Backer, H. Gohlke, et al., European guidelines on cardiovascular disease prevention in clinical practice (version 2012): the Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts), Eur. J. Prev. Cardiol. 19 (2012) 585–667. [9] S. Dubner, A. Auricchio, J.S. Steinberg, et al., ISHNE/EHRA expert consensus on remote monitoring of cardiovascular implantable electronic devices (CIEDs), Europace 14 (2012) 278–293.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Incidence of ventricular arrhythmias during World Cup football 2014 in patients with implantable cardioverter defibrillator Yusuke Kondo ⁎, Markus Linhart, Joerg O. Schwab, René P. Andrié Department of Medicine-Cardiology, University of Bonn, Sigmund-Freud Str. 25, 53127 Bonn, Germany
a r t i c l e
i n f o
Article history: Received 3 March 2015 Accepted 19 March 2015 Available online 20 March 2015 Keywords: Ventricular arrhythmia Implantable cardioverter defibrillator Emotional stress Football World Cup
Sporting events, such as football and rugby matches in World Cup, may increase the risk of cardiovascular events and mortality rates [1–4]. Such emotional stress has been proposed as a trigger for acute coronary syndrome [5]. However, little is known about the relation between sporting events and incidence of ventricular arrhythmias in patients with implantable cardiac defibrillator (ICD) patients. The Fédération Internationale de Football Association (FIFA) World Cup was held in Brazil from June 12 to July 13, 2014. It provided the opportunity to examine the relation between the football games and the incidence of ventricular arrhythmic events in patients with ICD in the World Cup champion nation. We analyzed the database of ICD clinic at our center and retrospectively compared incidence of antitachycardia pacing therapies (ATPs) and appropriate shock therapies during World Cup with all events occurred during the control period from June 12 to July 13 in 2012 and 2013. All variables are reported as means ± standard deviations. Categorical variables were expressed as percentages, using the Chi-square test for differences between groups. Continuous variables were compared with two-sided Student's t-test. Statistical significance was established at a P b 0.05. A total of 410 patients were included in this survey. One hundred forty three patients and 267 patients were seen during World cup in 2014 and the control period in 2013 and 2012 respectively.
⁎ Corresponding author. E-mail address: [email protected] (Y. Kondo).
http://dx.doi.org/10.1016/j.ijcard.2015.03.279 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Table 1 demonstrates the clinical characteristics of this population. There were no significant differences between two groups, except for the length of the follow-up period. Table 2 demonstrates incidence of ventricular arrhythmic events. During World Cup, 12 (9.7%) of 143 patients had ATPs and 5 patients (3.5%) shock therapies. During the control period, 15 (5.6%) of 267 patients had ATPs and 6 patients (2.2%) shock therapies. Incidence of ventricular arrhythmias increased during the period of World Cup football games in this population (incidence rate ratio (IRR) for ATPs, 1.49 [95% CI, 0.72–3.10]; IRR for shock, 1.56 [95% CI, 0.48–5.01]). Previous studies reported a causal relation between emotions and cardiovascular emergencies [1–6]). A study by Lampert R et al. described life-threatening ventricular arrhythmia that was triggered by emotions of anger in patients with ICD [7]. European Guidelines on cardiovascular disease prevention also indicate that anger and hostility are associated with an increased risk of cardiovascular events in both healthy and cardiovascular disease populations [8]. Incidence of out-of-hospital cardiac arrest is increased inside large football stadium when compared with the general population, and the absolute probability of suffering such an event remains low [5]. This is the first investigation to show a relationship between ICD therapies and major sporting events. Although the relationship was not statistically significant, presumably owing to the small absolute number of events, we suggest that in a country such as Germany where football is particular popular, World Cup matches involving the German team could be a trigger strong enough to increase incidence of ventricular tachyarrhythmias in patients with ICD. A possible explanation for this finding is that major sporting events lead to emotional triggers and behavioral change such as increase of non-compliance with medical routines or excessive food and alcohol intake. These factors seem to contribute to changes in physiological parameters such as heart rate and blood pressure. Nonmedical strategies, such as behavioral therapy for coping with stress, could be useful. In addition, remote monitoring of ICD is a rapidly evolving new technology that enables timely detection of high rate, reduced heart rate variability, non-sustained ventricular tachycardia or recent ATPs [9]. Interventions that should be considered include the administration or the increase in dose of beta-adrenergic-blocking drugs and antiarrhythmic drugs. During World Cup, incidence of ventricular arrhythmias increased in ICD patients of the champion nation Germany. This may be emotional stress caused by the major sporting games.
308
Y. Kondo et al. / International Journal of Cardiology 187 (2015) 307–308
Table 1 Values indicate number of patients (%) or the mean ± SD. SCD, sudden cardiac death; CAD, coronary artery disease; AF, atrial fibrillation; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association. Year
2014 (n = 143)
2013 and 2012 (n = 267)
P value
Age (years) Sex (male, %) Secondary prevention of SCD (%) CAD (%) AF (%) LVEF (%) NYHA class Follow-up period (months)
66 ± 13 79 54 63 51 38 ± 13 2.2 ± 0.7 78 ± 58
67 ± 13 76 50 56 50 41 ± 16 2.3 ± 0.7 95 ± 82
0.327 0.536 0.379 0.136 0.733 0.062 0.891 0.034
Table 2 ATPs, antitachycardia pacing therapies. (a) ATPs Year Number of patients Incidence of therapies Relative rate ratio (95% confidential index)
2014 (n = 143)
2013 and 2012 (n = 267)
12 15 9.7% 5.6% 1.49 (0.72–3.10)
(b) Shock therapies Year Number of patients Incidence of therapies Relative rate ratio (95% confidential index)
2014 (n = 143)
2013 and 2012 (n = 267)
5 6 3.5% 2.2% 1.56 (0.48–5.01)
Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
References [1] D. Carroll, S. Ebrahim, K. Tilling, J. Macleod, G.D. Smith, Admissions for myocardial infarction and World Cup football: database survey, BMJ 325 (2002) 1439–1442. [2] U. Wilbert-Lampen, D. Leistner, S. Greven, et al., Cardiovascular events during World Cup Soccer, NEJM 358 (2008) 475–483. [3] E. Katz, J.T. Metzger, A. Marazzi, L. Kappenberger, Increase of sudden cardiac deaths in Switzerland during the 2002 FIFA World Cup, Int. J. Cardiol. 107 (2006) 132–133. [4] P. Olsen, J. Elliott, C. Frampton, et al., Winning or losing does matter: acute cardiac admissions in New Zealand during Rugby World Cup tournaments, Eur. J. Prev. Cardiol. (2014 Jun 12) pii: 2047487314539433. [Epub ahead of print]. [5] F. van de Sandt, V. Umans, Acute cardiac events and deployment of emergency medical teams and automated external defibrillators in large football stadiums in the Netherlands, Eur. J. Cardiovasc. Prev. Rehabil. 16 (2009) 571–575. [6] M. Reppel, K. Franzen, F. Bode, et al., Central hemodynamics and arterial stiffness during the finals of the world cup soccer championship 2010, Int. J. Cardiol. 166 (2013) 627–632. [7] R. Lampert, T. Joska, M.M. Burg, et al., Emotional and physical precipitants of ventricular arrhythmia, Circulation 106 (2002) 1800–1805. [8] J. Perk, G. De Backer, H. Gohlke, et al., European guidelines on cardiovascular disease prevention in clinical practice (version 2012): the Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts), Eur. J. Prev. Cardiol. 19 (2012) 585–667. [9] S. Dubner, A. Auricchio, J.S. Steinberg, et al., ISHNE/EHRA expert consensus on remote monitoring of cardiovascular implantable electronic devices (CIEDs), Europace 14 (2012) 278–293.