Since the onset of the COVID-19 pandemic, athletes have expressed significant grief and frustration, attributed to alterations in routine, limited or modified training and the postponement of sporting events across the globe.1 2 The additional strain from the removal of team support networks, which are often crucial components for stress management,1 can result in significant mental and physical health consequences, including low mood, sleep disruption, worsening diet and deconditioning.2 There is a current lack of attention on the unique mental health needs of student-athletes (ie, athletes who participate in secondary or postsecondary school sport programmes during their academic studies) during the COVID-19 pandemic, leading to a limited response from sporting organisations and academic institutions in addressing athlete-specific concerns.3 Accordingly, the purpose of this editorial is to suggest directions for future research and provide recommendations to ensure the mental health needs of student-athletes are met during this period of extraordinary disruption and uncertainty.

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.

Purpose of Review Although rare, sudden cardiac death (SCD) in the young is a tragic event, having a dramatic impact upon all involved. The psychosocial burden associated with SCD can leave friends, families, and entire communities bereft. With only limited evidence to describe the volatile emotional reactions associated with a young SCD, there is an urgent need for care providers to better understand the psychological complexities and impacts faced by both at-risk individuals and those directly affected by these tragic events. Recent Findings Current knowledge of the psychosocial implications associated with SCD in the young has recently generated interest in the cardiovascular community, with the goal of addressing prevention strategies (screening), family bereavement, and the psychological impact of at-risk or surviving individuals. With the emergence of novel strategies aimed at reducing the public health impact of SCD in the young, further discussion regarding the psychosocial impact of SCD, encompassing prevention, survivorship, and the downstream communal effects of a young death is required. Support systems and intervention could assist in the management of the associated psychosocial burden, yet there is a lack of clinical guidelines to direct this form of care. Summary There is an important need for multidisciplinary collaboration across subspecialties to provide support to grieving individuals and manage patient well-being throughout the screening process for SCD. This collaborative approach requires the integration of cardiovascular and psychological expertise where relevant.

Systematic error, often referred to as bias is an inherent challenge in observational cardiovascular research, and has the potential to profoundly influence the design, conduct, and interpretation of study results. If not carefully considered and managed, bias can lead to spurious results, which can misinform clinical practice or public health initiatives and compromise patient outcomes. This methodological primer offers a concise introduction to the identification, evaluation, and mitigation of bias in observational cardiovascular research studies assessing the causal association of an exposure (or treatment) on an outcome. Using high-profile examples from the cardiovascular literature, this review provides a theoretical overview of three main types of bias - selection bias, information bias, and confounding - and discusses the implications of specialized types of biases commonly encountered in longitudinal cardiovascular research studies, namely, competing risks, immortal time bias, and confounding by indication. Furthermore, strategies and tools that can be used to minimize and assess the influence of bias are highlighted, with a specific focus on using the target trial framework, directed acyclic graphs, quantitative bias analysis, and formal risk of bias assessments. This review aims to assist researchers and healthcare professionals in designing observational studies and selecting appropriate methodologies to reduce bias, ultimately enhancing the estimation of causal associations in cardiovascular research.

Out-of-hospital cardiac arrest (OHCA) is a major global health challenge, characterized by poor survival outcomes worldwide. Resource-limited settings are burdened with suboptimal emergency response and worse outcomes than high-resource areas. Engaging the community in the response to OHCA has the potential to improve outcomes, although an overview of community interventions in resource-limited settings has not been provided. This review evaluated the scope of community-based OHCA interventions in resource-limited settings. Literature searches in electronic databases (MEDLINE, EMBASE, Global Health, CINAHL, Cochrane Central Register of Controlled Clinical Trials) and grey literature sources were performed. Abstract screening, full-text review, and data extraction of eligible studies were conducted independently by two reviewers. The PCC (Population, Concept, and Context) framework was used to assess study eligibility. Studies that evaluated community-based interventions for laypeople (Population), targeting emergency response activation, cardiopulmonary resuscitation (CPR), or automated external defibrillator (AED) use (Concept) in resource-limited settings (Context) were included. Resource-limited settings were identified by financial pressures (low-income or lower-middle-income country, according to World Bank data on year of publication) or geographical factors (setting described using keywords indicative of geographical remoteness in upper-middle-income or high-income country). Among 14,810 records identified from literature searches, 60 studies from 28 unique countries were included in this review. Studies were conducted in high-income (n = 35), upper-middle-income (n = 2), lower-middle-income (n = 22), and low-income countries (n = 1). Community interventions included bystander CPR and/or AED training (n = 34), community responder programs (n = 8), drone-delivered AED networks (n = 6), dispatcher-assisted CPR programs (n = 4), regional resuscitation campaigns (n = 3), public access defibrillation programs (n = 3), and crowdsourcing technologies (n = 2). CPR and/or AED training were the only interventions evaluated in low-income, lower-middle-income, and upper-middle-income countries. Interventions aimed at improving the community response to OHCA in resource-limited settings differ globally. There is a lack of reported studies from low-income countries and certain continental regions, including South America, Africa, and Oceania. Evaluation of interventions other than CPR and/or AED training in low- and middle-income countries is needed to guide community emergency planning and health policies.