1. health and fitness
2. disease

Current Opinion
European Heart Journal (2007) 28, 150–153
doi:10.1093/eurheartj/ehl313
Soccer world championship: a challenge for the
cardiologist
¨kel*, Michael Kindermann, Ingrid Kindermann, and Michael Bo
¨hm
Magnus Baumha
¨tsklinikum des Saarlandes,
¨r Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universita
Klinik fu
D-66421 Homburg/Saar, Germany
Received 19 September 2006; accepted 28 September 2006; online publish-ahead-of-print 16 October 2006
KEYWORDS
Soccer;
Football;
Cardiovascular risk;
Cardiovascular event
The 18th FIFA World Cup took place from 9 June 2006–9 July
2006 in Germany, with about 3.2 million spectators in the
stadiums and billions of viewers worldwide during the 64
matches. However, little is known about the incidence of
cardiovascular events during such a great sport event.
Herein, the increased risk of cardiovascular events for
players and spectators regarding various soccer matches
and tournaments is reviewed.
Exercise during soccer-games
Players
Playing soccer is comparable with a non-continuous exercise
with intermittent phases of high physical intensity. The real
playing time during a soccer match of 90 min is about 60 min,
with an average energy consumption of 1500 kcal.1 The
average distance per game is about 10 km with 10–20%
covered at maximum speed and a maximal aerobic power
of around 60–65 ml/kg/min oxygen uptake.2 This physical
intensity is comparable to the maximum of young adult
elite soccer players with an average aerobic capacity of
60 ml/kg/min oxygen uptake.3 Interestingly, there are
differences in maximal workload depending on players position. Defenders have a slightly lower mean aerobic capacity
and heart rate, with respect to midfielders or attackers (169
vs. 182 b.p.m.). Moreover, mean heart rate and aerobic
power decline in the second half of a match by about 5%.3
* Corresponding author. Tel:
þ 49 6841 1623289; fax: þ 49 6841 1623446.
E-mail address: magnus@baumhaekel.de
In conclusion, average oxygen uptake for elite soccer
players is around 70% of peak oxygen consumption, explained
by the 200 short intense actions of players during a game.4
Moreover, blood and muscle lactate levels in soccer players
are about 5–6 and 16 mM, respectively, with decrease of
muscle glycogen of 50% after a friendly match.5
Referees
Referees should also have good physical condition regarding
the physical and even mental requirements during a match.
Italian professional referees cover an average distance of
about 12.000 m.6 Approximately 1.800 m thereof were
covered with a high intensity of more than 18 km/h.
Additionally, about 1.000 m were run backwards. The
average time without movement is 11 min during a match
of 90 min.6 Although data are not available, referees have
to cope with huge emotional stress in addition to the high
physical requirements. Unclear situations during a match
or wrong decisions certainly have an enormous influence
on the autonomous nervous system with a potential impact
on the cardiovascular system.
Physical activity and cardiovascular events
Regular physical activity of modest intensity is known to
reduce the cardiovascular risk significantly in primary and
secondary prevention.7 In contrast, cardiovascular events
are associated with vigorous activities. Below the age of 30
years, exercise related incidence of sudden cardiac death
(SCD) is increased and associated with abnormalities as
right ventricular dysplasia or coronary artery disease (CAD)
& The European Society of Cardiology 2006. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
Downloaded from by guest on November 14, 2014
The 18th FIFA Soccer World Cup 2006 in Germany enthused millions of people worldwide, but only little is
known about the association of such an event with cardiovascular events. Modest physical activity is
known to reduce the cardiovascular risk significantly. On the other hand, vigorous physical activity
and emotional strain increase the cardiovascular risk and the incidence of cardiovascular events likely
due to an increased sympathetic tone with consecutive catecholamine stimulation of the heart. Few
reviews and case-reports are dealing with the risk of physical activity in cardiovascular high-risk patients
or athletes with congenital heart diseases (e.g. hypertrophic obstructive cardiomyopathy), but the
impact of highly competitive events on cardiovascular events, especially in spectators were rarely
addressed. Thus, the increased risk of cardiovascular events in players and spectators were addressed
in this review with respect to various soccer matches and tournaments, such as the FIFA World Cup.
Soccer and CV-Event
Emotional strain and cardiovascular events
Obviously, spectators of a soccer match might not exhibit
physical, but they rather experience psychological stress,
likely dependent on the course or result of the match.
During the quarterfinal of the FIFA World Cup 2006
(Germany against Argentina), a 24 h-ECG recorded the
heart rate profile of a mother of one of the German
players with a known coronary heart disease. While
average heart rate of this day was 71 b.p.m., mean frequency increased up to 99 b.p.m. during the extra time
and the penalty shoot-out without any cardiovascular symptoms (Figure 1). This indicates that thrilling scenes or
disputable referee decisions are likely to increase sympathetic tone and catecholamine stimulation of the heart.
Haemodynamic responses include an increase of heart
rate, vascular resistance, and blood pressure with consecutively enhanced cardiac oxygen demand and vascular shear
stress probably potentiating frequency of plaque rupture
in acute coronary syndromes. Moreover, the transient left ventricular apical ballooning syndrome (Tako-subo- cardiomyopathy) is a known cardiovascular entity mimicking an acute
myocardial infarction, which is related to emotional stress in
about one-third of all patients.15 In 75% of patients with a
Tako-subo-cardiomyopathy, plasma catecholamine levels
were increased. Therefore, catecholamine-mediated epicardial coronary spasms or myocyte injuries were suggested to
be involved as pathophysiological mechanisms. Thus, emotional strain is an important risk factor for cardiovascular events.
In a highly competitive sport event, especially spectators
with pre-existing cardiovascular risk factors or diseases are
probably at an increased risk for cardiovascular events.
In a young Italian spectator with type I diabetes, continuous glucose monitoring during two consecutive days revealed
significant increased blood glucose levels during the day of
the half-final at the European Soccer Championship in 2000
(Italy against the Netherlands) without eating any additional
food.16 Moreover, the transiently increased cardiovascular
threat during a soccer match can last several days. During
the FIFA World Cup in France in 1998, emergency admissions
for acute myocardial infarction were increased in England
for 2 days after the penalty elimination of England against
Argentina (Table 1).17 In contrast, admissions for myocardial
infarction, stroke, road traffic injury, or self harm did not
alter after loosing or winning a match before. Thus,
especially the high psychological strain during a penalty
shoot-out seems to influence the cardiovascular system negatively with corresponding cardiovascular events in predisposed spectators. These results are consistent with findings
in the Netherlands during the European Championship in
1996 in England. The quarterfinal was lost in the penaltyshoot out against France, with Clarence Seedorf misplaying
the last penalty for the Netherlands. At this day, incidence
of fatal myocardial infarction or stroke in men was significantly increased, while incidence in women did not change
(Figure 2).18
Incidence of SCD is known to be increased during psychological strain.19 Thus, SCD is suggested to be increased
Table 1 Observed and expected numbers of emergency admissions for acute myocardial infarction on day of the match and
5 days after England lost to Argentina by penalty shoot-out in
1998 Soccer World Cup17
Figure 1 Profile of heart rate of a German players mother during the quarter
final Germany against Argentina (5:3 after penalty shoot-out).
Day of match
1 day after
2 days after
3 days after
4 days after
5 days after
Number of
admissions
observed/
expected
Actual/
expected
Adjusted
risk ratio
91/72
88/72
91/71
76/74
71/74
83/72
19
16
20
2
23
11
1.25 (0.99–1.57)
1.21 (0.96–1.57)
1.27 (1.01–1.61)
0.99 (0.77–1.27)
0.92 (0.71–1.19)
1.13 (0.89–1.43)
Downloaded from by guest on November 14, 2014
and active myocarditis.7,8 Moreover, hypertrophic cardiomyopathy is known to increase the risk of sudden death,
and physical effort can provoke significant intraventricular
gradients.9 Thus, in athletes with signs of a structural
cardiac disease, echocardiography with physical or pharmacological stress testing is a valuable tool to detect certain
high-risk patients.
In addition, left ventricular (LV) hypertrophy (LVH) as a
structural and functional adaptation to increased wall
stress is known to predict cardiac events and mortality.10
LVH even appears in athlete hearts, but with a normal systolic and diastolic function and a supranormal coronary vasodilator reserve.11 Especially high class soccer players are
suggested to develop eccentric cardiac hypertrophy more
likely compared to other sports, but training induced LVH
is not supposed to increase the cardiovascular risk.1,12
Over the age of 30, almost all exercise related cardiovascular events are due to coronary heart disease. In these
patients, submaximal exercise was shown to increase
plasma viscosity, haematocrit, platelet count, and tissue
plasminogen activator.13 Therefore, soccer-players, particularly with a silent cardiovascular disease, are supposed to be
at an increased cardiovascular risk. However, a report of six
SCDs in a 30-year-period in Croatia revealed a death rate
among athletes of 0.15/100.000, whereas death rate in an
exercise practicing population reached 0.74/100.000
(P , 0.001).8 In addition, a survey revealed that life expectancy is not decreased in male athletes.14
151
152
M. Baumha
¨kel et al.
Figure 2 Death from myocardial infarction or stroke in Dutch males in June
1996 during the Soccer European Championship.18
Table 2 Number of sudden cardiac deaths in the Frenchspeaking population in Switzerland during the soccer World Cup
2002 and the same period 1 year before20
World Cup
31 May 2002–
30 June 2002
P-value
38
62
0.02
26 (68%)
12 (32%)
46 (74%)
16 (26%)
0.01
0.02
during a soccer match or tournament. Actually, total number
of SCD was increased in the French-speaking population in
Switzerland during the FIFA World Cup 2002 in Japan/South
Korea compared to the period 1 year before (Table 2).20
Surprisingly, the significant increase in SCD could be
observed in both genders. Regarding the gender specific
differences in frequency of cardiovascular events at the
European Championships in 1996, one could reason that
interest of females in soccer matches and especially championships increased over the last few years.
Although different effects of positive or negative emotional excitement are not clear, these results suggest an
increased risk of cardiovascular events dependent on a
specific soccer match or tournament, likely due to extended
psychological stress in respect of loosing a match. However,
positive emotional stress is thought to be without any negative influence on the cardiovascular system.21 In line with
this suggestion were observations during the final match of
the FIFA World Cup 1998 in France. The French players
won the match against Brazil with 3:0. Consequently,
number of deaths from myocardial infarction was significantly decreased in the male French population at this day
(Figure 3).22
In conclusion, great and important sport events as a
soccer European- or World-Championship are afflicted with
an increased physical stress in players and an enormous
emotional strain for certain groups of spectators, especially
in case of loosing of their favourite teams. Regarding
this physiologicial and emotional strain, increased sympathetic tone and catecholamine levels are likely to influence
the cardiovascular system negatively with subsequent
cardiovascular events, particularly in cardiovascular highrisk patients. Thus, observation in a highly competitive
sport event might provide insights into the impact of physical and emotional stress on cardiovascular events. With
respect to the FIFA World Championship 2006 in Germany,
cardiovascular events in players were not likely, because
for the first time in history, all players had to undergo a standardized medical examination including echocardiography.
Assessments of cardiovascular events in spectators are difficult, regarding the 3.2 million spectators in the stadiums,
millions of spectators at ‘public viewing’ facilities and billions of spectators worldwide in front of the television.
However, these data are extremely important and should
be collected in prospectively designed national and international surveys.
Conflict of interest: none declared.
References
¨ rzteblatt
1. Kindermann W. Gesundheit und Leistung im Profil. Deutsches A
2006;23:1370–1375.
2. Ekblom B. Applied physiology of soccer. Sports Med 1986;3:50–60.
3. Stroyer J, Hansen L, Klausen K. Physiological profile and activity pattern
of young soccer players during match play. Med Sci Sports Exerc
2004;36:168–174.
4. Bangsbo J, Mohr M, Krustrup P. Physical and metabolic demands of
training and match-play in the elite football player. J Sports Sci 2006;
24:665–674.
5. Krustrup P, Mohr M, Steensberg A, Bencke J, Kjaer M, Bangsbo J. Muscle
and blood metabolites during a soccer game: implications for sprint
performance. Med Sci Sports Exerc 2006;38:1165–1174.
6. Castagna C, Abt G. Intermatch variation of match activity in elite Italian
soccer referees. J Strength Cond Res 2003;17:388–392.
7. Brukner PD, Brown WJ 3. Is exercise good for you? Med J Aust 2005;
183:538–541.
8. Durakovic Z, Misigoj-Durakovic M, Vuori I, Skavic J, Belicza M. Sudden
cardiac death due to physical exercise in male competitive athletes.
A report of six cases. J Sports Med Phys Fitness 2005;45:532–536.
9. Cotrim C, Loureiro MJ, Simoes O, Cordeiro P, Henriksson I, Vinhas H, Almeida
A, Carrageta M. Intraventricular gradient during effort in a professional
soccer player. Clinical significance. Rev Port Cardiol 2005;24:1395–1401.
10. Vakili BA, Okin PM, Devereux RB. Prognostic implications of left ventricular hypertrophy. Am Heart J 2001;141:334–341.
11. Pluim BM, Lamb HJ, Kayser HW, Leujes F, Beyerbacht HP, Zwinderman AH,
van der Laarse A, Vliegen HW, de Roos A, van der Wall EE. Functional and
metabolic evaluation of the athlete’s heart by magnetic resonance
imaging and dobutamine stress magnetic resonance spectroscopy.
Circulation 1998;97:666–672.
12. Blair SN, Kohl HW 3rd, Barlow CE, Paffenbarger RS Jr, Gibbons LW,
Macera CA. Changes in physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men. JAMA 1995;273:1093–1098.
Downloaded from by guest on November 14, 2014
Number of
sudden cardiac
deaths
Males, n (% total)
Females, n (% total)
31 May 2001–
30 June 2001
Figure 3 Death from myocardial infarction in French male in July 1998
during the Soccer World Championship.22
Soccer and CV-Event
13. Bacon SL, Ring C, Hee FL, Lip GY, Blann AD, Lavoie KL, Carroll D. Hemodynamic, hemostatic, and endothelial reactions to psychological and physical
stress in coronary artery disease patients. Biol Psychol 2006;71:162–170.
14. Sarna S, Sahi T, Koskenvuo M, Kaprio J. Increased life expectancy of world
class male athletes. Med Sci Sports Exerc 1993;25:237–244.
15. Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review.
Eur Heart J 2006;27:1523–1529.
16. Cavallo MG, Romeo S, Coppolino G, Pozzilli P. Continuous glucose
monitoring during the European Soccer cup semifinal, Italy against
Holland. Diabetologia 2001;44:268.
17. Carroll D, Ebrahim S, Tilling K, Macleod J, Smith GD. Admissions for
myocardial infarction and World Cup football: database survey. BMJ
2002;325:1439–1442.
153
18. Witte DR, Bots ML, Hoes AW, Grobbee DE. Cardiovascular mortality in
Dutch men during 1996 European football championship: longitudinal
population study. BMJ 2000;321:1552–1554.
19. Hart J, Weingarten MA, Druckman A, Feldman Z, Shay A. Acute cardiac
effects of ‘SCUD’ missile attacks on a civilian population. Med War
1993;9:40–44.
20. Katz E, Metzger JT, Marazzi A, Kappenberger L. Increase of sudden
cardiac deaths in Switzerland during the 2002 FIFA World Cup. Int J
Cardiol 2006;107:132–133.
21. Siltanen P. Stress. coronary disease, and coronary death. Ann Clin Res
1987;19:96–103.
22. Berthier F, Boulay F. Lower myocardial infarction mortality in French men
the day France won the 1998 World Cup of football. Heart 2003;
89:555–556.
Clinical vignette
doi:10.1093/eurheartj/ehl178
Online publish-ahead-of-print 3 August 2006
Contained aortic rupture secondary to post-surgery mediastinitis due to Aspergillus fumigatus
Jaime Nevado Portero1*, Mariano Ruı´z Borrell2, and Lourdes Go
´mez Izquierdo3
1
* Corresponding author: Tel: þ34 653830847; fax: þ34 954272333. E-mail address: jaimenevado@hotmail.com
Male, aged 74, with chronic respiratory
disease and degenerative aortic stenosis,
operated 45 days ago to replace the valve
with a biological prosthetic valve. The
patient came for a consultation due to class
III dyspnoea and long-term oppressive retrosternal pain. Transthoracic echocardiography
was carried out showing normal prosthetic
functioning, good contractility in all segments, and collapsed right atrium due to
severe pericardic haematoma (Panel A). The
transoesophagic echocardiography showed
the haematoma from the aortic root, spreading upwards across the whole of the mediastinum (Panel B). Intimal flap, double lumen, or
bleeding was not seen. Given these findings,
it was decided to carry out a thoracic CAT,
which gave pictures of a large-scale haematic
collection displacing the mediastinal structures to the left. Its density is heterogeneous
suggesting an acute extravasation originating
at the level of the aortic root (Panel C).
In light of these findings, it was decided to
carry out emergency surgery. After sternotomy, intense haemorrhage resulted, which
could not be controlled, eventually causing exitus due to haemorrhagic shock. The proximal ascending aorta was damaged and the
tissues presented signs of infection. Samples were sent for histopathological examination. The Gomori-Grocott stain revealed the invasion of Aspergillus fumigatus in the external third of the aortic wall (Panel D).
Mediastinitis, post-heart surgery, due to Aspergillus fumigatus, is extremely rare. Unfavourable prognosis presented due to the
potential complications and given that the case developed sporadically and it was ensured that the hospital atmosphere was
optimal; it was postulated that the aetiology of the picture was the passage of the micro-organism to the mediastinum by pleural incision
in the patient with chronic respiratory disease and colonized pulmonary parenchyma.
Downloaded from by guest on November 14, 2014
Department of Cardiology, Virgen del Rocı´o University Hospital, Av. Manuel Siurot s.n., Seville 41013, Spain;
Department of Cardiology, San Juan de Dios del Aljarafe Hospital, Av. San Juan de Dios s.n., Bormujos 41930
(Seville), Spain; and 3 Department of Pathological Anatomy, Virgen del Rocı´o University Hospital, Av. Manuel Siurot s.n.,
Seville 41013, Spain
2