Cardiovascular Risk and Knowledge, Attitudes and Beliefs of Football Referees Towards Acute Coronary Syndrome Events

BACKGROUND: Although exercise is protective against cardiovascular disease, a transient increase in acute coronary syndrome (ACS) exists during heavy exertion. Psychological stressors are also known to precipitate ACS events. Football (soccer) referees are exposed to both physical and emotional stress when officiating a match, as well as being potential first responders for cardiovascular events among players. However, there has been limited research into cardiovascular risk and knowledge among football referees. AIM: To evaluate cardiovascular risk factors in Australian football referees and assess their knowledge, attitudes and beliefs towards symptoms of ACS. METHOD: An anonymous, online survey administered using REDCap was completed by Australian football referees at all levels of football, from grassroots to professional level. Participants were asked to select which risk factors they had from a pre-existing list. A modified version of the ACS Response Index assessed referees' knowledge of ACS symptoms and their attitudes and beliefs regarding response to ACS symptoms RESULTS: Overall, 134 participants completed the survey, with a majority male (87.3%) and a median age of 47.0 years. Participants had refereed for an average of 12.5 (±8.9) years, with most officiating at the grassroots/amateur level (62.7%). Risk factors included hypercholesterolaemia (17.2%), hypertension (9.7%), diabetes mellitus (3.7%), peripheral vascular disease (2.2%) and tobacco smoking (0.8%). Overall 30.5% had a positive family history of cardiac disease and 9.7% had been previously diagnosed with a heart condition (including a heart attack or angina). Participants had only a moderate knowledge of ACS symptoms (12.9 [±3.0] with a maximum scale score of 21), scoring well for typical symptoms but less well for atypical symptoms or distinguishing from cerebrovascular events. Almost all would stop play immediately if a player complained of chest pain (95.9%), however, two-thirds (65.0%) would continue for at least 5 minutes if they had unusual chest pain in themselves. A majority were not sure they could recognise a heart attack in themselves or someone else (70.8%). They were supportive of further education to improve knowledge regarding ACS symptoms and interventions (90.9%). CONCLUSIONS: Football referees are both at risk of ACS events and potentially first responders to events in players. This population of sampled referees had moderate knowledge of ACS symptoms, with a strong willingness to receive further education.