Fight or Flight?
The heart of my family
Vulnerable hearts
IT was 35 minutes into the game between Sevilla and Getafe in the Spanish League. When spectators were going wild with anticipation of a goal, Antonio Puerta, who brought his team to the heights of the UEFA Cup 2006, jogged towards his goal when, he suddenly went to his knees and lost consciousness. Fellow team mates Andrés Palop and Ivica Dragutinovic rushed to his side and freed his tongue, preventing his airways from being blocked. He was roused, and even walked himself into the changing room, when he collapsed again. Even seemingly normal people who are involved in mild or moderate exercise can experience (exertion-induced) sudden cardiac arrest, said Dr Noor Ibrahim Mohamad Sakian, a medical lecturer in the Faculty of Allied Health Sciences, Universiti Kebangsaan Malaysia.
Hours later, Clive Clark, and Irish defender collapsed in the dressing room at half time of a match between Leicester and Nottingham Forest in England.Clark survived, Puerta didn’t.Spanish international Antonio Puerta shocked his team mates and the world with his sudden death, leaving thousands of Sevilla fans mourning the passing of an upcoming football star, a father-to-be and most importantly, a young man. However, Puerta was hardly the first death for Sevilla, and he was hardly the first casualty in sports. Cameroonian international Marc-Vivien Foé, Hungarian Miklós Fehér, Brazilian Paulo Sérgio de Oliveira Silva and Spaniard Pedro Berruezo Martin were among many young footballers who died due to sudden cardiac (heart) arrests (SCA) in the past. Like Puerta, they left behind their families, their career, and their lives. Such events are rarely reported, as it only gains media coverage when it occurs in big sports events, with famous players. What we did not know is that exercise-induced SCA can affect every one who is involved in any physical activity. Many other casualties, including amateurs who died during training, social football and less known tournaments, are not known. Chances are, the annual incidence of sudden death due to undiagnosed cardiovascular disease is largely underestimated. The New York Times, in one of its features, reports the increase of exercise-induced sudden deaths in the United States.
“We used to see figures saying there were 20 cases or so a year,” said Barry Maron, the director of the Hypertrophic Cardiomyopathy Center at the Minneapolis Heart Institute Foundation. But a national database that Maron has helped compile suggests a much higher prevalence. “We’ve documented around 125 cases a year of sudden cardiac death among young competitive athletes,” he said. “That represents about one death every three days in the US. And that number is almost certainly an underestimate.” The reason for this underestimation is mainly because exercise-induced sudden deaths do not only affect young athletes.
Even seemingly normal people who are involved in mild or moderate exercise can experience (exertion-induced) SCA, said Dr Noor Ibrahim Mohamad Sakian, a medical lecturer in the Faculty of Allied Health Sciences, Universiti Kebangsaan Malaysia. If you haven’t been exercising for a long time, and suddenly decide to go for a run, you may have to think twice. Your heart may not be ready to cope with the sudden demand, leading it to overwork and fail.
“When it comes to healthcare and fitness, it is better to be progressive and get advice from a professional,” said K. Prabaharan, a sports physiotherapist based in KL.
Healthy victims
Perhaps the harshest reality about SCA is the fact that it can affect young, healthy people. Unlike coronary heart attacks, which we can see coming for those who live sedentary lifestyles, SCA sneaks in and robs active, energetic youths of their lives. “Indeed, the possibility that young, highly trained high-school, college, or even professional athletes may harbour potentially lethal heart disease or be susceptible to sudden death under a variety of circumstances ?seems counterintuitive,” a review from The New England Journal of Medicine said. Portsmouth manager, Harry Redknapp, had described Marc-Vivien Foé as a “fantastic boy, as strong as an ox.” Puerta had also been healthy. Sevilla president Jose Maria del Nido said that he had not noticed any problems in his star player. Although Puerta’s team mates admitted that he had multiple fainting spells and nausea before the event, he was otherwise healthy. Or was he?
“Some heart abnormalities cannot be detected, even at rest,” said Dr Noor. “They should go one step further. We should check them [athletes] while they are exerting themselves.” The test that can evaluate heart function on exertion is called an exercise stress test. In this test, the heart is monitored using electrocardiograms (ECG) while the patient walks on a treadmill. “If the coaching team suspects something amiss in the player, such as breathlessness, fainting spells and palpitations, they should be honest about it,” said Prabaharan. “Many of these athletes are born with (heart) problems, but it is hard to detect.” Although there are no known cases of sudden death caused by cardiac complications in Malaysian major football events, Prabaharan had known of a few cases involving people who play social football dying after a football match.
Medical conditions
Studies in the United States have shown that hypertrophic cardiomyopathy (HCM) has consistently been the single most common cardiovascular cause of sudden death [in young athletes]. It is a genetic cardiac disease, which involves the thickening of the left ventricle (left chamber of the heart) without obvious reasons. According to the US Hypertrophic Cardiomyopathy Association, “In Hypertrophic Cardiomyopathy (HCM), the muscle thickening occurs without an obvious cause.” The thickening of heart muscles can also be caused by the adaptation of the heart to the greater demand of oxygenated blood to the various parts of the body during exercise. Over a period of time, the heart develops thicker muscles (hypertrophy) and leads to a benign condition called athlete’s heart. The thickening of heart muscles may cause the heart to be electrically unstable, leading to arrhythmias (irregular impulses in the heart), which can cause heart attacks. Second in line is a peculiar condition called commotio cordis (Latin term meaning “commotion of the heart”). Some people call it concussion of the heart. It happens when a person receives a direct blow to the chest from a blunt object at a certain velocity in the interval between two heartbeats. The impact interferes with the pumping of the heart, which can lead to a heart attack .Death by commotio cordis is often associated with baseball and lacrosse players, where the risk of taking a blow from a ball is very much greater.
Lacrosse player George Boiardi was one of the fatalities associated with this condition, when he died after taking a shot to the chest in a game at Cornell’s Schoellkopf Field. There were 152 known cases of commotio cordis at the time of Boiardi’s death.The third most frequent cardiovascular cause is congenital coronary (heart)-artery abnormalities, which predisposes the individual to irregularities in the blood flow to their heart.Other possible causes for SCA are myocarditis (inflammation of the heart muscle), arrhythmogenic right ventricular cardiomyopathy (ARVD) and coronary artery disease.
“The sport adds fuel (to the underlying medical condition),” said Prabaharan. It is not the sport that kills the athletes, but rather, sports precipitates the attack by adding stress to the heart, he explained. A large Italian cohort study conducted over a period of 21 years reported that sports activity triggers sudden death (SD) in male and female athletes, who are predisposed to ventricular arrhythmias because of underlying cardiac conditions, but such activity is not the “cause” of increased mortality.
Early detection and prevention
“Ignorance, arrogance and self-confidence,” answered Prabaharan, when asked why some athletes are still allowed to play in the field, and some people continue playing sports although they are experiencing symptoms of heart problems. People may be ignorant about the telling signs of heart problems, said Prabaharan. “Fainting spells is a common symptom for people with arrhythmias,” said Dr Noor Ibrahim. Other symptoms are palpitations, sudden breathlessness and chest pain; signs that we often pass off as fatigue.”
“They (athletes) may also hide their medical concerns, especially when a contract, or a big game is in the horizon,” noted Prabaharan. “In some cases, even the team kept quiet about it. He may be a good player.” According to Dr Noor, a lot of cardiovascular events can be prevented, if pre-participation screening is implemented. “Any individual intending to participate seriously (leisure or professional) in mild, moderate, or vigorous activities should go for medical check-up. If they are intending to do it regularly, they should go for a doctor’s examination at a regular basis. By right, athletes should be screened (regularly). If you have fainting spells, do not take it lightly. We have to be concerned,” said Dr Noor.
Although certain congenital and genetic abnormalities in the heart could not be detected by routine medical check up, a pre-participation screening can at least make sure the person is fit enough to take on physically taxing activities. A few decades ago, Italy had initiated a national governmental programme that requires all athletes at all levels to undergo compulsory annual medical clearance, including cardiovascular screening by certified sports physicians.
“The most important thing is to use common sense and listen to your body,” said Prabaharan. In most cases of heart attacks, the body has been sending out warning signals, which we easily overlook as fatigue or heat stroke. “If they (athletes) experience any symptoms, they should slow down and go for a more detailed screening,” he added. This applies to everyone who is considering taking up any physical activity seriously. “Physical activity is a double-edged sword, if you do it correctly, you will get benefits; if you do it wrongly, it may be bad for you,” said Dr Noor. Like diet, physical activity should be customised to meet individual needs, taking into consideration the physical condition, level of fitness and health of the person. In the West, exercise prescriptions are given out by exercise physiologists to aid people with different health conditions practise exercises that are suitable for their state of health.
“Whether you are doing professional, amateur or social sports, it is better to do some medical screening and get clearance from a physician before you start an activity,” said Prabaharan. In the local sports scene, the National Sports Medicine Division offers services such as athlete physical examination, diagnosis, treatment, recovery, X-ray and medical laboratory tests to our athletes.
The aftermath
Puerta’s death has brought with it a renewed resolve to make sports safer for our young. “Maybe, screening would spare some of them. Maybe painkilling drugs should be at the top of the banned list. Maybe Puerta should not have played after reportedly having muscular problems last week,” wrote Rob Hughes (International Herald Tribune) in his article. Even so, some may say that screening is costly and time consuming; painkilling drugs role in heart disease is elusive; and players still play for their clubs despite multiple injuries. The solution may lie within creating awareness among coaches, players, advertisers, sponsors, medical personnel, teachers and the public on the health risks involved in sports and physical activities.
References:
1. Review Article: Sudden Death in Young Athletes by Barry J. Maron, M.D., The New England Journal of Medicine
2. Sudden Cardiac Death in Athletes - What Can be Done? Joydeep Ghosh, MD, FACC, Indian Pacing Electrophysiol J. 2006 July–September; 6(3): 139–141.
