Anyone can succumb to sudden cardiac arrest, from professional athletes to couch potatoes. Indeed, it is a silent killer as the symptoms are not always detectable.
WHEN a professional athlete dies from a sudden cardiac arrest in the field, the world is stunned. While it is ironic that the strongest and fittest of us all can simply drop dead, heart abnormalities are sometimes difficult to detect.
Last month, there were two cases of athletes in their 20s who suffered sudden cardiac death (SCD). Ecuadorian international footballer Christian Benitez, 27, complained of stomach pains and died a few hours later. Malaysian basketball player Jacky Ng, 25, collapsed on the bench and was pronounced dead two hours later.
SCD can be due to a heart attack, a rhythm problem such as arrhythmia, or even a stroke.
“When you have a sudden cardiac arrest, it’s mainly two issues. It’s either a plumbing issue, that is, the narrowing of a blood vessel, which is blocked, or an irregular heart rhythm, where the heart rate goes either too fast or too slow,” says consultant cardiologist and electrophysiologist Dr Azlan Hussin. “Whatever the cause, the end point is that a person dies suddenly.”
The symptoms that precede SCD include fainting, chest tightness, dizziness, shortness of breath, vomiting, seizures and stomach ache. In some cases, it’s asymptomatic. While the symptoms can give rise to suspicion, it’s not specific in pointing out if someone is at risk for sudden death. It is not age-specific and can occur in babies as well.
Cardiovascular disease is the number one cause of death in Malaysia, both among men and women, although men tend to suffer from heart disease at a younger age.
Although the deaths of young athletes have recently hogged the headlines, the incidence of SCD in athletes is rare. There is not much data available worldwide on athlete SCD, but studies show that the range is from 0.33 to 3.6 deaths per 100,000 persons for periods between 1980 to 2006 in Italy, Israel and the United States.
“It’s not a common problem, but there are a lot of emotions tied to it because of press exposure and patients dying young. Sudden death in athletes is a bit complex because if you look at the statistics of the causes of death in the National Collegiate Athletics Association levels in the United States, 51% were due to accidents, with only 16% cardiac-related,” says Dr Azlan, who also presented a paper on “Sudden Cardiac Deaths in Athletes” at the second International Congress in Sports & Exercise Medicine (ICSEM 2013) held in Kuala Lumpur recently.
Of the cardiac causes, 26% comprise hypertrophic cardiomyopathy, where the heart muscles are too thick. The rest are from commotio cordis or chest trauma (20%), coronary artery anomalies (14%), and various other causes. Topping the list of SCD victims are athletes in basketball, followed by American football, track and soccer.
Based on Malaysian statistics compiled from 1995 to 2005, the figures are quite different.
There were 44 SCDs during sporting activities. Those in the 40-49 age group had the highest percentage (38.64%), followed by those in the 50-59 age group (31.82%). All were males.
This is unlike the American experience, which had high incidences of SCD among younger athletes, as their data is drawn from college-level sports.
The Malaysians were not necessarily professional athletes. Some were amateurs who played sports recreationally.
Casualties were highest in badminton, football (soccer) and jogging, and most prominent among the Chinese, followed by the Malays and Indians.
Dr Azlan explains: “Our data is different because instead of taking a pool of athletes and screening, these are post-mortem specimens. By right, we cannot use such data because it’s post-mortem data compiled by pathologists from Universiti Malaya. But, we don’t have any other data to go by, so we have to use this when we discuss SCD in athletes in Malaysia.”
To screen or not
Doctors cannot always detect the problem despite routine cardiac screening. Some professional athletes also do not want to be screened because athletics is their bread-and-butter, and a problem detected during screening may affect their careers.
Can these tests save a life? Perhaps, although there is a lot of debate surrounding this.
“Doing a physical and an ECG (electrocardiogram) doesn’t necessarily mean you’re okay if it shows up normal. You might end up spending a lot of money trying to screen athletes, and even then, you may not be 100% successful in preventing SCD,” observes Dr Azlan.
In the case of English football club Bolton’s Fabrice Muamba, 23, whose heart stopped for an astonishing 78 minutes after he collapsed during an FA Cup match last year, he was lucky. Paramedics brought him back to life by relentlessly performing cardiopulmonary resuscitation (CPR).
“It was probably excellent CPR that saved him. He had no circulation and they maintained it for 78 minutes, and he came out unscathed. He is a good specimen to begin with because he’s young and fit,” reckons Dr Azlan.
On how long CPR should be performed, it’s the judgment call of the team leader. It could range from 30 minutes to more.
“In Muamba’s case, he probably showed some form of return of circulation, so the paramedics continued doing CPR. For those who are (CPR) administrators, they should actually be taking a course in advance cardiac life support.”
Can exercise help?
Many experts believe that exercise prevents death from premature heart disease, but is this really true?
Optimists might say yes, while pessimists might disagree. Dr Azlan cites the example of James Fixx, a marathon runner whose pioneering Complete Book of Running encouraged millions to pound the streets in the pursuit of near-immortality.
His transition from a heavy young man who smoked two packs of cigarettes a day into a trimmer non-smoking athlete seemed to ensure a healthy life. Alas, he dropped dead at 52 while jogging!
“The post-mortem revealed that his arteries were all blocked. Why? Because he had been a smoker before. He managed to sustain for 10-15 years, but eventually, his bad habits caught up with him. It doesn’t disappear just because you have a healthy lifestyle now.
“I have seen a few athletes, after playing 90 minutes of football, rush out to smoke rather than get a drink. They end up with massive heart attacks after that. The fact that an athlete smokes is in total opposition to him being an athlete, because you want to be on top of your game.”
Still, exercise does have its benefits. Besides enabling you to look trimmer and fitter, it improves your mood, helps control weight, and boosts energy.
However, some professional athletes, and those who exercise a lot, tend to have enlarged hearts.
Dr Azlan says: “The enlarged heart is a physiological adaptation to exercise, especially if it involves high-intensity exercises. For example, endurance athletes such as long distance cyclists and marathoners, may have larger hearts.
“A good corollary is that of a body builder. They do repetitive weight-lifting exercises, and over time, the muscle bulks up and becomes enlarged. The same happens with the heart. It usually is not much of an issue, but the problem occasionally arises when a doctor needs to make a differentiation on whether the heart is either physiologically or pathologically enlarged. In some instances, that can be challenging.”
Fret not if you are a fitness freak. As long as you have no known heart problems, you can continue to slave away at your regime, although it might take a toll on your musculoskeletal system.
“When you exercise beyond your maximal heart rate, your metabolic needs can’t be supplied by the aerobic cycle alone. Your metabolism needs to shift into an oxygen-independent metabolic cycle called the anaerobic cycle. One of its by-products is an acid named lactic acid, which is quite toxic to the muscle and causes a reduction in muscle efficiency, cramps, fatigue, etc.
“Therefore, an athlete can only maintain maximum or beyond maximum heart rate for a short period of time before the lactic acid accumulates.
“That’s why in a 100 metre sprint, the runner can only accelerate for approximately one-third of the time, maintain speed for another third, and decelerate for the last third of his race. He can’t accelerate all the way. His lactic acid build-up will not allow him to do that,” reveals Dr Azlan.
Weekend warriors, especially those in their 30s and 40s starting on a fitness routine, have to be cautious in their approach to exercise. If you have high cholesterol or are diabetic, get medical clearance.
“Watch out if you have any form of surgery done to your heart. Then, even if you’re in your 20s, please go for screening,” he says.
Some of the signs to look out for in sudden cardiac arrest include:
·Any surgery/procedure done to the heart when young
·Severe giddiness or unexplained dizziness during exercise
·A congenital heart abnormality
·A strong family history of heart problems or sudden unexplained death
·Drug habits or smoking