Sudden death in young athletes
Once again we are hit by this tragic and devastating phenomenon. A young and apparently healthy athlete in the prime of his life, collapses during a high intensity soccer match and has to be resuscitated. Fans and spectators are left in deep shock. Our thoughts are with the young man, his family and friends. We pray and hope that he may pull through.
Sudden death in young athletes, associated with athletic activity, is a rare but well-known disorder. It is a shocking and tragic event because the victims are usually young people who are commonly role models due to a healthy lifestyle, training discipline and sportsmanship. The majority of sudden cardiac death incidents in athletes are due to severe disturbances in heart rhythm (ventricular tachycardia or ventricular fibrillation), leading to loss of blood circulation. Immediate treatment is aimed at restoring normal heart rhythm, usually by electric shocks given by so-called defibrillators.
The most common cause of disturbances in heart rhythm leading to sudden death in young athletes is underlying heart disease. Most commonly, this disease is not diagnosed until after the event. As a result, there is great interest in detecting such abnormalities early, in order to be able to define appropriate activity restrictions for the individual. The most common underlying heart disease is so-called hypertrophic cardiomyopathy. This is a disorder which sometimes runs in families. However, in many cases there is no family history at all. In this disease, the muscle of the left ventricle of the heart becomes abnormally thick. Young people with this disorder commonly have no symptoms at all. However, there is a risk of severe disturbances in heart rhythm during high intensity physical activity. There are a number of other underlying heart diseases that may lead to sudden death. Most of them are rare. Some may be temporary, such as viral infections of the heart muscle. Some may be congenital.
In order to be able to prevent sudden cardiac death in young athletes we have to find the underlying heart disease before it leads to collapse and sudden death. This is a huge challenge, because some of these diseases are difficult to detect. However, prevention is the only way forward. The responsibility is both within the medical community and among sports regulatory authorities.
Sudden death has been relatively common among soccer players compared to many other sports. Although soccer may partly be defined as an endurance sport, it includes a lot of “burst” exertion involving rapid acceleration and deceleration. A soccer match at the highest competitive level places huge demands on the heart and circulation. It is a team sport with high demand for achievement, and individuals may not always have the judgement or opportunity to limit their activity during a match. It is therefore extremely important that soccer players at the highest competitive level undergo regular cardiac evaluation in order to exclude underlying heart disease.
There are two important questions that have to be asked concerning screening for heart disease and risk factors for sudden death in young athletes. The first one involves how screening should be performed and what methods should be used. The second addresses what restrictions should be placed on athletes who turn out to have heart disease.
There are few data and no randomized trials on the impact of screening programs on the incidence of sudden deaths among athletes. A mandatory screening program for competitive athletes was launched in Italy in 1982. Following this, the annual incidence of sudden cardiac death in athletes decreased from 3.6/100.000 person – years in 1979 – 1980 to 0.4/100.000 person – years in 2003 – 2004. This implies an 89 percent reduction in 25 years. During the same period there was no change in the incidence of sudden cardiac death among non-athletes in the same age group.
Both the American Heart Association (AHA) and the European Society of Cardiology (ESC) have proposed guidelines for the screening of young athletes participating in competitive sports. The main difference between these proposals is that the AHA guidelines rely on history and physical examination without further routine testing, while the ESC guidelines include an ECG (electrocardiogram). Inclusion of an ECG is in accordance with the Italian experience. Individuals with abnormal findings in screening are referred for further testing. Such testing may involve echocardiography (ultrasound of the heart), ambulatory heart rhythm monitoring, exercise – ECG or cardiac magnetic resonance imaging (MRI).
Although an ECG can sometimes be helpful in detecting heart disease it is commonly abnormal among healthy young athletes. This is one of the reasons why the AHA does not include an ECG in their guidelines. Furthermore, some heart diseases me not be detected by history, physical examination and ECG. Therefore some specialists have suggested that an an echocardiography should be included. This may sometimes be the only way to detect disorders like for example hypertrophic cardiomypathy.
In 2008 the UEFA (The Union of European Football Associations) put forward new rules concerning medical examination of players participating in European competition. Apart from history, physical examination and blood tests an ECG and an ultrasound of the heart should be performed.
This is the text as it appears in the UEFA guidelines: “As a principle, a standard 12-lead electrocardiogram (ECG) and an echocardiography must be performed at the earliest opportunity during the career of a player and in particular if indicated by clinical examination. If indicated by anamnestic and clinical indication it is recommended to perform repeated testing including an Exercise-ECG and an echocardiography. It is mandatory to perform one standard 12-lead ECG and one echocardiography a) to all players who belong to the first squad at the latest before their 21st birthday; and b) to all players who are older than 21 years and belong to the first squad if they have not yet an ECG and echocardiography in their personal medical records.”
In my opinion the inclusion of echocardiography, although not included in AHA and ESC guideline, would be an important step forward in a group of athletes participating in competitive sports such as soccer at the highest level. However, I find the UEFA recommendations a little unclear in some aspects. ECG and ultrasound should be performed at least once and preferably before the age of 21. However repeated testing is only recommended if there is a clinical indication, based on history or physical examination. My opinion is that echocardiography should be performed at regular intervals (of 1-2 years) among players competing at the highest competitive level which certainly is the case in the European soccer leagues. This is a relatively simple and inexpensive procedure that gives a lot of information about the heart chambers, the heart muscle and the heart valves.
I do not have information on how English Premier League football teams perform medical examinations on their players. I don´t know how often they use methods like ECG and echocardiography. A recent article in the Independent suggested that annual screening is not performed by all Premier league clubs in England. It is likely that English Football Association (FA) have their own specific guidelines on screening for heart disease in soccer players. However, I have not seen these published. I also assume that English teams participating in European competition comply with the UEFA regulation. It is important to remember however, that certain conditions will not be detected, even by extremely comprehensive screening.
The second question I would like to address is what restrictions should be placed upon athletes who on screening turn out to have signs of heart disease. The devastating impact of sudden death incidents justifies restriction of athletes from athletic competition if they have heart disease. The question is who should make the decision. In my opinion, informing the athlete about the increased risk and let himself decide whether to continue participating in competitive sports would be unjust. However, it can be very hard for an athlete to accept being banned from competitive sports due to signs of heart disease. Although there may be increased risk for sudden death for that particular athlete, the absolute risk may indeed be very low. These are all difficult questions that have to be addressed. Although the answers may be difficult to deal with, these issues can not be left unsolved.
Although sudden death in young athletes is uncommon, it is a devastating and tragic event. Prevention is the only sensible way forward. We can only hope that the medical community and sports regulatory bodies will be able to professionally deal with this problem in the future.