Sudden Cardiac Death in Athletes

I read a very sad story a couple weeks ago.  As is sometimes the case with tragedies the tale started out as a golden moment.  A 16-year-old star basketball player on the undefeated Fennville High (Michigan) varsity team had the ball with 30 seconds left in overtime and a tie score.  Wes Leonard, described as a “good kid, a good friend to have and a good person to hang around with” threw up the game-winning shot, assuring his team a 20-0 season record.  The crowd went wild.  Then the tragic events unfolded:

After the teams exchanged handshakes, Fennville players celebrated. Some began scrambling to organize a team photo that would commemorate their undefeated record. That's when the 6-foot-2, 215-pound Leonard collapsed, with an estimated 1,400 fans watching.

"Thirty seconds earlier, he was laying in the winning bucket," said Ryan Klingler, basketball coach in Fennville, about 200 miles west of Detroit. "And then 10 seconds later ... everything's pulled out from under you, from out of nowhere."

Leonard was rushed to nearby Holland Hospital, where paramedics performed CPR before he was pronounced dead. An autopsy conducted Friday by the Ottawa County medical examiner showed Leonard died of cardiac arrest due to an enlarged heart.

What’s even more tragic than the sudden and unexpected death of an “all-American kid” is the sad fact that this seems to be a recurring theme.  Here are some prominent examples:

Flora (Flo) Hyman, American Olympic volleyball silver medalist, dropped dead during a match in 1986.  An autopsy demonstrated a ruptured aorta due to undiagnosed Marfan’s syndrome.

 

Hanks Gathers was a star basketball player at Loyola Marymount who collapsed during a game in 1989.  He was diagnosed with an arrhythmia and was told to take medication which he apparently neglected.  He died during a game only 5 months later.  The autopsy showed hypertrophic cardiomyopathy (HCM), a readily detectable cardiac abnormality that is known to confer a high risk of sudden death.

 

Reggie Lewis was an all-star small forward for the Boston Celtics with a career average of 17.6 points per game.  He suffered cardiac arrest and died during an off-season practice.  He was similarly found to have HCM.  Sadly, he had also experienced previous symptoms, including collapsing during an NBA game, that could have led to an early diagnosis.

 

Marc-Vivien Foé became another victim of HCM when he collapsed on the soccer field while playing for the Cameroon squad in the FIFA Confederations Cup.  Medics tried unsuccessfully for 45 minutes to resuscitate him.

 

Ryan Shay, an elite American runner, suffered cardiac arrest 5 miles into the 2007 Olympic marathon trials in New York City.  The autopsy was inconclusive but strongly suggestive of arrhythmia due to HCM.  He had previously been diagnosed with “an enlarged heart” but had been cleared to run.

 

This list would go on for pages if we were to include the names of less-known athletes, including those in high school and college.  For young people who participate in competitive sports, unanticipated cardiac arrest is the leading cause of death with an average of one person in this country suffering this every three days.  Even with prompt treatment only 11% of victims survive the initial episode.

Most cases relate to an underlying structural heart problem that predisposes to a rhythm abnormality—most often ventricular fibrillation—that produces rapid loss of consciousness and imminent death.  HCM, the most common cause, is an abnormality of heart muscle that leads to thickening and enlargement of the ventricle and an unstable electrical system prone to storms of arrhythmia.  A somewhat similar condition is dilated cardiomyopathy, a weakening of the heart muscle that can arise as a result of a genetic abnormality or a prior viral condition, and can similarly increase the risk of exercise-induced cardiac arrest.

Others are victims of problems that are purely electrical in nature, such as long QT syndrome, Brugada syndrome, and Wolf-Parkinson-White.  Such patients will have a normal echocardiogram but will frequently demonstrate abnormalities on the resting electrocardiogram (ECG).

The good news about most of these dangerous cardiac conditions is that they tend to be relatively easy to detect with only an echocardiogram and ECG.  If an athlete experiences sudden lightheadedness or fainting during a sporting event it’s not terribly difficult to determine if an ominous cardiac abnormality was the cause.  A more complicated issue arises when we address the screening of athletes who have not had symptoms.

A quarter century ago the Italians became fed up about frequent reports of young soccer players dying of cardiac arrest.  In response they began a massive screening program that required a thorough evaluation—including an ECG—of each student who wanted to participate in competitive sports.  Thanks to this effort the death rate among young athletes is now nine times lower than it was in 1982 when the program was initiated.

Translating these findings to a proposal for this country is not simple.  The prospect of screening 15 million college and high school athletes is costly and fraught with the possibility of the clinical, psychological and legal ramifications of false positive results leading to further testing.  And how could you limit such a program to the lucky minority who happen to be good enough to make the varsity team?  Clearly you’d have to expand the program to include all 75 million young people in the country.  As it stands the American Heart Association maintains that such an endeavor would be inordinately costly (one estimate would be $2 billion), legally challenging, and not necessarily tremendously effective, and has therefore recommended against it.

I can buy this.  I know enough about cardiology to know that a screening ECG alone would be a poor way to tease out the one in 220,000 young athletes at risk of cardiac arrest.  What I don’t understand is our lack of decisive action once an athlete suffers precursory symptoms that raise red flags about his or her individual risk.  Any person under the age of 35 who “blacks out” during a sporting event (or during any kind of exertion, for that matter) deserves a thorough evaluation that includes at least ECG and echocardiography.  Other worrisome symptoms include exercise-related lightheadedness, palpitations, and chest pain.

Of the high-profile cases I listed above three had already suffered symptoms and undergone testing that should have resulted in their being sidelined from competitive sports indefinitely.  Why weren’t they?  An illusory case was reported in the New York Times

recently.  Julian Boyd is a 6’7” basketball stand-out for Long Island University whose rare congenital heart problem is a significant cause for concern among the cardiologists the team has consulted.  One doctor ultimately cleared Boyd for competition, but those near to him remain anxious:

“I think about it all the time,” said Danny O’Connor, the head athletic trainer at L.I.U. “It’s in the back of my mind all the time.”

Boyd’s stepfather, Terrell Thames, calls his stepson a “beast of a kid.” Even though he knows Boyd has been cleared to play, “every time he takes the court, it’s a little nerve-racking,” Thames said.

My question for all involved is this:

where are the grown-ups when you need them? If Boyd were a weekend warrior instead of an all-star there wouldn’t be any question about the wisdom of allowing him to compete.  If you leave the decision to the coach, athletic director, or (heaven forbid) the college boosters, their answer will be resounding: “Let him play! And if a doctor says no, just go find another one.”

Of course you can’t leave it to the player to reach this decision.  These are athletes whose whole existence revolves around the field of competition and would give up almost anything to stay on the court.  A number of years ago Sports Illustrated reported the results of a survey among world-class athletes: if you could legally take a drug that would dramatically enhance your performance but would cut 10 years off your life, would you?  The answer was overwhelmingly yes.

I don’t have an answer to the very complicated issue of mass screening of our youth, but I have a very strong opinion about the wisdom of our approach to those who’ve already been identified as living on the edge.  No team or sports career is worth the untimely death of a young athlete.  We need mature voices to speak up and support the hard but wise decision.

Life is worth more than a winning season.