How to reduce the risk of sudden death in athletes.

The sudden death of young athletes often shock and mystify the sports world. How can such a devastating thing happen to our highly conditioned, elite, young athletes -- the paragons of health and vigor?

Ask anyone to describe an athlete, and the three most common adjectives you'd most likely hear are active, physical, and healthy. The least likely would be sickly and diseased.

Whenever an athlete collapses on the field and dies, it is rarely attributed to anything having to do with the aging process. The causative factor is usually a congenital cardiac abnormality or inherited cardiac condition called cardiomyopathies.

The most common form is hypertrophic cardiomyopathy. This often congenital condition may be asymptomatic for years, but its first clinical manifestation could be sudden death. It often occurs in children and young adults, frequently during or after physical exertion.

RISK OF SUDDEN DEATH

In symptomatic patients, the most common complaints are dyspnea (shortness of breath), angina pectoris (heaviness, tightness, squeezing pressure in the chest, which often radiates to the jaw, head, groin, shoulder blades, and/or left arm), diaphoresis (profuse sweating), fatigue, syncope (suspension of consciousness), and/or near-syncope(1).

The disease and symptoms related to the cardiovascular complications and sudden deaths of young athletes often arise during physical exertion. When total or partial coronary blockage occurs -- the most frequent cause of death in patients over 15 years of age -- it provokes myocardial ischemia -- the lack of oxygenated blood to the cardiac muscle(3).

The increase in heart rate increases the cardiac workload and 02 demand. In a diseased heart, however, the reduction of blood flow in the coronary arteries starves the myocardium and, unless treated, causes tissue nectrosis (death) or infarction(2).

Warning signs are often experienced months, weeks, even days before the fatal event. Symptoms include chest or stomach discomfort, dizziness, palpitations (irregular or elevated heart rate), or fainting episodes. Shockingly, most of the subjects continue to train and compete without seeking medical advice(3).

Once the athlete discontinues training or competition, the myocardium no longer demands the extra consumption of 02 blood, thus reducing the cardiac workload and alleviating the pain and discomfort.

The athlete will usually give minimal attention to his discomfort once the discomfort has dissipated. With each new exertive activity, however, the pain will return and the cycle will continue.

The accompanying table shows the incidence of sudden death among competitive athletes in the U.S. from 1985 to 1995 with specific reference to age levels.

Since it is virtually impossible to screen everyone, athletes who experience such signs and symptoms should seek medical advice immediately.

A medical evaluation might include a resting electrocardiogram (EKG), 24 hour holter monitor, graded exercise stress test (GXT), thallium GXT, adenosine-thallium testing, echocardiogram, transesophageal echocardiography (TEE), or a combination of these, which would cost the athlete $2,000 or more.

With an estimated 5.8 million high school athletes in the USA, such extensive medical screenings are not usually covered by health insurance(3).

An alternative plan would include educating coaches about the underlying cardiac conditions and the signs and symptoms associated with each. The coaches could then pass the information on to the athletes during a mandatory classroom lecture.

The athlete could then be required to fill out the following questionnaire for use in medical evaluation. This survey, coupled with the physical exam, win identify signs, symptoms, and family histories suggestive of the common abnormalities associated with sudden death in athletes(3).

Sample questionnaire for cardiovascular screening for athletes (adapted from "Preventing Sudden Death, Cardiovascular Screening of Young Athletes," from Physician and Sportsmedicine, 1992):

1. Has it been more than two years since you had a physical exam that included a blood pressure reading and listening to the heart?

2. Have your parents or has a physician ever told you that you have a heart murmur?

3. Have you experienced resting or exertional chest pain, pressure, dizziness, or fainting within the past two years?

4. Has anyone in your family died suddenly at a young age (under age 45)?

5. Has a physician diagnosed anyone in your family with an abnormally thickened heart or Marfan's syndrome?

6. Do you use, or have you ever used, cocaine or anabolic steroids?

7. Has a physician ever suggested that you refrain from athletic competition? (*) Especially important for athletes over age 35:

8. Does your family (parents, grandparents, brothers, sisters) have a history of coronary artery disease (CAD) including: heart attack, bypass surgery, balloon angioplasty, or angina, before 65?

9. Do you smoke, have high blood pressure, high cholesterol, or diabetes?

Warning: Failure to answer these questions as honestly and accurately as possible may be hazardous to your health.

If an athlete indicates a family history of cardiac defects or (CAD) coronary artery disease, related to smoking, hypertension (elevated blood pressure 120/80 mm/Hg) and/or hypercholesterolemia (elevated cholesterol serum, 200 mg/dL), a more thorough medical evaluation should be required before allowing him to return to action. This is a preventative measure and by no means conclusive of cardiac disease.

The evaluation should be conducted by either a physician, his/her assistant, or registered nurse, all of whom are qualified to recognize heart disease, obtain a cardiovascular history, and perform a physical exam(5). If any abnormalities should arise, the athlete may be referred to a cardiologist, who will likely perform one or more of the extensive medical evaluations.

If, during or after competition, an athlete should suddenly collapse on the playing field, the following actions should be taken: (Note: If a head trauma is suspected, do not move the athlete.)

1. Get a history (onset, duration, precipitating events).

2. Past history (current medications, medical illnesses, pacemaker, allergies).

3. Symptoms (chest pain, palpitations, syncope, dyspnea).

4. Take vitals (heart rate, blood pressure, respirations).

5. Observe skin (cool, clammy, pallor, cyanosis).

6. Observe neck (flat or distended neck veins).

7. Observe respiratory (respiratory distress, congestion).

8. Observe pulse (absent, irregular).

9. Observe level of consciousness.

10. Observe peripheral edema (swelling of hands, feet, etc.).

11. Stabilize (monitor vitals, CPR may be necessary, Call EMT (4).

Coaches have to educate their athletes at the beginning of every season. They should teach the athletes to stay aware of the signs and symptoms and, if any arise, to notify either a coach, trainer, or team physician.

This brings up the importance of open communication between coaching staff and athletes -- defining the line between a life-and-death situation. If and athlete feels intimidated by a coach, lacks self-esteem, loses a coach's trust, or diminishes the lines of communication in some way, he may create a potential life-threatening shadow on the playing field.

Athletes must be trained to confide in the coach and avoid any conflicts on or off the field.

Secondly, the use of other professionals is also needed to ensure an understanding of these complex issues. The chances of finding coaches with full or partial understanding of such cardiac conditions range from slim to none. Coaches will be wise to consult with the team physician for a foundation of facts.

As long as the coach has an awareness of the athletes' specific needs with regard to their paroxysmal episodes and encourages the athletes to alert him to their needs, the proper precautions can be administered.

Since these complications often arise during physical exertion, it is essential to make proper supervision and care part of the daily routine. Once the team steps onto the field or court, coaches and staff officials should make sure to know where every athlete is located.

This should apply not only to practices and games, but to weight-training sessions and sport-specific drills away from the playing field, and it should not conclude until the athletes are prepared to leave the grounds.

Cardiomyopathies and myocarditis continue to steal the lives of young athletes year after year. The prevention or reduction of such tragedies depends upon our knowledge of the facts related to the causative defects and conditions, the quality of our leadership, team camaraderie, and communication.

References

[1.] J.& E. Branwald Wynne: "The Cardiomyopathies and Myocarditis, Part7," Disorders of the Cardiovascular System, 1994.

[2.] R. Wiederthold: "Limitations of the Monitoring Lead," Electrocardiography: The Monitoring Lead, 1988

[3.] B.A. Franklin, C.X. Bryant, & J.A. Peterson: "Sudden Death In Athletes and Fit Adults, What Are the Risks?" ACSM's Health & Fitness Journal, Mar/Apr 1997

[4.] (NA): "Prehospital Care Protocols, Arrhythmias," Micromedec Inc., 1974-97

[5.] (NA): "Sudden Death In Young Athletes: Hypertrophic Cardiomyopathy is the Most Frequent Cause, and Conventional Preparticipation Screening Rarely Detects it," Emergency Medicine, Apr. 1997

[6.] B.J. Maron, J. Shirani, L.C. Polica, R. Mathenge, W.C. Roberts, F.O. Mueller: "Sudden Death In Young Competitive Athletes, Clinical Demographic, and Pathological Profiles," Journal of the AMA, 1996

[7.] Adapted from Ades, P.A.: "Preventing Sudden Death, Cardiovascular Screening of Young Athletes," The Physician and Sportsmedicine, 1992

Incidence of Sudden Death from 1985-1995

                                    Age Range in Year
Total Deaths          12-15   16-19   20-23   24-27   28-30   31-40

Basketball     (48)   10      23      10      3       1       1
Football       (44)   13      24       7      0       0       0
Track          (19)    5      12       1      1       0       0
Soccer          (6)    5       1       0      0       0       0
Baseball        (5)    1       4       0      0       0       0
Swimming        (3)    0       2       1      0       0       0
Volleyball      (2)    1       0       0      0       1       0
Ice Hockey      (2)    1       1       0      0       0       0
Boxing          (1)    0       1       0      0       0       0
Crew            (1)    0       0       1      0       0       0
Ice Skating     (1)    0       0       0      0       1       0
Tennis          (1)    1       0       0      0       0       0
Wrestling       (1)    0       1       0      0       0       0

Totals                37      69      20      4       3       1

(Adapted from "Sudden Death in Young Competitive Athletes in USA from 1985-95," Journal of AMA, 1996)