Death on football pitch: the challenge of diagnosing sudden cardiac arrest in athletes

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Cardiac arrests accounted to dozens of deaths in athletes over the years with heart disease being a scourge of the 20th century. It can be difficult to eliminate stress or change one’s lifestyle choices, but can modern medicine predict a heart attack and save someone from an early death?

Collapses at the football match

History knows many examples of young, seemingly healthy and strong people dying on the spot of heart attacks. One of the most striking examples was when football superstar Marc Vivien Foe collapsed in the middle of the field at the 72nd minute of a FIFA Confederations Cup match in Lyon on June 26, 2003. The 28 year-old with an impressive career in Manchester City and Olympique Lyonnais, who at the time was representing the Cameroonian national team, died from cardiac arrest. 

Foe’s death caused a profound shock among football professionals and fans, remembering him for his joyous personality and infectious humour. As a tribute after his death, Manchester City retired his number 23 shirt and Olympique Lyonnais removed the number 17 jersey, in which he used to play. Footballer was also given a state funeral in Cameroon. 

While exercise is one of the most powerful tools to stay fit and healthy, extensive training in a small number of individuals, harboring cardiac conditions, can lead to sudden cardiac death (SCD). A study, published in Houston Methodist Debakery Cardiovascular Journal, says SCD is the most frequent medical cause of sudden death in athletes. A recent estimate of SCD incidence ranged from 1 in 40,000 to 1 in 80,000 athletes per year, depending on population.

Many die after regaining consciousness 

According to an American study, conducted in 2003, the victim of sudden cardiac arrest is usually male and associated with such high-performance competitive sports as football, basketball or ice hockey. Statistically, many deaths occur after the athlete was able to regain consciousness. 

That was the case of another football star, who died after the game in Spanish Seville in 2007. Antonio Puerta, who kicked off his career in Seville FC in 1992, became an acclaimed defender in Real Madrid and Manchester United by 2007.

On August 25, during a high pressure La Liga match, Antonio collapsed and lost consciousness in the penalty area of the pitch. After recovering he managed to walk to the dressing-room, but then fainted again and was urgently delivered to the intensive care unit at Virgen del Rocío Hospital in Seville. He died on 28 August leaving behind not only a promising football career but also a seven-month pregnant girlfriend.

Challenging screening

Cardiovascular diseases are the number one cause of death globally. According to the World Health Organisation, an estimated 17.9 million people died from a heart-related disease in 2016, representing 31% of all global deaths. Of these deaths, 85% are due to cardiac arrest and stroke. 

Experts believe that most cardiovascular diseases can be prevented by addressing such issues as tobacco and alcohol use, unhealthy diet and physical inactivity on a state level. However, for some people who are at higher risk of stress due to their work environment need an early detection system. It is advised for the management to use counselling and medicines, as appropriate.

When it comes to professional sports, most athletes are monitored by a group of specialized healthcare professionals and to partake in any serious competition, like UEFA, one has to go through a thorough health screening process. 

Professional football clubs have a screening programme for academy players as young as 16. According to football medics, elite athletes have a higher chance at dying from an underlying heart disease as systematic adrenaline spikes, changes in electrolytes and dehydration put them at a much higher risk.

Some leading experts in the area believe that the problem is highly underrated. 

Estimates say that seven in every 100,000 players die of cardiac arrest.

In an interview to BBC, Cardiologist Professor Sanjay Sharma, who led the research at St George’s, University of London urged the football community to “open our eyes to the fact death rates are higher than we thought, although they are still rare.”

Scientists gathered data on more than 11,000 youth players in the UK. In the paper, published in the New England Journal of Medicine, they concluded that in 20 years of screening, 42 academy prospects were found to be at risk.

All of them underwent treatments, including corrective surgery and heart drugs and 30 of them could resume their careers. The rest were advised to stop playing competitive sport.

Despite intensive screening, eight people died during the course of the study and only six of them were diagnosed with a heart disease. 

Some of the participants in the study had near-death experiences although the scientists cleared them for playing professional sports. For example, Bolton Wanderers midfielder Fabrice Muamba suffered a cardiac arrest and collapsed during an FA Cup match against Tottengam in March 2012. 

The 23 year-old survived, leaving scientists with the enigma of how to diagnose and prevent death from cardiac diseases in competitive sports. Because of the challenge, England’s Football Association has introduced additional screening at ages 18, 20 and 25.

Insufficient equipment

Another important issue is access to timely and sufficient medical help and such ambulance equipment as defibrillators. An aspiring Russian hockey star Alexei Cherepanov who played for Avangard Omsk in the Kontinental Hockey League (KHL) collapsed on the bench during a KHL game in October 2008. The 19 year-old could not be resuscitated and died later that day in hospital.

According to medics, he suffered a heart failure. After his death, the KHL launched an investigation and found that the team officials and physicians didn’t provide a sufficient emergency response to Cherepanov and didn’t perform sufficient health screening during his career. 

In an interview to ESPN, Pavel Krasheninnikov, the member of the Russian Hockey Federation’s supervisory council at the time, said there was no ambulance on duty at the Moscow region arena where Cherepanov was playing.

He also asserted emergency workers took too long to respond and didn’t have a defibrillator – a machine that sends an electric current through the chest to restart the heart after a stop. “There are elements of negligence here,” Krasheninnikov said to ESPN.

The young hockey genius, in 2007 Cherepanov was selected to play in the National Hockey League (NHL) by the New York Rangers, although he never played professional hockey in North America. After his death, Avangard retired Cherepanov’s #7 jersey, and the KHL renamed its Rookie of the Year trophy to the Alexei Cherepanov Trophy.

After Cherepanov’s death, KHL reviewed its policy on medical help and medical drug use by hockey players. 

Professional sports associations have very specific rules when it comes to medical equipment of its members. For example, in 2012 the UEFA Medical Committee defined minimum medical requirements for players, team officials, referee teams and match officers at matches and tournaments.

The host club or national association is required to provide pitchside medical equipment like defibrillators, spinal boards or resuscitation equipment, an Advanced Life Support Ambulance and an equipped emergency room. Trained medical staff must be present on site. 

In 2018 the European football market was worth €25.5bn. But most money goes to the big clubs and smaller clubs often find themselves neglected with insufficient access to medical help.  

Predicting cardiac death 

After Foe’s death, an autopsy concluded that he was suffering of hypertrophic cardiomyopathy, a hereditary condition known to increase the risk of sudden death during physical exercise. Cardiac arrest in athletes, often young and seemingly healthy people, is very difficult to predict for modern medicine. Scientists invest considerable effort to better understand the causes of SCD in athletes and to discover optimal strategies for prevention. 

Heart attacks occur as an artery leading to the heart becomes blocked and the part of the heart muscle that is fed by that artery becomes damaged. 

“Cardiac arrest is an electrical problem. The natural rhythm of the heart that generates every heartbeat that you have suddenly either just completely stops and becomes electrically silent, or it becomes so fast and erratic that your heart muscle essentially can’t keep up with all the electrical signals and so it just quivers – literally quivers – and it can’t generate any pumping output”, explains Dr. Chris Simpson, chief of cardiology at Queen’s University to The Globe and Mail.

There can be an array of reasons for SCD, most of which are genetically inherited heart rhythm disorders. These conditions can be difficult to diagnose, especially in young people, but in most cases, the medics observe some warning signs such as dizzy spells or fainting during exercise.  

RANKEL Cardiocode is the world’s first hemodynamic analyzer capable of determining the potential of an athlete. The procedure lasts about 10 minutes and it allows to see the change in heart rate, potential for fatal rhythm disorders, arteriosclerotic heart disease and heart attack at different stages of their development.

RANKEL Cardiocode can help choose the most optimal form of training and physical effort to prevent sudden cardiac death and identify conditions that may lead to it. It is an irreplaceable diagnostic device for sports clubs and other training facilities.

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