By By Dr Aishah Mohd Hafiz
The recent tragic death of a young badminton player brings about several mind-lingering questions. How can a seemingly healthy young athlete, at the peak of his physical fitness, suddenly collapse, resulting in death? Secondly, was it at all preventable?
Sudden Cardiac Arrest (SCA) among athletes is fairly uncommon. However, SCA is the leading medical cause of death among athletes during physical activity, affecting the male gender more than their female counterparts by 10-fold. Contrary to general belief, SCA does not equate to a heart attack, though it may be a consequence of one. Essentially, SCA happens when there is a sudden disruption of the heart’s normal electrical conduction activity, resulting in the heart to either stop abruptly or beat abnormally (ventricular fibrillation or ventricular tachycardia). In both instances, the heart fails to function as a pump, denying the vital organs from receiving a continuous blood flow rich with oxygen and nutrients. If normal rhythm of the heart is not promptly restored, this can lead to death.
In the majority of cases, the cause of SCA during sport activity is due to structural and electrical changes in the heart, which can be either congenital or acquired.
A recent study in the United Kingdom reports the leading cause of SCA among their athletes are actually unknown. It is hypothesised that this may still be due to cardiac anomalies, at a molecular level. Though not apparent physically, these abnormalities can trigger cardiac arrest arrhythmias. This again poses the question of genetic predisposition and whether genetic screening is necessary.
Screening for Risks of SCA.
Although the likelihood of SCA occurring during a sporting event is rare, the aftermath is devastating, nevertheless. Preventative measures through advocation of pre-participation health screening is essential to identify, especially young athletes at risk. While this is common
practice prior to major events such as the Olympics, smaller competitions such as at school or intervarsity levels may not enforce this. In addition, screening is not a pre-requisite for participation in endurance sporting events that are open to the public, such as marathons and
long-distance cycling races. Instead, participants are only mandated to sign a waiver form, releasing the organisers from any responsibilities in the event of SCA. In such instances, it is up to the individual athletes, parents, teachers and the sport team members to take on necessary screening measures.
The American Heart Association (AHA) recommends a targeted medical history and a focused cardiovascular physical examination as sufficient initial steps to identify high risk patients. This includes seeking for symptoms such as shortness of breath, chest pain, fainting spells or episodes of transient loss of consciousness, or a notable decline in physical performance. Specific inquiries regarding sudden deaths within the family, relatives with known inherited cardiac conditions, as well as family members with pacemakers or defibrillators in place, should be made.
Further tests in the form of electrocardiograph (ECG) and echocardiogram can be done in the identified athletes. The ECG looks at the electrical activity of the heart and can display any abnormal rhythms, while the latter looks for any structural abnormalities and the function of the heart. By this stage, consultation with a cardiologist is greatly advised for their expert opinion.
Among athletes aged 35 years and above, coronary artery disease stands out as the most frequent cause of sudden cardiac death. In older athletes, further screening questions should include pre-existing risk factors for a heart attack, such as a strong family history, actively
smoking, and chronic illnesses such as diabetes and hypertension. These characteristics, when present poses additional risks for SCA, thus should be addressed before continuing with any vigorous sporting activities.
Life saving measures in SCA
Certain individuals may still develop SCA despite receiving the clean bill of health. Preparticipation screening is useful in detecting certain inherited conditions, however as discussed, for some the cause of SCA remains unknown. Other aggravating factors such as extreme heat
or dehydration during the day of event may unmask an underlying condition, which may not be detected during screening.
In the event where SCA occurs, then all efforts should be made to improve survival outcomes and prevent death. The effectiveness of CPR and early defibrillation using an automated external defibrillator (AED) for the treatment of SCA is proven and well-established. Essentially,
chest compressions mimic the pumping action of the heart, providing the vital organs with any remaining oxygen in the blood. In certain situations, this may be sufficient to restart the heart. The attempts to provide continuous blood flow minimize permanent injury to the vital organs, improving the outcome if and when normal circulation is restored. An AED on the other hand, is an easy-to-use device that can quickly detect any life-threatening arrythmias and can promptly deliver an electrical shock to terminate the abnormal rhythm when needed.
The key factor for successful resuscitation with favourable outcome is early CPR initiation and defibrillation, which ultimately requires rapid recognition of the signs of SCA. Therefore, it is of upmost importance that the general public have heightened awareness of SCA and possess these basic lifesaving skills, so that treatment can be initiated by anyone even before medical assistance arrives. In addition, it is the responsibility of the sporting event organisers to ensure the AED devices are readily available and accessible, strategically placed within the compounds of the event. An Emergency Response Plan should also be formulated prior to the event, which includes appointing a highly trained and certified medical standby team.
In conclusion, even though athletes are the epitome of peak physical health, SCA can still occur within this population due to several reasons. Pre-participation screening is beneficial to detect certain inherited conditions especially among the younger age group, and those at risk of developing a heart attack. On many occasions, however, SCA cannot be prevented. What can be done is to shorten the duration of cardiac arrest and attempt to restore the normal function of the heart as quickly as possible through basic lifesaving skills.
The lingering question that should remain now is – are we prepared to save a life?
The author is a senior lecturer in emergency medicine at the School of Medicine, Faculty of Health and Medical Sciences, Taylor’s University.
