By Batrisyia Jay
With 16 swimming records to his name, Kenneth To had his sights set on the 2020 Tokyo Olympics. On 18 March, while on a three-month training programme at the University of Florida, the record-breaking Hong Kong-Australian swimmer suddenly took ill after a training session. He died in hospital the next day, aged only 26 years.
This is not the only tragedy involving the sudden death of a young sportsperson. On 17 February, a 16-year-old student from SMK Rancha-Rancha in Labuan died while competing in a sprint event.
Norsahfiza Jaratin was competing in a 200 m race when she collapsed about 20 metres from the finishing line. According to reports, the 8.55 a.m. incident took place at the Labuan Matriculation College sports field. Her death was initially thought to have been due to heat stroke but the Labuan Health Department has since denied that this is the cause of death.
What is Behind the Cases
What could be causing the deaths of these young adults, particularly young athletes, all over the globe? One such cause is known as Sudden Cardiac Death (SCD) which is due to the sudden loss of heart functions. When the heart is unable to pump blood to the rest of the body, it leads to cardiac arrest, which usually occurs within one hour of the onset of symptoms. In any case, sudden death in people younger than 35, often due to undiscovered heart defects or overlooked heart abnormalities, is quite rare.
As is commonly known, death due to cardiac arrest often occur in older adults, particularly those with coronary artery disease. However, it has been reported that cardiac arrest is the leading cause of death in young athletes, where its incidence of is yet to be known. Moreover, when these sudden deaths occur, the victims are often reported to be in the midst of a physical activity, such as playing a sport. Men are more likely to be victims than women.
The Cause
In a study published in the New England Journal of Medicine by the multi-institutional research team, the Race Associated Cardiac Arrest Event Registry (RACER) Study Group in 2012 showed that nearly 80 per cent of the non-survivors of cardiac arrest collapsed in the last 25 per cent of the distance of marathons and half-marathons, or shortly after finishing.
What is alarming is that the study showed that younger runners under the age of 40, who were experiencing cardiac arrest, were almost seven times less likely to survive than runners over 40 years of age.
“When someone suddenly dies in an athletic event, particularly in teenagers and those in their 20s and 30s – the most common cause is hypertrophic obstructive cardiomyopathy,” says Peter A. McCullough, M.D., M.P.H., a cardiologist at the Baylor University Medical Centre in Dallas.
“This is a genetic abnormality of the proteins used by heart muscle cells. The heart becomes abnormally thick in one area and when the heart pumps, it has trouble ejecting blood past that thick point. The heart becomes very, very thick – two to three times as thick as normal,” said Dr McCullough.
Sunway Medical Centre consultant cardiologist Dr Lim Bee Chian is of a similar opinion. According to him, SCD among people younger than 30 following physical exertion is related to congenital heart conditions, such as hypertrophic cardiomyopathy (HCM).
“These congenital heart conditions would predispose sufferers to cardiac arrest due to the physical and emotional stress when they exercise or compete in sport events,” said Dr Lim. He added that as these conditions are asymptomatic, they are often undiagnosed and undetected.
Dr Lim likened the condition of these athletes to pressure cookers that explode when they are over their capacity. “They are fine and healthy when they do not exceed their capability. But when they engage in extreme exercise, the heart will give out due to the pressure and this will result in sudden cardiac arrest and death,” he explained.
SCD in young people can be caused by the following conditions:
- Hypertrophic cardiomyopathy (HCM): In this usually inherited condition, the walls of the heart muscle thicken. The thickened muscle can disrupt the heart’s electrical system, leading to fast or irregular heartbeats (arrhythmias), which can lead to sudden cardiac death. This condition, although not usually fatal, is the most common cause of heart-related sudden death in people under 30. It is the most common identifiable cause of sudden death in athletes. HCM often goes undetected.
- Coronary artery abnormalities: Sometimes people are born with heart arteries (coronary arteries) that are abnormally connected. The arteries can become compressed during exercise and not provide proper blood flow to the heart.
- Long QT syndrome: This inherited heart rhythm disorder can cause fast, chaotic heartbeats, often leading to fainting. Young people with long QT syndrome have an increased risk of sudden death.
Apart from the above, causes of SCD in young people include structural abnormalities of the heart, such as undetected heart disease that was present at birth (congenital) and heart muscle abnormalities. Additionally, other causes include inflammation of the heart muscle, which can be caused by viruses and other illnesses.
Another rare cause of sudden cardiac death that can affect anyone is Commotio cordis. This is caused by a blunt blow to the chest, such as being hit by a hockey puck or by another player. If the blow to the chest occurs at the wrong time in the heart’s electrical cycle, it can trigger ventricular fibrillation and ultimately cause death.
The Symptoms
Oftentimes, these deaths strike with no warning. Although shortness of breath or chest pain could indicate that a person is at risk of SDC, these could also indicate other health problems in young people, such as asthma.
However, there are indications to watch for, as listed below:
- Unexplained fainting (syncope): If this occurs during physical activity, it could be a sign that there is a problem with the heart.
- Family history of sudden cardiac death: Another major warning sign is a family history of unexplained deaths before the age of 50. Take note if this has occurred in your family, talk with your doctor about screening options.
Is There a Cure?
If a person is at high risk of SCD, their doctor will usually suggest that they avoid competitive sports. Depending on the underlying condition, medical or surgical treatments might be appropriate to reduce the risk of sudden death.
Another option for some people, such as those with hypertrophic cardiomyopathy, is an implantable cardioverter-defibrillator (ICD). This pager-sized device implanted in your chest, like a pacemaker, continuously monitors your heartbeat. If a life-threatening arrhythmia occurs, the ICD delivers electrical shocks to restore a normal heart rhythm.
Some countries, such as Italy, screen young people with an electrocardiogram (ECG or EKG), which records the electrical signals in the heart using ultrasound. However, this type of screening is expensive and can produce false-positive results — indications that an abnormality or disease is present when it isn’t — which can cause unnecessary worry and additional tests. Be that as it may, there is a debate in the medical community about screening young athletes to attempt to identify those at high risk of sudden death.
“The cardiac community is divided on this, but I fall in the camp where I think that everyone involved in serious athletics should have an echocardiogram, just like every woman who gets pregnant has two or three ultrasounds,” said Dr McCullough.
However, others feel that the large sum needed to perform ECGs in order to prevent the few SCD deaths is not cost-effective. The consumer health information site, iTriage, lists the average, U.S. out-of-network cost for an echocardiogram as about $1,960 (RM 7,959.36).
Moreover, it is not clear that routine exams given before athletes are to participate in competitive sports can prevent SCD. It can, however, help identify the few who are at increased risk. Thus, those with a family history or risk factors for conditions that cause SCD are recommended to have further screening, even if the first heart evaluation was normal.
As regular exercise is encouraged for people with heart disease, it is not necessary to stop exercising in order to avoid SCD. Physical activities are known to regain heart muscle strength and improve blood and oxygen circulation throughout the body, as well as lowering blood pressure and cholesterol levels. Thus, as a precaution, it is advisable to start exercising slowly and not to engage in strenuous activities, especially an unfamiliar one.
Dr Lim, however, stressed that this does not mean those at risk of SCD cannot exercise. According to him, brisk walking, swimming or kayaking are safe ways of exercising, even if one is predisposed to SCD. “The only restrictions are competitive events or extreme sports,” warned Dr Lim.
