Christian Eriksen and sudden death in young athletesSunday, June 20, 2021
Dr Ernest Madu & Dr Paul Edwards
In an article we published in the Sunday Observer of November 14, 2014, aptly titled “Don't Let our Athletes Die Young”, we attempted to highlight the urgency for proper cardiac screening of our athletes in Jamaica to minimise the risk of catastrophic sudden death events during sporting activities.
That article was necessitated by the sudden death of St Jago High student Cavahn McKenzie in Trinidad. Young McKenzie collapsed and died after completing a 5K race on February 22, 2014, while representing Jamaica in the North American, Central American and Caribbean (NACAC) Cross-Country Championships in Tobago.
On July 29, 2014, another young Jamaica College (JC) student/footballer collapsed and died in the bleachers of the Sports Complex at the St Elizabeth Technical High School (STETHS) grounds. The issues highlighted in our 2014 article remain relevant today.
Sudden death of young athletes continues to be reported around the world. A week ago, the sporting world was traumatised when Christian Erickson, a Danish footballer collapsed on the pitch at Parken in Copenhagen during his side's 1-0 Euro 2020 Group B loss to Finland. The entire horrifying episode was captured on live TV and was witnessed by millions around the globe. Fortunately, the 29-year-old midfielder was successfully resuscitated and will be fitted with a heart starter, Implantable Cardioverter Defibrillator (ICD), to protect him from possible sudden death episodes in the future.
Daley Blind, Netherlands and Ajax defender, was diagnosed with a heart condition in December 2019 and returned to action in February 2020 after having an ICD fitted. The 31-year-old is now part of his country's squad at Euro 2020 and played in their opening game, which was a 3-2 win against Ukraine.
However, former England cricketer James Taylor, 31, had his career ended by heart ailment in 2016. He was subsequently fitted with an ICD, a device that is half the size of mobile phone that is placed under the chest and connected to the heart muscles with a set of wires. It is a life saving device that jump starts the heart to avert sudden death when the electrical circuit malfunctions.
Possibility of sudden death of young, well-trained athletes is now well recognised and could be a tragic and devastating event for involved families and communities. It is therefore necessary to proactively put measures in place to minimise the risk of sudden death in young persons who engage in competitive sporting events. Considering this, the Heart Institute of the Caribbean (HIC) announced its sponsorship of the Jamaica Premier League (JPL) that would see HIC providing cardiac screening of more than 400 players and coaches within the JPL complemented with regular seminars and educational activities designed to improve cardiovascular health of athletes and coaches while reducing the risk of sudden death.
HIC's sponsorship of the JPL is an initial three-year commitment worth about $40 million. This is a continuation of our commitment to the development of safe sports and athletics in Jamaica. Since 2014, HIC has been the title sponsor of the HIC/Wesley Powell Invitational track and field meet held annually at Excelsior Community College.
On April 16, 2014, HIC and the Jamaica Athletics Administrative Association (JAAA) signed a four-year partnership agreement with HIC donating $10 million in free cardiovascular screening to JAAA athletes over a four-year period (2014-2018). At the press announcement of HIC/JAAA “Play Smart” Cardiac Screening programme of athletes, we extended an open invitation to all sports authorities and organisations in Jamaica to take advantage of the expertise and facilities at HIC and HIC Heart Hospital and screen our young athletes to protect them and reduce the risk of sudden death. Our sponsorship of JPL is therefore a natural extension of our commitment to safe sporting activities in Jamaica.
Sudden death in athletes is not a new phenomenon and was first described in 490 BC, when Phidippides, a young Greek messenger collapsed and died suddenly after running 26.2 miles from Marathon to Athens to deliver the news of the Greek victory over the Persians.
High-intensity sporting activity may trigger sudden death in athletes with undetected heart or blood vessel abnormalities by predisposing them to life-threatening electrical conduction abnormalities or heart pump failure. The majority of cases are thought to be due to a condition called hypertrophic cardiomyopathy, an inherited condition that results in unusual thickening of heart muscles and a propensity for development of lethal abnormalities in heart rhythm that could be provoked by intense activity. Other major causes include congenital conditions like anomalous coronary arteries, abnormal electrical conduction patterns and Marfan's syndrome, another inherited condition resulting in unusual enlargement of the aorta and tendency to rupture. In some cases, acquired premature cardiovascular disease may be a factor.
Sudden cardiac death (SCD) in a young athlete commonly brings to focus, the need to seek ways to close the gaps in knowledge and to act proactively to predict and prevent these tragic events. These deaths represent an important and emotionally charged public health issue.
It is estimated that sudden cardiac death occurs every three days in the United States among competitive athletes. Except for media reports, we do not have reliable information on the prevalence of sudden cardiac death among athletes in Jamaica.
The frequency with which sudden death occur remains to be precisely defined by sex, age, race, nationality, and sport. However, about three-15 per cent of athletes at risk for sudden death may be identified through structured and standardised screening.
Even though chest pain, fainting, dizziness, palpitations, fatigue, and excessive or prolonged shortness of breath can be innocent sensations that can accompany intense exercise, when they are reported by the athlete, they should be properly evaluated by a competent specialist.
Italy has offered a State funded and mandatory national pre-sports screening programme for nearly 40 years. The programme includes a 12-lead electrocardiogram (ECG) (evaluating electrical activity of the heart), limited stress test (evaluating heart function during exercise) and selective use of echocardiograms (to look at the structures of the heart and heart muscles). This programme has been shown to lead to a significant decline in deaths among athletes in Italy. An increasing number of countries and organisations, including the International Olympic Committee (IOC), now mandate medical pre-participation screening that includes a baseline ECG with the objective of detecting underlying cardiovascular conditions that may predispose young athletes to sudden death. Restriction of athletic activity may be mandated based on the premise that this restriction would reduce the incidence of sudden death.
Notwithstanding, the universal acceptance of the goal of prevention of sudden death in the athletes, each society must determine the proper screening and intervention strategies that are unique to their culture and characteristics. Development of an effective pre-participation screening strategy that can reliably detect underlying cardiovascular conditions predisposing to SCD in athletes should be seen as a necessary public health priority.
Pre-participation medical screening programmes should be designed to enhance the detection of potentially life-threatening cardiovascular diseases likely to manifest with sudden cardiac death during athletics. It should be noted, however, that identification of a potentially lethal condition offers no significant benefit to either the athlete or society unless effective preventive strategy is implemented to reduce the risk of SCD to the athlete. This intervention may unfortunately include withdrawal of the athlete from competition while further evaluation or treatment is pursued. In some cases, it may be possible to return to active participation in sports as in the case of the Ajax defender, Daley Blind, or in some cases, as in the English cricketer James Taylor, it may be prudent that the athlete is permanently barred from competitive sports to save their lives.
The Heart Institute of the Caribbean has developed a robust template for cardiovascular screening of athletes and has used this successfully with JAAA athletes and will use the same for JPL footballers with the goal of reducing the risk of sudden death in our young athletes. The HIC Play Smart Cardiovascular Screening programme systematically evaluates each athlete with a structured medical history and examination, mandatory electrocardiogram to evaluate cardiac electrical activity, selective echocardiogram to assess cardiac walls, structure and function, focused stress test to evaluate cardiovascular response to exercise and a 24-hour Holter if indicated for further assessment of cardiac electrical activity. This template can serve as a foundation for an organised national screening programme for Jamaica.
Dr Ernest Madu, MD, FACC and Paul Edwards, MD, FACC are consultant cardiologists at HIC and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region.
Dr Madu is a main TED Speaker whose TED talk has been translated into 19 languages, seen, and shared by more than 500,000 viewers. He has received the Distinguished Cardiologist Award, the highest award from the American College of Cardiology, and has been named among the 100 most influential people in health care and among the 30 most influential in public health. Dr Madu is also a recipient of the Global Health Champion Award from the University of Pennsylvania. Dr Madu was past CEO of HIC and is currently the chairman of IHS Holdings Ltd, an asset management company with interests in the USA, Africa, and the Caribbean.
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