I just received my weekly edition of Morbidity and Mortality Weekly Report. This publication with a somewhat macabre name is actually a very important and interesting periodical produced by the Centers for Disease Control. I was surprised to read that October is “National Sudden Cardiac Death Awareness Month”. I wasn’t aware Sudden Cardiac Death had its own month.
The month is dedicated to educating the public about what sudden cardiac arrest is and how to respond to it.
Blockage of arteries to the heart is responsible for heart attack, the most frequent sudden fatal cardiac event. In many cases, the narrowing of these blood vessels has progressed over many years. If a person is more fortunate, gradual symptoms may prompt medical care before experiencing an actual heart attack.
In pediatrics, we have become increasingly aware of physically fit adolescents or young adults, in the prime of their youth and health, succumbing suddenly, unexpectedly, and irreversibly to a terminal cardiac event. We hear about it all too often, in high school students, college students, and in professional sports. Unlike older individuals, it is seldom due to obstruction of coronary arteries. Most often, an abrupt, critical event affecting rhythmic regulation of the heart causes it to stop beating.
By and large, these events have occurred in the midst of strenuous athletic activity. In the U.S., there are approximately 5 million high school athletes, 50,000 collegiate athletes, and 5,000 professional athletes. Although the risk of death to a young athlete is estimated to be one in 100,000-300,000, with so many young athletes, even a rare event can add up to tragic numbers.
What makes certain athletes vulnerable? Causes can include unrecognized structural heart problems they were born with, heart problems they acquire, or sudden direct chest trauma. Well known victims include football pro Reggie Lewis, marathon runner Jim Fixx, Olympic volleyball star Flo Hyman, and basketball greats Hank Gathers and “Pistol” Pete Maravich. In Maravich’s case, he had a stellar college and professional career, and died outside his own home playing basketball with his son. He had an unsuspected birth defect involving one of the arteries supplying blood to his heart. There are many other names—most of them the sons and daughters of ordinary people who are not in the public spotlight.
How can this be prevented? It starts with a pre-participation evaluation, which includes a history of symptoms suggesting possible heart problems, and a physical examination. The important questions to ask include:
- Is there chest pain with exertion? Not side-aches, or occasional brief, sharp little twinges many of us get from time to time, but pain that makes you stop what you are doing?
- Is there shortness of breath or difficulty breathing with exertion? Not the normal windedness we all experience with exertion, but something that forces you to drop out of an activity well before your peers?
- Have there ever been any fainting spells or near-fainting with exertion? (I always screen patients for a heart rhythm problem if they have fainted).
- Have there been palpitations, or a feeling of your heart racing, during or after exercising?
- Is there a history of sudden cardiac death in a family member under the age of 50, or of a cardiac rhythm problem?
If the answer to any of these questions is “yes”, further evaluation is warranted.
During physical examination, checking blood pressure and careful examination of the heart should be done routinely. In fact, the athletic pre-participation visit has become quite specialized because there are other factors to be considered, such as considering any history of concussion, and bone and joint health. Some experts feel the sports physical should be a special visit apart from a routine annual physical examination. In reality, this doesn’t turn out to be very practical. But the days of physicians just signing a little green athletic form without evaluation are over.
However, even careful clinical screening will not identify all problems. Some are just not evident, even after asking all the right questions and doing a thorough examination. Some experts have suggested screening all teenage athletes with tests such as electrocardiogram (EKG) and echocardiogram (ultrasound video of the heart). Although in the best possible world money would not be an issue, the cost would be astronomical. Even if we were to screen every child in this way, not all at-risk children would be identified.
The CDC stresses steps to improve survival from sudden cardiac events. They are:
- Call 911.
- Start CPR; this year is the 50th anniversary of modern CPR.
- Use an automated external defibrillator.
An Automated External Defibrillator (AED) is a device that should be available in every athletic facility. It can deliver an electrical shock to the heart of a cardiac victim, and potentially restore a normal heart rhythm. Anyone, whether in the medical field or not, can be trained to use an AED. The electronics in the device determine when an electrical current should be delivered. It is a goal that every athletic event has someone present who is familiar with the device.
Project ADAM (Automated Defibrillator in Adam’s Memory) is a program that helps schools acquire an AED. It was started in 1999 after the death of Adam Lemel, a 17-year old high school athlete at Whitefish Bay High School. The program was initiated by Adam’s parents in his memory. For more information, contact the Herma Heart Center at Children’s Hospital of Wisconsin.