Sudden Death Causes in Young Athletes
Considering the relatively recent sudden deaths of such well-known athletes as Florence Griffith Joyner, Reggie Lewis, Pete Maravich, Hank Gathers, and Len Bias, heart disease in athletes has received much media attention. Certainly, anyone planning to participate in organized sports should have thorough history and physical performed by his or her physician. The physician may then opt to send the patient to a cardiologist, or may perform further testing including ECG, chest x-ray, and echocardiogram (ultrasound of the heart). While this site is in no way intended to take the place of these essential examinations, it is worthwhile to explore some of the implications and risks of certain conditions as they pertain to heart disease in the young athlete.
Sudden death in athletes is RARE. It is estimated that the risk of sudden death for high school athletes is 1:200,000 participants. With this in mind, it is important to note that the vast majority of young athletes can participate without worry of encountering this sort of catastrophic event. It is, however, understandable that this rare occurrence raises fear and anxiety in the minds of participants and parents alike. The most common cause of sudden cardiac death in young athletes is undoubtedly hypertrophic cardiomyopathy (disproportionate enlargement of heart muscle), resulting in a sudden change of heart rhythm. Other causes include unusual structure of the blood vessels supplying the heart, rupture of the main artery (aorta) leaving the heart, valve problems, and heart rhythm disturbances.
Cardiovascular Genetic Disorders that Cause Sudden Death
While the specifics of these particular genetic conditions are outside the scope of this discussion, it is important that these disorders be mentioned to raise awareness of their association with sudden cardiac death (usually due to a change in heart size, structure, or rhythm). Included are Familial Hypertrophic Cardiomyopathy, Familial Dilated Cardiomyopathy, Autosomal Dominant Dilated Cardiomyopathy, X-linked Dilated Cardiomyopathy, Myotonic Dystrophy, Huntingtons Disease, Friedreichs Ataxia, Arrhythmogenic Right Ventricular Dysplasia, Long QT Syndrome, Kearne-Sayre Syndrome, Wolff-Parkinson-White Syndrome, Marfan Syndrome (discussed in more detail on this site), glycogen storage diseases, mucopolysaccharidoses, and sphingolipidoses.
Marfan syndrome is an inherited disorder of connective tissue (i.e. tissues that hold the body together) with life threatening manifestations among athletes. Approximately 1:10,000 people spanning all races suffer from this disease, but it is likely that this ratio increases amongst sports participants (this is because the syndrome results in the sports-related assets of tall stature and long limbs). Marfan syndrome becomes apparent to physicians when a young, tall athlete presents with changes in his heart, eye, or musculoskeletal examination. The disease is particularly risky to young athletes from a cardiovascular standpoint, when the tissues that hold together blood vessels, heart valves and other essential cardiac structures are weakened. One of the most common catastrophic events related to the disorder is a "dissection" or splitting-apart of the aorta (the large blood vessel leaving the heart and supplying blood to the body) which can be brought about by exercise.
Substance Abuse and Its Impact on the Heart
Highly competitive athletes have recently given unprecedented publicity to the impact of cocaine, alcohol, anabolic steroids, and other drugs on the heart. Cocaine-related cardiovascular events escalated during the 1980s as cocaine became cheaper, purer, and easier to obtain. Cocaine abuse, regardless of route or forms, even in the first time user, can result in fatal cardiac complications. These include abnormal heart rhythm, death of cardiac muscle, fluid collection in the lungs, rupture of aortic artery (main blood supply from heart to the body), death of brain tissue, infection of heart tissue, blood vessel swelling and shrinking, and progressive heart failure. While these events may or may not be related to physical exertion, the glamorization of this potentially lethal drug by professional athletes makes it an issue for young, impressionable student-athletes.
Alcohol, also closely associated to professional athletes, often via endorsements, is the most widely used drug among athletes today. The role of this substance in the development of heart disease has been reported for more than a century. Consequences of alcohol use include high blood pressure, stroke, heart attacks, cholesterol abnormalities, heart rhythm problems, and generalized heart failure.
Anabolic steroid use has received tremendous media attention as its banning by most athletic organizations has resulted in the expulsions of many prominent athletes (e.g. Ben Johnson, world-class Canadian sprinter). Although steroid use enhances performance and increases muscle mass in athletes, its deleterious side affects harm many organ systems. These include fatal and non-fatal heart attacks, blood vessel disease, cholesterol problems, cardiac muscle disorders, liver disease, kidney dysfunction, and disorders of genitalia.
The continued introduction of new performance-enhancing drugs has resulted in drug testing program adjustment by major athletic organizations. Now often included are short-acting stimulants, beta-blockers (heart medication), diuretics (water-pills), anabolic steroids, narcotics, certain hormones, and drugs that may affect the testing of other drugs. Testing is also in place to check for blood doping, and chemical and physical alterations of specimens.
While cardiac manifestations may be the most severe complication of substance abuse, the impact of this problem is many-faceted. Problems with almost every bodily system have been documented, and the psychological affects of some substances can be devastating to the young athlete. There will seemingly always be a need for the drug testing of athletes, not only so that they may not participate with an unfair advantage, but so that they may be saved from the possibly lethal affects of their abuse.
Race and Gender in Sudden Death of Young Athletes
Although data has shown there to be a disproportionate impact of sudden cardiac death on the subgroup of male African American athletes, there seems to be a preponderance of black athletes involved in competitive sports such as basketball and football (80% of professional basketball players and 67% of professional football players are black). These are the sports in which the highest number of deaths occur. Participation of women is underrepresented in those active sports, and this further compounds the problem of interpreting data that purports the black male athlete to be at greatest risk of sudden cardiac death. More data is needed to completely study this phenomenon.
Ethical and Legal Issues of Athletes with Heart Disease
Physicians, coaches, schools, courts, and the athletes themselves are all involved in decisions regarding the student athlete with heart disease. Physicians must offer an honest "expert" opinion of the risk associated with a given conditions. Schools and coaches must interpret these opinions along with biases that come from the benefits of strong athletic programs, and the drawbacks of having an athlete die on the playing field. As athletes and schools form different views on a students participation in sports, courts are forced to decide who is responsible for the choice to play, and who is responsible for catastrophic outcomes. In a world with many risks, and the often elusive promises of future income from sport, athletes can be forced to make difficult decisions regarding athletic participation with a cardiac disease.
Pre-participation Cardiovascular Screening for Young Athletes
The recommendations of the American Heart Association from a 1996 panel state that some form of pre-participation cardiovascular screening for high school and college student-athletes is compelling based on ethical, legal, and medical grounds. Although specific tests such as ECG, echocardiogram (ultrasound of the heart) or testing during exercise can be helpful to diagnose cardiac disease, they are not recommended routinely from a cost-benefit standpoint. It is up to the individual physician to decide, based on a complete history and physical examination, which tests are appropriate in any given situation. Because of the very low frequency of cardiac-related athletic deaths, mass diagnostic screening would likely result in more tests being "falsely positive" than those that would indicate true cardiac disease. The young athlete can rest assured that, in the face of a normal thorough examination by a competent physician, the overall risk of sudden cardiac-related death during athletic participation is minute.
All references for this portion of material taken from this excellent reference:
Williams RA, The Athlete and Heart Disease: Diagnosis, Evaluation & Management. Lippincott Williams & Wilkins, Philadelphia, 1999.