IN 490 BC, 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. This is probably the first recorded incident of sudden death of an athlete.

While the possibility that young, well-trained athletes could die suddenly seems incomprehensible, it is now well recognised and not in any way unusual.

On April 16, 2014, the Heart Institute of the Caribbean (HIC) and Jamaica Athletics Administrative Association (JAAA) signed a four-year agreement that would see HIC donating $10 million in free cardiovascular screening to JAAA athletes from 2014 to 2018. This agreement came on the heels of the sudden death of St Jago High student Cavahn McKenzie in Trinidad and Tobago. Cavahn collapsed and died after completing a 6K 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, the Jamaica Observer reported the sudden death of another young man, a Jamaica College (JC) footballer who collapsed and died in the bleachers of the sports complex at the St Elizabeth Technical High School (STETHS) grounds. Apparently, the student was among a group of JC Manning Cup players resting in the bleachers after a road run minutes earlier.

INVITATION OPEN

At the press announcement of HIC/JAAA “Play Smart” Cardiac Screening programme of athletes, HIC extended an open invitation to all sports authorities and organisations in Jamaica to take advantage of the expertise and facilities at the institution and screen young athletes to protect them and reduce the risk of these devastating outcomes. That invitation remains open.

On January 29, 2009, Dr B Waine Kong, president, HIC Foundation, published an article to bring attention to this matter. Dr Kong wrote: “Exercise, track and field, and sports in general are of great public interest in Jamaica where we have an excellent sports tradition and our athletes are world class. The perception is that our athletes are physically fit and the picture of health. This misconception has fuelled a carefree attitude to health of athletes and unfortunately diseases of athletes have received scant attention until the sudden death of Mr Matthew Hilton (18 years), [a] swimmer of Ardenne High School, and Terrence Golding (17 years), [a] footballer from Eltham High School. These two cases brought home to all of us that sudden death of young athletes during competition is tragic but avoidable with proper screening. It is, therefore, our duty and responsibility to determine, with a reasonable degree of reliability, whether students who are participating in sports are free from cardiovascular abnormalities that could increase the risk of death during athletic training and competition. It is shocking when a young, gifted college student who is asymptomatic, dies suddenly during competition. These deaths are not flukes.”

WHY ATHLETES MAY DIE YOUNG

The issues highlighted in the 2009 article remain true today.

High-intensity sporting activity may trigger sudden death in athletes with heart or blood vessel abnormalities by predisposing them to life-threatening heart irregularities or cardiac pump failure. While there are many potential causes of sudden death in young athletes, the majority of cases are thought to be related 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 is a factor.

Sudden cardiac death (SCD) in a young athlete commonly brings to the forefront 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.

On average, every three days in the United States a competitive athlete experiences a sudden cardiac death. Data from other countries are similar to those in the United States. The data for Jamaica is unknown, except for the media reports that bring such deaths to national attention.

SCREENING ATHLETES

Although the underlying causes of sudden death in the athlete are known, the frequency with which sudden death occurs, remains to be precisely defined by sex, age, race, nationality, and sport. Available data suggests that when properly done, about three to 15 per cent of athletes at risk for sudden death may be identified through structured and standardised screening.

While chest pain, syncope (fainting), dizziness, palpitations (sensation of a rapid or irregular heart beat), 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 evaluated by a competent specialist.

In Italy, 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) have been routinely obtained as part of a mandatory national comprehensive screening programme since 1982. This State-funded and mandated systematic screening has been associated with a significant decline in deaths among athletes there.

Following the Italian experience and similar data from a few others, an increasing number of countries and organisations, including the International Olympic Committee, now mandate medical pre-participation screening that includes a baseline ECG with the objective of detecting occult cardiovascular conditions that predispose young athletes to sudden death. Restriction of athletic activity is then mandated based on the premise that this restriction reduces the incidence of sudden death. Jamaica can definitely do the same. It is critical, however, that such screening is designed and performed only by competent cardiovascular specialists with special training and/or expertise in cardiovascular disease in athletes.

DETECTION AND INTERVENTION

While there is 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 is an intuitively appealing public heath priority that should be given utmost attention. A key objective of such pre-participation screenings should be the detection of potentially life-threatening cardiovascular diseases likely to manifest with sudden cardiac death during athletics. It must be clear; however, that identification of a potentially lethal condition is useful only if an effective preventive strategy is implemented to reduce the risk of SCD. This intervention may unfortunately include withdrawal of the athlete from competition while further evaluation or treatment is pursued. In some cases, it may be prudent that the athlete is permanently barred from competitive athletic competition to save their lives. This is a decision that requires courage and discipline to make, particularly when a top-class medalling athlete is involved.

HIC Play Smart Cardiovascular Screening 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.

Professor Ernest Madu, founder of the Heart Institute of the Caribbean, is an internationally acclaimed cardiologist and expert on innovative health solutions. HIC is a centre of excellence for cardiovascular care in the English-speaking Caribbean. Please send questions and comments to emadu@caribbeanheart.com or call 906-2105-8.