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Thursday, August 30, 2007

Heart attacks in sport - a tragic death and call to action

For the last week or so, we've focused exclusively on the IAAF World Champs in Osaka. But over the past few days, two very sad events in soccer have also made headlines. First, the tragic death of a Spanish International footballer, Antonio Puerta, aged just 22 (see news article here). This was followed only days later by a heart attack to Clive Clarke, suffered during half-time of a Carling Cup match in England. Clarke is reported to be in a stable condition (click for article).

The case of Puerta, in particular, sent shock-waves through the football community, when it was announced that he had died in hospital. He collapsed on the field after 35 minutes of the opening La Liga match. Team-mates and doctors rushed to his aid, prevented him from swallowing his tongue, and then escorted him off the field, as he recovered enough to walk to the change rooms. However, once there, he collapsed again, was given cardiac resuscitation and rushed to hospital. Sadly, his condition deteriorated and he died in hospital. The images of a professional sportsman collapsing on the field were of course extremely disconcerting, another reminder that even professional athletes are not immune to cardiac arrest or heart failure.

In this light, Professor Jiri Dvorak, who if FIFA's Chief Medical Officer, has called for regular heart screening of professional players. This was actually done prior to the 2006 World Cup, and Dvorak stated that FIFA "wanted to send a clear message that if you're in professional sport, we believe cardiac screening should be mandatory".

In terms of logistics, it's not immediately clear who would be responsible for the screening, most likely the clubs. One would think that even though this might impose quite a burden on the clubs, it would be met with little resistance if recommended (officially) by FIFA. This remains to be seen.

From a sports science point of view, the cause of death is of course very difficult to identify after the fact. About one month ago, we did a post looking at marathon runner Alberto Salazar's heart attack (non-fatal), and SOME of the possible causes for it. Even on that occasion, we received some emails commenting that electrical disturbances in the heart might be more likely to blame. Of course, we do acknowledge that these are possible, although in that particular instance, we were pretty close to accurate in our article on Salazar (and other runners, like Jim Fixx, doyen of running in the 1970's).

But the emails were correct - we didn't cover everything, because it's just not possible, unless you were prepared to plough through dozens of possible causes. And the post-mortem on Puerta and the tests of Clarke must first ascertain just what happened. At this stage, it's still not even clear whether these players suffered heart attacks or cardiac arrest - a heart attack is a circulatory problem, while cardiac arrest is electrical. It's been reported as both, mistakenly in some instances then. Most of the reports, and certainly the comments from Professor Dvorak and other experts suggest that this was electrical, cardiac arrest, and thus different from the situation we wrote on previously.

The screening processes will have to examine a range of possibilities, which we won't go into here. What the testing would involve is a stress-ECG, where players exercise while connected to a machine that monitors the electrical activity over the heart. There is a 'normal' heart rhythm, and during the test, any deviations from that normal rhythm can be identified and specific problems detected for further investigation. These include fibrillations, often lethal conditions, where the heart muscle contracts in an unco-ordinated fashion, failing to pump blood. This is often treated with a defibrillator, as was reported to be the case in the two footballers recently. It is not the only condition, however. The testing/screening is believed to be successful, reducing the number of cardiac arrests in Italy, for example, where it is used more widely.

For now, these events serve as another reminder that everyone is susceptible. Regular testing would pick up most (but not all) of the potential causes, allowing management or avoidance of risk, and so perhaps FIFA's approach, which is certainly the prudent one, is the one that should be adopted, but all sporting codes.