The Leading Cause of Death Among Competitive Athletes

This silent killer is called sudden cardiac arrest, and it stalks the unsuspecting.

Sixteen-year-old Zachary Schrah appeared to be the picture of health. He was a strong, boisterous big brother who loved to fish and play competitive sports. So it was shocking when, near the end of a routine workout with the Plano East Panther football team in April 2009, he collapsed and later died of sudden cardiac arrest.

“I never in a million years would have thought there was something wrong with his heart,” says Karen Schrah, Zac’s mother. “I just never thought it could happen.”

Zac’s unexpected death is far from an isolated incident. Sudden cardiac arrest—when the heart stops beating—occurs about 300,000 times each year. Many of those affected suffer from coronary heart disease, meaning they have heart arteries blocked with fatty buildup. But sudden cardiac arrest victims also include those without that condition. In fact, it’s the leading cause of death for competitive athletes.

In pure statistical terms, sudden cardiac arrest afflicts up to 28 high school athletes out of every 100,000, according to the American Heart Association. But it’s devastating for loved ones because the pain of loss is compounded by shock and surprise. Athletes, after all, appear to be the healthiest and least vulnerable members of society. In most cases, they’ve shown no prior symptoms and have passed their sports physicals with flying colors.

Episodes of sudden cardiac arrest are often confused with heart attacks. When Boston Celtics basketball star Reggie Lewis died of sudden cardiac arrest in 1993, for instance, many media outlets reported that he had suffered a massive heart attack.

In fact, heart attacks occur when the heart’s arteries are clogged with cholesterol, and they involve severe chest pain as blood supply to part of the heart muscle is blocked. Some experts describe heart attacks as a plumbing problem, and sudden cardiac arrest as an electrical problem.

In cases of sudden cardiac arrest, the normal electrical impulses that make the heart beat speed up dramatically or become chaotic. That phenomenon, known as arrhythmia, causes the heart to suddenly stop beating. Sudden cardiac arrest can be caused by a heart attack. But it can also be caused by a number of underlying structural abnormalities or genetic conditions that usually can’t be detected through routine physicals.

A frequent culprit is known as hypertrophic cardiomyopathy, a disease in which the heart muscle becomes abnormally thick. Other victims are born with arteries that are connected abnormally to the heart. Still others suffer from Long QT syndrome, a genetic disorder that can cause fast, chaotic heartbeats. Such conditions, combined with the adrenaline spikes that come with strenuous physical activity, can lead to arrhythmia and sudden death.

Working out in the Texas heat does not help matters. It can lead to dehydration, which can strain the heart and lead to arrhythmia and sudden cardiac arrest in susceptible individuals, notes Dr. Mark Peterman, Texas Health Presbyterian Hospital Plano’s medical director of cardiovascular services.

Non-athletes also at risk

Sudden cardiac arrest strikes males at least twice as often as it does females, says Dr. Hafiza Khan, a cardiac electrophysiologist with Arrhythmia Management, in Plano. And although it’s usually associated with competitive athletes, it can strike anyone.

Stacy Ettinger, of Dallas, is a living witness to this fact. In 2001, when Ettinger was 21, she began having what she calls “startling episodes” upon waking up in the morning. The alarm clock would startle her out of sleep, into a spell of shaking, sweating, and heart pounding that would last 20 to 30 seconds before subsiding.

The episodes worsened, giving way to seizures. Ettinger’s doctors at first suspected panic attacks. Then, thinking it was epilepsy, they put her on medication that failed to work. Finally, as epilepsy specialists monitored Ettinger over the course of a night at a hospital, they were stunned to find her heart rate beating erratically and swinging from a very slow rate to more than 200 beats per minute.

Ettinger was immediately transferred to an intensive care unit. Two years after symptoms began, she was diagnosed with Long QT syndrome and was fitted with an implanted device that has corrected the problem.

Today Ettinger works as a nurse practitioner at Children’s Medical Center in Dallas. She knows that she has cheated death dozens of times; somehow, her heart had regained its normal rhythm during each spell. “I was very lucky,” she says.

Preventing sudden cardiac arrest is something of a conundrum, because warning signs are often non-existent. Zac Schrah had never experienced symptoms like fainting or the sensation that his heart was racing without a reason. And there was no family history of heart trouble.

Would-be victims who have such warning signs should consider themselves lucky. Because it’s rare to survive sudden cardiac arrest, heeding them and getting diagnostic tests can be a lifesaver.

All families should be aware of their family health history, at least as far back as their grandparents, Khan says. Unexpected chest pain, shortness of breath or fainting during sports should be taken seriously.

“Fainting while exercising is definitely not normal,” Khan says. “It could be a first warning sign.”

Any of the warning signs should result in a trip to a pediatrician or family doctor, who should conduct a thorough check of pulses and listen for abnormal heart sounds.

The doctor may recommend an electrocardiograph, often referred to as an EKG, to determine whether an abnormal electrical pattern is present. The procedure is non-invasive: It involves placing electrodes on the chest, which pick up the minute electrical charges on the skin that result from heartbeats.

Beyond high school physicals

A precise tool for finding many structural abnormalities related to arrhythmia is an echocardiogram—an ultrasound of the heart. Like the EKG, it’s a non-invasive test. Echocardiograms produce two-dimensional images of sections of the heart, and are used to spot leaky heart valves, abnormal thickening or thinning of heart tissue and any other structural abnormalities.

How widespread echocardiograms should be is a matter of debate that centers around risk and cost. Schrah, who heads Living for Zachary, an educational organization set up in her son’s memory, says all high school athletes should get the most thorough screening—not just a routine physical.

“I don’t think the physicals are enough,” she says. “I don’t think EKGs are enough—there have to be more questions asked and more testing done.”

Cost is a barrier to the sophisticated tests that can detect conditions that can lead to sudden cardiac arrest. Testing can run into the four-figure range, and is usually not covered by insurance. Given the cost and the low overall likelihood of sudden cardiac arrest —just one in 1.5 million exercise sessions leads to an episode of heart failure that’s not related to blocked arteries—many argue that blanket testing of athletes doesn’t make sense.

 “Honestly, just putting AEDs [automated external defibrillators] in all athletic facilities is probably as  important, or more important than screening the athletes,” says Peterman, “just so you’re prepared when it does happen.”

Yet a battery of sophisticated tests that can detect the disorders that lead to sudden cardiac arrest is available. Through its Living for Zachary screening program, Heart Hospital Baylor Plano provides an EKG, an echocardiogram, and blood-pressure screening for just $100 for those age 13 through 22. (Call 1.800.4BAYLOR for an appointment.)
Needless to say, an individual’s positive test should prompt other family members to get tested as well.

It’s impossible to overstate the importance of having AEDs within close reach when an athlete collapses, doctors say. Every minute lost—running to the nurse’s office to get the AED, and back to the football field, for instance—slashes the odds of survival by 7 percent to 10 percent, according to the American Heart Association.

The machines, which cost about $1,500, guide users with clear audible instructions. The end result is a shock that puts the heart into a normal rhythm. “Anybody with any common sense can use one of these devices,” says Peterman. “You put the two patches on the chest and press go.”

Easy-to-use AEDs are one of many recent improvements in the treatment of sudden cardiac arrest. Implantable defibrillators and pacemakers are growing smaller, and the technology is better able to monitor heart rhythms. And during the past few years, hospitals have increasingly turned to hypothermia—deliberately cooling victims’ body temperature after a sudden cardiac arrest episode—to improve survival odds and limit neurological damage.

Life after diagnosis 

Survivors of sudden cardiac arrest can live a normal life with the help of treatment. Depending on patients’ underlying condition, they may be prescribed medication known as beta-blocker, which helps to block the effect of adrenaline on the heart. If that drug is not sufficient, an ICD—implantable cardioverter-defibrillator—is implanted in the chest.

ICDs, which are powered by batteries, are programmed to detect arrhythmia; once arrhythmia is found, the device delivers a shock that returns the heart to its normal rhythm. The shock is a powerful one—“It feels like being slugged,” as Peterman puts it. But being slugged is better than being dead.

Often, patients can resume physical exercise, Khan says. “Most of them can walk, bike or run,” she says.
 
But in many cases, returning to competitive sports is deemed unsafe. And the possibility of having to leave the football team, or the volleyball team, or the track team, some worry, can make athletes keep symptoms to themselves—putting their lives at risk.

Sports training staffs and coaches should let players know that they won’t be singled out if they report worrisome symptoms, says Peterman, who says that peer pressure—especially in football—concerns him.

 “Football culture definitely encourages the idea of toughness—don’t show any weakness to your coach or teammates,” says Peterman, who himself played high school football. “And that certainly puts these kids at risk.”

A year and a half after losing her son, Schrah estimates that she has addressed 2,000 people—football players, booster clubs, school counselors, and others—about sudden cardiac arrest. Through the screening program set up in her son’s name, doctors have evaluated 336 youths—and referred 35 of them for advanced diagnostics and follow-up care.

None of these things, Schrah knows, will bring back her son. But it may prevent the unthinkable from happening to one of Zac’s friends, to someone in the community, or even to a young person she has never met.

“I don’t want this to happen to another family,” Schrah says.

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