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How an athlete’s heart is cared for to avoid the dreaded sudden deaths

21 Dec 2023   ·   

On 11 November, the football industry was gripped with fear and uncertainty. The 28-year-old Ghanaian player Raphael Dwamena died in the middle of an Albanian Super League match while playing for K.S. Egnatia due to a heart condition he had been diagnosed with in 2017. The news of his sad death sparked a scientific, technological and ethical debate due to information revealed by cardiologist Antonio Asso who treated him during his time at Real Zaragoza in the 2019/2020 season. The specialist doctor from the Miguel Servet Hospital Cardiology Service and the Quirónsalud Arrhythmia Institute claimed that the international player had disobeyed his advice and removed a defibrillator in Switzerland that had been implanted during his time at La Romareda.

Dwamena suffered from a life-threatening cardiac arrhythmia. “We were able to convince him of the urgent need to have a defibrillator implanted to at least guarantee his life, while at the same time discouraging him from playing professional sports. I insisted that as the disease evolved, at some point we could address the origin of the arrhythmia by means of an ablation intervention, but that required him to be kept alive, and for that the defibrillator was essential,” explained Asso in a letter published in El Heraldo de Aragón on 14 November.

A defibrillator implanted in a patient’s heart is a device capable of detecting an unusual heart rhythm called an arrhythmia. When the device, about the size of a watch, senses the abnormal rhythm, it produces an electrical shock that restores the heart to a normal pulse, saving the patient’s life. Dwamena, due to religious beliefs and his decision to continue his professional career, had the device removed. “A couple of years ago, I was told that the defibrillator had saved his life when he had a malignant arrhythmia that had been correctly and automatically treated by the device. We had subsequently lost contact. A year ago I learned from the press that he had requested the removal of the defibrillator implanted by us and that it had finally been explanted (I think in Switzerland). It was too late, his decision was irrevocable and he placed all his responsibility on himself and on the will of the God he believed in. From that moment on I was aware that one day the tragedy that took place on Saturday on a football pitch in Albania would happen,” Asso explained in his letter.

This event leads us to wonder how the heart of athletes is prevented and cared for in professional football clubs. María Sanz de la Garza, a cardiologist at the Hospital Clinic in Barcelona, is in charge of cardiovascular assessment prior to sports practice at Futbol Club Barcelona and the Blume Residence (a high-performance sports centre). As coordinator and teacher, she teaches the certificate in Sports Cardiology at the Barça Innovation Hub.

“The European recommendations regarding cardiovascular assessment prior to sports practice recommend that all competitive athletes should undergo an assessment that includes a detailed medical history and physical examination and an electrocardiogram. In this regard, in 2013 a consensus document was drawn up for the homogenization of the preparticipation screening within the scope of Catalonia, which is the one we follow in our daily practice,” explains Sanz de la Garza. For a higher level of athletes, the cardiology experts in Catalonia who work with FC Barcelona, the Sant Cugat High Performance Center and the Joaquín Blume Residence, add more tests for “advanced screening”.

 

FCB player undergoing medical tests

 

“In elite professional athletes, those who do highly demanding sports such as triathletes and master athletes (over 35 years of age), an echocardiogram and a maximal stress test are added, that is to say that the athlete reaches exhaustion. It is a 100% stress test that we perform in a laboratory,” he adds. “In the sports field, we are using more and more devices adapted for inhalation monitoring of the echocardiogram during exercise. This monitoring is very useful because it allows us to evaluate the echocardiogram in real life of the athlete, during training and competitions. This is especially interesting in sports with abrupt start-up and/or acceleration situations such as soccer, in which conventional stress tests are unable to simulate this sporting stimulus,” exemplifies the cardiologist.

The echocardiogram allows us to observe the cardiac structure of the athlete in terms of dimensions and functionality and also how the valves function with the different flows. In the case of documenting with these initial tests any alteration that makes us suspect a cardiac pathology, we request additional complementary tests such as a cardiac RN, a Holter ECG, an exercise echocardiogram or a coronary CAT scan based on the diagnostic suspicion. The preparticipatory screening aims to identify early cardiac pathologies potentially causing sudden death in order to advise the patient depending on the documented pathology. In some cases we will be able to treat the pathology effectively and the athlete will be able to continue practicing sports, as in the case of Wolff Parkinson White Syndrome, which is solved by ablation of the accessory pathway, and in others it will be necessary to decide, based on the pathology and its evolution, whether the athlete can continue competing at a high level or whether this means an unacceptable risk. In addition, screening allows us to monitor the impact of competitive sport on “minor” cardiac pathologies that at the time they are diagnosed do not pose a risk to the athlete but which we must follow closely and assess their evolution.

The development of protocols and tests to detect possible pathologies has advanced in recent decades, often associated with bad news. Since the sudden death of Sevilla FC player Antonio Puerta in 2007, FIFA began to implement prevention and research measures such as mandatory screening. Despite the social impact of the cases, experts assure that statistics do not show an increase in cases of sudden death in athletes. In fact, the incidence of sudden death has decreased as a result of a combination of early detection of cardiac pathologies potentially causing sudden death through screening and also better field assistance in the events that occur.

The erroneous perception that cases may have increased is also due to the fact that in the general population, outside the statistics among athletes, we are seeing a progressive increase in the incidence of acute myocardial infarction in people under 35 years of age, a population traditionally considered “immune” to this pathology, with a deterioration in healthy lifestyle habits being the most likely cause of this effect. Another interesting statistic is the sex-dependent variation. Several hypotheses have been suggested to explain this difference, among which the protective effect of estrogens and the lower adrenergic tone of women stand out,” explains Dr. Sanz de la Garza.

The periodicity of the preparticipation screening will depend on the age of the athlete and his or her competitive level. In the case of professional athletes it is done annually. However, throughout the season the athlete is in close contact with the sports doctor, nutritionist and physiotherapist in charge. They, as well as their coach, are aware of the alarm symptoms that should make them request a cardiological evaluation, such as: chest pain, palpitations, unjustified shortness of breath, dizziness or loss of consciousness, especially when these symptoms occur during sports practice. This close contact that allows the medical team and the trainer to have an evolutionary vision of the athlete is what will allow an early detection of these symptoms that can sometimes be mistakenly considered by the athlete as just another sensation associated with high-intensity sport.

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