The sudden deaths of young sportmen raises the question of widespread cardiac screening, writes Dr Charles Daly.
A FEW WEEKS ago a father brought in his teenage son, a keen athlete who was about to take part in an important race, to be examined and deemed fit to proceed. At the time, newspapers were full of reports of sudden fatalities in young sportsmen around the country and I remembered some high-profile tragic deaths in recent years. They included Cormac McAnallen, the Tyrone GAA captain, who died from previously undiagnosed cardiac illness; footballers Marc-Vivien Foe of Cameroon and, in January of this year, Phil O'Donnell of Motherwell, both of whom died on the soccer pitch from what was described as heart failure.
I examined the lad, who seemed quite normal, and asked about a family history of sudden or premature death, which was negative. Just to be thorough (or to appear to be so), I did an ECG on the boy, which was also normal. I explained to the boy and his father that, within the confines of my necessarily limited examination, there was no reason why he should not continue his training. They seemed reassured, but I wondered to myself how far should one go in screening apparently normal adolescent athletes for potentially lethal cardiac conditions.
A few days later I met, socially, a London cardiologist who has made a life-long study of sudden adult death, especially its genetic aspects, in determining how to identify who is at risk. When I asked his advice on my recent dilemma, he told me that, in his opinion, if examination is normal, if there is no family history of sudden death and if an ECG is normal, such a patient has a far greater chance of being knocked down by a bus than of dying suddenly. This was very reassuring to hear!
Sudden death in sport has been known since ancient times, when in 490BC the unfortunate Pheidippides ran 26 miles from the battle of Marathon to Athens with news of the Greeks' victory over the Persians, and promptly dropped dead. It's unlikely that a post-mortem was done, but if it had been, it is possible that a condition known as hypertrophic cardiomyopathy (HCM) might have been responsible for his untimely demise.
In HCM, abnormal overgrowth of the left ventricle can interfere with cardiac function by impairing normal blood.
It commonly presents during the teens and twenties, may cause no or few symptoms and is often picked up incidentally. It is the most common cause of sudden cardiac death in young athletes and is the most common familial genetic disease of the heart.
To what extent should children be screened, if at all, for HCM? It makes sense to screen close family members of someone with confirmed HCM who has died suddenly, but even normal findings are no guarantee that they will not be at risk of a similar fate.
Many sports clubs have acquired defibrillators and athletes, players, trainers and back-up staff are becoming familiar with basic resuscitation procedures. This is a good thing in the acute situation and has been shown to save lives, but the value of widespread screening of all athletes for potentially lethal cardiac abnormalities is open to question.
In an emotive area such as sudden death in sport, it is difficult to discuss these matters in terms of a cost-benefit equation - as in how many screening procedures must be carried out before one significant abnormality is discovered.
The problem is how to decide what is significant and what is not. Health spending is not infinite - widespread screening of this type would inevitably take resources away from other worthy causes.
We are constantly encouraging youngsters to take part in sport and athletics, and this is becoming more and more critical in the couch-potato era where many children spend more time at television and computers than in physical activity and are at greater risk of obesity, diabetes and hypertension than ever before.
It would be a shame if poorly thought-out, over-zealous cardiovascular screening would spawn a generation of young cardiac neurotics who may end up returning to the sedentary life we are desperately trying to discourage.
Dr Charles Daly is a GP in Co Waterford