Before the race, Lobo Lui Hun-tak, associate dean of the School of Health and Physical Education at the Education University of Hong Kong, said the risk of death among marathon runners was about one in 100,000, most of which were related to hidden congenital heart conditions.
Chinese badminton players and coaches, wearing white jackets and black armbands, pray together for the late Chinese player Zhang Zhijie along with all the players competing in the 2024 Badminton Asian Junior Championships in Yogyakarta, Indonesia on July 1, 2024. Photo: AFP
According to the Mayo Clinic in the US, the leading cause of death in young athletes is sudden cardiac arrest – the sudden loss of all heart activity due to an irregular heartbeat.
It is estimated that 1 in 50,000 to 100,000 young athletes die from sudden cardiac death each year, compared with approximately 1 in 1,000 in the general population each year.
A 2012 report in the journal Circulation found that, on average, an athlete in the United States suffers sudden cardiac death every three days.
Dr Miles Chan, a cardiology specialist and honorary associate professor at the School of Medical Therapy at the Chinese University of Hong Kong, said that although sudden death can be due to neurological causes such as cerebral hemorrhage, most sudden deaths are cardiac-related.
Causes of sudden cardiac death vary by age, and are more common among older people and those with underlying heart disease, he said. It rarely occurs in healthy people under 40. But it is the leading cause of death in athletes, and is more common in men than women, he said.
In many cases, the cause is structural heart disease or a previously undiagnosed congenital abnormality.
Dr Miles Chan is a cardiology specialist and Honorary Associate Professor in the School of Medical Therapy at the Chinese University of Hong Kong. Photo: Chinese University of Hong Kong
Dr Boon Lim is a London-based cardiologist and electrophysiologist who specialises in diagnosing and treating problems with the heart's electrical system. Dr Lim says it's important to recognise a family history of early, sudden death, typically of unknown cause, in family members, even if it happened while sleeping and not during sport.
Lim said the deaths could be due to inherited electrical abnormalities called channelopathies, or disorders of proteins responsible for controlling the flow of ions such as potassium and sodium through heart cells.
These include Brugada syndrome, a genetic disorder that increases the risk of arrhythmia, and long QT syndrome, a heart rhythm disorder that causes fast, irregular heartbeats and can be life-threatening.
Chang warns that even healthy people with no obvious heart defects can go into cardiac arrest due to electrolyte abnormalities or blunt chest trauma, a condition called commotio cordis. This rare heart rhythm disturbance occurs as a result of a blow to the area directly above the heart at a critical moment in the cardiac cycle. If not treated within minutes, it can be fatal.
Chan said such situations could occur in high-speed, high-impact collisions on sports fields.
Italian law requires all competitive athletes to undergo an annual pre-participation evaluation to identify cardiovascular diseases that pose a risk of sudden death during competition. Photo: Shutterstock
Should seemingly healthy young athletes also be tested regularly?
The issue is controversial, says Chan, and there is currently no useful consensus or guidelines on how to screen young athletes for heart disease.
“Testing all athletes may not be cost-effective and may result in false-positive test results,” Chan said. This could raise unnecessary concerns and lead to more expensive and unnecessary testing. He added that routine screening is not common in most countries around the world.
Lim agrees: “There is still debate about pre-testing for sporting events, particularly in semi-professional and amateur competitions where large numbers of athletes take part and the costs and logistics of providing testing could be prohibitively high.”
Dr Boon Lim is a London-based cardiologist and electrophysiologist. Photo: Dr Boon Lim
But screening is becoming more common after a large study from Italy suggested that sports could cause sudden death in athletes “with pre-existing cardiovascular disease that predisposes them to life-threatening ventricular arrhythmias during exercise.”
Italian law requires all athletes taking part in competitive sports to undergo an annual pre-participation evaluation to identify cardiovascular diseases that pose a risk of sudden death during sport, as well as other conditions that may threaten the athlete's health.
In a study of 5,910 seemingly healthy young athletes in the country, the assessment found that 2% of athletes had a range of illnesses: 1.5% had cardiovascular-related illnesses and 0.5% had non-cardiovascular-related illnesses.
In total, 32 athletes (0.5%) were temporarily or permanently disqualified from competition, which could have potentially saved their lives. The tests cost approximately 79 euros (87 US dollars) per athlete.
Even without pre-screening, Chan said some tragedies could be avoided and lives saved. If an athlete goes into cardiac arrest, he said, cardiopulmonary resuscitation (CPR) and the use of an AED (automated external defibrillator) should be administered immediately.
“This should be available in any competitive sporting setting,” he said, adding that the AED automatically detects arrhythmia and delivers a shock to the patient to help the heart beat normally again.
This proved to be a lifesaver for Danish midfielder Christian Eriksen, who went into cardiac arrest while playing for Denmark at the Euro 2020 football tournament in June 2021.
The team captain began CPR and medical staff continued treatment with the help of an AED. The footballer, who was 29 at the time, has since made a full recovery.
Chan says AEDs should be available in all competitive sports arenas. Photo: Shutterstock
According to the American Heart Association, the survival rate of people who suffer cardiac arrest outside of a hospital nearly doubles when an AED is used in conjunction with CPR. CPR helps keep blood flowing, and an AED ensures proper heart rhythm.
Athletes of all ages should know their family history: If they have relatives who have suffered sudden cardiac death or have symptoms that could suggest an underlying cardiac problem, such as fainting, brief loss of consciousness, unusual shortness of breath or chest pain, “these are the people who would benefit most from a more comprehensive evaluation,” says Chan.
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