Pistol Pete Maravich may have possessed the highest scoring average in the history of college basketball, but his fatal heart attack after a pickup game at a Pasadena church was a classic case of death far more common in young American men than most people would like to believe, doctors say.
Preliminary autopsy results, released Wednesday afternoon, indicate that Maravich succumbed to a kind of early, apparently undetected, blockage of the arteries supplying blood to his heart, a common syndrome that increases eight-fold as a cause of death in men after they turn 35.
A Clean-Living Vegetarian
While sudden death among celebrity athletes like Maravich and runner Jim Fixx, who collapsed and died while jogging in 1984, attract national attention, cardiology experts agree such cases are far from rare. Rather, they are high-profile examples of a type of death that is as unsettlingly common as it is sudden and unexpected.
"My patients this morning were all asking me, 'What's going on?' " said Dr. Paul Thompson, a Brown University expert on sudden-death heart attacks, in a Wednesday telephone interview. "And I told them that I liken what happened to Maravich to being in the stock market.
"We believe exercise reduces the risk of (heart disease). We also think the stock market makes you money, but when you're putting your money down, you're taking a risk. You also take a risk while you're exercising.
"If you have only one hour to spend alive, you should go to bed, but if you have a lifetime of one hours, you don't want to spend it physically inactive. You buy stock because you accept the risk because you are looking for long-term gain. The same thing is true of exercise. You're looking for longevity."
Turning Point at 35
In fact, American Heart Assn. statistics indicate that age 35--not later demarcations like 50 or 65--may be the most telling turning point in increased risk of sudden heart attack deaths among American men.
In 1985, the last full year for which figures are available, men between 25 and 34 had suffered the most common type of catastrophic heart attack--myocardial infarction--at a rate of 2.9 seizures for every 100,000 men. But for men 35 to 44, the rate jumped to 23.9 per 100,000.
Nationwide, in 1985, only 618 men between 25 and 34 died of such heart attacks, while the death toll for those in the next decade of life increased to 3,738. Heart attacks in women in the same age brackets are rare. For recreational athletes 40 and older, said Dr. Jere Mitchell of the University of Texas Southwestern Medical Center in Dallas, this reality makes it all the more important to warm up carefully before exercise and to unfailingly engage in "warm-down" behavior after, in which loads on the heart are gradually--not suddenly--reduced.
"If you start suddenly, you can have an arrhythmia and if you suddenly stand still and stop, your heart vessels are still very dilated and you can have a drop in your blood pressure," said Mitchell, a former chairman of the heart association's task force on exercise and heart disease. "If you have any obstruction in your coronary arteries, that is when you can have a (catastrophic alteration in the heartbeat pattern and) sudden-death event."
While being in good physical condition and maintaining a regular exercise program continue to be seen as clear-cut advantages in preventing heart problems, medical experts emphasize that coronary artery disease and its often sudden, fatal consequences can occur in active and former world-class athletes as easily as in ordinary people. For people Maravich's age, sudden death is the most common first sign of heart disease.
"We know that professional sports certainly does not immunize a person from coronary artery disease," said Dr. Ronald McKenzie of Centinela Hospital in Inglewood. "There are risk factors that professional athletes share with the general population. One of them is simply being male."
Maravich had been resting at court side when the four-on-four pickup game stopped, according to Jim Dobson, another player.
'I Feel Great'
"I asked how he was feeling," Dobson said, "He said, 'I feel great.' He turned around, took one step and he fell and hit the ground hard and never moved. It was like the sound of flesh against a hard floor."
As Maravich may have done, potential victims often deny, even to themselves, that warning signs are anything to worry about. Those signals could lead to the early diagnosis of a problem.
In Maravich's case, it was a mysterious shoulder pain, he told friends, that had sometimes been so intense he could hardly move his arm, Dobson said. Maravich told him it was neuritis--a type of inflammation. Back home in Covington, La., Maravich mentioned it several weeks ago to his physician, Dr. William Mitchell, but apparently also told Mitchell the pain had gone away. "Born-again" Christians both, Mitchell and Maravich often jogged together in Covington. "We may never know the actual cause of death," Mitchell said. "But Pete was a committed Christian and he has gone to his heavenly reward. We know that."
Mitchell said he never evaluated the shoulder problem because Maravich insisted the pain had disappeared. A physical about a year ago in which Mitchell administered an electrocardiogram and standard tests for high blood pressure and elevated blood cholesterol levels found him to be healthy.
Maravich didn't use drugs of any kind, Mitchell said. He had specifically reviewed Maravich's family medical history and examined his patient to make sure the 6-foot-5 athlete didn't have Marfan Syndrome, an inherited disorder common to tall people that makes the joints and the tissue of the heart dangerously prone to sudden failure.
But cardiology experts agreed that such apparently spotless medical records are common in people who later turn out to have been developing potentially catastrophic heart disease for as long as several years. They escape detection precisely because they appear to be so healthy.
The Smaller Arteries
Looking back on it, said Dr. George Beller of the University of Virginia, the apparently fleeting shoulder pain could have been an early warning of a heart whose coronary arteries--not the large vessels that carry blood to and from the heart but the smaller arteries that supply blood to the heart muscle itself--were diseased.
Attributing such pain to minor injuries or some cause other than one that is heart-related is classically normal, fatally common, human behavior, Beller said. "Most often, people with silent coronary artery disease also have periods where they do have symptoms. It's unusual to have (cases) that are totally without pain," Beller said.
"Patients who have recurrent shoulder or arm pain could have heart involvement even if the pain does not include the chest. So Maravich may have misinterpreted it as bursitis or neuritis. There are individuals who use a defense mechanism of denial quite frequently in this regard. One cannot always be sure a person who died suddenly was not having some symptoms but was either denying them or misinterpreting them."
Mitchell said he hadn't given Maravich a stress electrocardiogram test, in which the subject walks on a treadmill while instruments monitor the performance of the heart. Such tests are the only reliable first line means of diagnosing hidden cardiac disease of the type Maravich turned out to have. But in patients--like Maravich, Mitchell said--with no history of heart attacks in close relatives, experts agree stress tests seldom seem necessary for people as young as Maravich.
The way the narrowing of the arteries becomes lethal, experts questioned by The Times agreed, is by gradually interfering with the blood flow to the heart muscle, steadily increasing the risk of a sudden heart failure that is signaled by a change in the electrical system of the heart that controls the beating sequence. But the closure of the arteries can bring about sudden failure of the electrical sequence, commonly leading to ventricular fibrillation, a rhythm disturbance in which the heart's natural beating action is lost and the heart muscle, instead of pumping in an orderly manner, merely quivers without effect.
Ventricular fibrillation can also occur in the absence of damage to the coronary arteries, in cases in which factors still not clearly understood spontaneously bring on electrical failure.
Jolts of Electricity
Cardiopulmonary resuscitation--which was attempted on Maravich by Dobson and another of the basketball players--seldom is effective in saving the lives of people who collapse with such sudden electrical failures. They can sometimes be saved by jolts of electricity from defibrillators, but the shocks have to be administered almost immediately.
Pasadena Fire Department records indicate that while the response of fire units to the Church of the Nazarene where Maravich collapsed was good, it was several minutes after the heart attack before paramedics arrived with the appropriate equipment.
"Lots of things can lead to narrowing of the arteries," said Brown's Thompson, who is also a cardiologist at Miriam Hospital in Providence, R.I. "One of the main things is that you don't want to be normal or average in America. Because if you are average here, you probably have cholesterol levels that are actually far too high and arterial damage that begins by age 45 at the latest."
Beller said he recomments that people 35 to 40 have a stress test if there is a strong family history of heart disease, if they are smokers or if there is a history of high blood cholesterol levels or blood pressure. Maravich had none of those risk factors, Mitchell said, so he became an imponderable from his doctor's perspective.
"I think in people with no risk factors and no family history, the cost-benefit ratio of a stress test is probably low," Beller said. "You end up with more false positives than you would like." But through this net, people like Maravich can slip.