Sudden Cardiac Death: Signs Often Go Unheeded

The fatal frenzy of the heart that on Sunday apparently killed college basketball star Hank Gathers takes the lives of about 400,000 Americans each year. Experts say one reason may be that physicians as well as patients underestimate early warning signs that could lead to sudden cardiac death.

Those warning signs--such as blackouts and heart palpitations reflecting an invisible defect in a person’s heart--can now be explored using various new techniques, and may be effectively treated to prevent the development of something worse.

But some physicians are unaware of the seriousness of those signs and the importance of getting patients to specialized centers for screening, experts say. And some patients, particularly athletes, resist taking drugs that can impair their performance.

“We’re very steamed about this issue, because there are so many cases of this around,” said Dr. David S. Cannom, director of cardiology at the Hospital of the Good Samaritan and co-chairman of a group called the Coalition for the Prevention of Sudden Death.

“There are still well-meaning people that don’t realize the potential risk to the patient,” Cannom said.

Nevertheless, cardiologists said Monday that it can be difficult to assess precisely the degree of risk a person faces from a heart abnormality. And it is a rare case in which a physician can tell a patient absolutely what exercise to do and not to do.

They also emphasized that sudden cardiac death occurs only in people with diseased or damaged hearts. There is no evidence, they stressed, that exercise poses any risk to people with normal, healthy hearts.

Gathers, 23, the sixth-leading collegiate basketball scorer in the country, died Sunday after collapsing during the first half of the Lions’ West Coast Conference tournament semifinal game between his school, Loyola Marymount, and the University of Portland.

The precise cause of Gathers’ death was not known Monday. The Los Angeles County coroner’s office performed an autopsy Monday afternoon, but no results were to be released for at least several days pending completion of toxicological tests and tissue studies.

However, Gathers was known to have had so-called cardiac arrhythmia, an abnormality of the rhythm or rate of the heartbeat. The condition had been diagnosed during tests performed in December after Gathers passed out during a basketball game.

Arrhythmia, caused by a disturbance in the electrical impulses to the heart, can lead to cardiac arrest. It is often related to structural defects in the heart, either congenital or acquired through disease.

In interviews Monday, cardiologists said sudden cardiac death occurs most frequently in older men with heart disease. But perhaps one in 10 cases occurs in people under age 30, many of whom have had no previous indication that anything was wrong with their heart.

Approximately 10 to 20 young athletes succumb each year to sudden cardiac death, said Dr. Steven Van Camp of San Diego, who has been studying such cases. Almost invariably, he said, an autopsy turns up some sort of defect or disease in the heart.

“We have no evidence that exercise damages the healthy heart,” said Van Camp, vice president of the American College of Sports Medicine. “But if people have significant heart disease, then exercise can present an increased risk.”

“Of the millions of apparently healthy athletes in this country, all but a handful are fully able to compete,” Van Camp said. “The issue is how to find the handful who are at greatest risk.”

One tip-off can be difficulties brought on by exercise--an unusual shortness of breath, chest discomfort, irregular heart rhythms or blackout spells. People who experience those symptoms should be evaluated carefully to assess their degree of risk, specialists say.

Such an evaluation might involve monitoring the patient’s heart during treadmill exercising, examining the heart’s structure using ultrasound and recording with an electrocardiogram the electrical impulses that precede contraction of the heart muscle.

If necessary, additional tests can be done to pinpoint the cause of an abnormal rhythm, Cannom said. Those include an angiogram to look for evidence of coronary artery disease, a biopsy of heart muscle tissue for infection, and other more elaborate procedures.

Using those tools, it is now possible to estimate whether a patient is at low or high risk of cardiac arrest and sudden death, Cannom said. Patients, physicians and families must then decide how aggressively they wish to treat the condition.

The choices include anti-arrhythmic drugs, which suppress the excitability of the heart, and a device called a defibrillator, which can be implanted in a person’s chest to shock the failing heart back into normal rhythm when it goes awry.

“Some may decide that it’s a one-in-100 risk (of cardiac arrest) and they’ll live with it,” Cannom said. “Some will decide it’s one in 20 and not to live with it and to have a defibrillator put in.”

Unfortunately, each treatment has drawbacks. A defibrillator can cost $50,000 to install and there can be complications. Anti-arrhythmic drugs can lower blood pressure, decrease heart rate and affect performance.

“Young people often are not compliant with their medication,” Van Camp said. “And athletes especially may be reluctant to take medications which they feel are affecting their performance, especially if they have been doing well for some period of time.”

Gathers, who began taking anti-arrhythmic drugs after his blackout in December, appeared lethargic initially and blamed the medication. Friends said Sunday night that Gathers had reduced his dosage or stopped taking medication altogether.

It is often unclear how much to restrict a patient, physicians said.

“The concept is: How much smoke is there?” said one specialist who asked not to be named. “There are some very clear-cut cases in which people are restricted, and other cases in which they are not at high risk. Then there is a whole spectrum in between.

“Then, if they are found to have abnormalities, and they are on medication, the issue is (whether) the medication is controlling the abnormality well enough, and will the patient take the medication,” the specialist said.

Furthermore, an underlying abnormality in the heart may not be the whole story.

Dr. Thomas N. James, president of the University of Texas Medical Branch at Galveston and a cardiologist who has studied sudden death and cardiac function among athletes, said sudden cardiac death is more often attributable to several factors.

PATH OF A HEARTBEAT

There are many types of abnormal heart rhythms, or arrhythmias. Some--occasional skipped heart beat--do not interfere with daily activities. Others--very rapid or very slow heart beats--can cause lightheadedness or fainting. Extremely abnormal rhythms prevent the heart from pumping blood and are often fatal.

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