Gathers: Lesson of the Heart : Sudden Death: More people die of heart-rhythm disorders than cancer. Finding and treating high-risk individuals is a priority for the ‘90s.
If any good is to come out of the Hank Gathers tragedy, it will be in helping to prevent such a premature ending to other lives, whether young or old.
The problem of sudden and unexpected death caused by cardiac arrhythmias is a huge public-health issue. The American Heart Assn. estimates that 400,000 Americans will die this year in the United States of a lethal heart-rhythm disorder--more than will die of cancer and roughly half of the 700,000 annual deaths from cardiovascular causes.
Yet the American public knows little about sudden death and, to some extent, that is also true within the medical profession.
Which types of structural heart disease--disease of the heart muscle and coronary arteries--are most commonly associated with serious heart rhythms? Most such conditions are diseases of men and women more than 35 years of age and not of young athletes. By far the most common cause of sudden death over age 35 is coronary artery disease. In patients dying suddenly under age 35, congenital heart disease--heart disease present from birth--is the most common cause.
Which are the high-risk groups of patients? Experts estimate that approximately 25% of all patients experiencing a heart attack--which doctors call a myocardial infarction, usually caused by a clot in the narrowed coronary artery--have sudden death as their first and only symptom. In retrospect, such patients have often had vague complaints but were unaware of any heart trouble until they abruptly fibrillated and died. This group numbers hundreds of thousands of patients a year. A typical victim is the 45-year-old jogger who keels over on his Saturday morning run and dies.
We cannot yet specifically screen this group of patients in terms of sudden-death risk. The best we can do is screen for risk factors associated with early coronary disease, including high cholesterol, cigarette smoking and high blood pressure. We know that if we can lower or eliminate coronary disease, the risk of sudden death will be lowered as well. Large numbers of people without symptoms--asymptomatic individuals--must be screened if we are to identify a sizable high-risk population, much less prevent any but a few sudden deaths. More specific non-invasive screening and preventive techniques for sudden death are necessary to help this large population of completely asymptomatic patients. Although sudden death rates in this group are falling, much remains to be done.
Groups with a statistical risk of sudden death, higher than among the asymptomatic people, have been clearly identified over the past decade. A patient who experienced a prior heart attack has a 6% risk of death in the first year of recovery; half these deaths are sudden. The risk of death rises steeply if the heart attack was large or associated with serious ventricular rhythm disorders. Former Commissioner of Baseball A. Bartlett Giamatti was such a sudden-death victim.
Most cardiologists aggressively screen patients after a heart attack for both serious arrhythmias and extensive muscle damage, using a combination of invasive and non-invasive testing to identify the high-risk patient. Considerable controversy still exists, however, about which treatment is best to prevent subsequent sudden death. Large population studies, such as the highly publicized Cardiac Arrhythmia Suppression Trial (CAST), help teach us which medicines, if any, best control abnormal heart rhythm.
The highest-risk patients are those who have survived a previous cardiac arrest or have required an electrical cardioversion. Patient groups with up to a 40% one-year risk of recurrent cardiac arrest can be identified. Such patients are aggressively treated in most centers with implantable defibrillators or open-heart procedures to correct the arrhythmia. Most progress of the last decade has been made with such patients. If appropriately treated, such patients can have their one-year risk of sudden death reduced to about 1%. While highly visible, this patient group nonetheless represents only a small percentage of the total number who will die suddenly this year.
Other heart conditions associated with an increased incidence of sudden death include cardiomyopathy, mitral valve prolapse, the Wolff-Parkinson-White (WPW) syndrome and the long-QT syndrome. The latter two conditions are rare, although of great interest to cardiologists as models of electrical short-circuits in the heart. Mitral valve prolapse is commonly diagnosed but rarely causes sudden death. Cardiomyopathy, or primary heart muscle disease, is usually acquired following a virus infection. Hank Gathers’ post-mortem examination showed such a diffuse cardiomyopathy.
About half the athletes who die suddenly have a different kind of muscle disease called a hypertrophic cardiomyopathy. Such hearts are always thick and “muscle-bound,” either in part or all of the cardiac structure. However, such a condition does not spell a potential episode of sudden death unless coupled with a serious ventricular rhythm disturbance.
There is no agreement on how to screen young athletes for potential risk of sudden death if they are truly asymptomatic. Mass screening programs involving physician examinations and non-invasive testing are not cost-effective. As many as 200,000 asymptomatic competitive athletes under 30 need to be thoroughly screened to identify one potential sudden death victim.
In many ways, the Gathers case is typical of what we know about the sudden-death victim. He had a history of a skipping, rapid pulse. He had blacked out during a basketball game in December but quickly revived. Such a symptom is a red flag of concern in any age group.
Subsequent testing by experts in heart-rhythm disorders identified irregular beats originating from the lower portion of his heart as the cause of the blackout. He was given specific medication to treat the irregular rhythm; there was an implication that if he took the medication he would be protected from serious problems. The medicine, a beta blocker, slowed his enormous talents--and he may have cut back on the drug. He then collapsed during a game in March and could not be resuscitated. The triad--loss of consciousness in the presence of serious extra heart beats and known muscle damage--identified him as being at high risk, no matter what his age group or underlying cardiac diagnosis.
The other cornerstone of sudden-death prevention--in addition to detection and treatment of the high-risk patient--is cardiopulmonary resuscitation--CPR. The American Heart Assn. and Red Cross teach thousands of volunteers each year how to perform CPR. Citizen CPR in conjunction with a rapid-response paramedic system can successfully resuscitate a high percentage of patients who collapse from cardiac arrhythmias. In cities such as Seattle and Miami, where paramedics respond quickly and half the citizenry knows CPR, up to 30% of sudden-death victims will be resuscitated and eventually discharged from the hospital.
Sadly, resuscitation did not occur in the gymnasium when Hank Gathers had his serious arrhythmia. Such missed opportunities are repeated in shopping malls, city streets and homes of heart patients 1,000 times each day in this country.
The next decade will see cardiologists further cut the sudden-death toll. More patients with the combination of serious arrhythmias, symptoms and known heart disease will be referred for treatment. More effective, less-toxic medications will be developed. Better implantable devices will be perfected. Large population studies will tell us which patients need the most aggressive treatment and which need only reassurance. More citizens will learn and practice CPR, perhaps in a simpler form.
If Gathers’ death has helped alert us to the scope of the problem and its prevention, then the tragedy will have served some human purpose.
