When Danish midfielder Christian Eriksen collapsed on the field during the recent Euro cup playoffs, the hearts of thousands of football fans must have surely missed a beat. One moment he was racing down the field and the next minute, he collapsed on the grass in Copenhagen during the UEFA Euro 2020 match against Finland. The swift, composed and effective actions of the team and the stadium doctor were in stark contrast to the expressions of worry, grief and fear the fans and fellow team members wore on their faces.
Christian had clearly not been pushed, shoved or kicked. There was no foul play. So, what had happened to the 29-year-old footballer? Why did he collapse while playing a major championship?
The Danish national football association informed the media that the Danish midfielder had suffered a cardiac attack and has since undergone a successful medical procedure where he was fitted with an ICD. An ICD or Implantable Cardioverter-Defibrillator is a device surgically placed in the chest and helps detect irregular heartbeats and monitor heart-rhythm.
Dr Adam Mather, consultant interventional cardiologist at Mediclinic City Hospital believes that, even though the incidence of heart attacks increases with age as coronary artery disease is an age-related disease, it is not uncommon for patients in their twenties to present with heart attacks.
"In those below 35 years of age, sudden cardiac death (SCD) is mainly due to congenital/inherited cardiac abnormalities, while coronary artery disease (CAD) leading to heart attacks, is the most common cause in older patients," he says.
Incidentally, Christian is not the only young athlete to have suffered a cardiac condition while on the field.
Fabrice Muamba, 23 at the time and currently retired, was a central midfielder with Bolton Wanderers, who collapsed during an FA Cup match against Tottenham Hotspur. Muamba was treated on the field before being rushed to hospital. It was reported that his heart stopped beating for 73 minutes.
Closer home, Sourav Ganguly, 48, the current president of the Board of Control for Cricket in India, was reported to have at least three blocked coronary arteries and had to undergo angioplasty despite having led an active life till his retirement.
Hank Mathers, a star American basketball player at Loyola Marymount University collapsed during a game and was later diagnosed with abnormal heartbeat. Self-reducing the dosages of his prescribed medication as he believed the drugs affected his performance, he resumed playing again but he collapsed again during another game and died shortly afterward at the age of 23.
A 2017 Reuters report said Italian researchers believed that some Olympic athletes may be at risk while training and competing because of heart defects that they may be unaware about. To underscore the report, about 4 per cent of Italian athletes who were studied over a 10-year period, displayed cardiovascular disorders – a higher proportion than researchers expected to find.
With so many athletes suffering from various heart defects at a young age, the question on top of people’s minds is: how common are heart conditions among seemingly fit and active youth?
"Although the health benefits of physical activity are undisputed, somewhat paradoxically, vigorous exertion may transiently increase the risk of acute cardiac events," says Dr Mather, who has several published research articles and is an international opinion leader in the field.
Excerpts from an interview:
First, can you define heart attack and cardiac arrest?
Heart attacks occur because a blood clot blocks an artery supplying blood to the heart (coronary artery). This will result in the patient experiencing chest pain (angina).
A cardiac arrest refers to the condition when the heart actually stops beating. This abrupt loss of heart function leads to cessation of breathing, loss of consciousness and, if not treated immediately, will cause sudden death.
Although sudden cardiac arrest is not the same as a heart attack, a heart attack can sometimes trigger an electrical imbalance in the heart, which will cause a cardiac arrest.
Survival from cardiac arrest is possible with fast, appropriate medical care. Cardiopulmonary resuscitation (CPR), using a defibrillator, or just effective chest compressions and rescue breathing, can save lives.
How common is heart attack among the youth worldwide? What is the youngest age that one can suffer from a heart attack/cardiac arrest?
According to the World Health Organisation figures, cardiovascular diseases (CVDs) are the leading cause of death globally. An estimated 17.9 million people died from CVDs in 2019 – 32 per cent of all global deaths. Of these, 85 per cent were due to heart attacks and strokes. Out of the 17 million premature deaths (under the age of 70) due to non-communicable diseases in 2019, 38 per cent were caused by CVDs.
In the UAE too, CVDs remain the leading cause of death.
The incidence of heart attacks increases with age as coronary artery disease is an age-related condition. However, it is not uncommon for patients in their 20s to present with heart attacks. These patients tend to be males, smokers and those with a family history of premature heart disease.
Are any ethnicities or genders at a higher risk/prone to suffering from a heart condition?
The prevalence of heart disease is higher in males than females. Ethnicity can also increase risk of developing heart and circulatory diseases. For example, South Asian, African or African Caribbean people have a higher risk of developing cardiovascular disease than white Europeans.
Why are young people, especially those who are seemingly in good health like the Danish footballer Christian Eriksen, prone to suffering from cardiac conditions?
In the young (below 35 years), sudden cardiac death (SCD) is mainly due to congenital/inherited cardiac abnormalities, whilst coronary artery disease (CAD) leading to heart attacks, is the most common cause in older patients.
In general, the risk of SCD approximately doubles during physical activity and is two- to three-fold higher in athletes compared to non-athletes.
Nevertheless, the incidence of SCD in young athletes is in fact very low, at around one to three cases per 100,000.
However, such cases attract much public attention, as we have seen recently with Christian Eriksen.
At what age and how frequently would you recommend people to get a full health check done?
In the UAE, the average age of a patient presenting with their first heart attack is 52. This is more than 10 years earlier than similar patients in western Europe. As we know, prevention is better than cure, so it is important to identify risk factors for heart disease early so that management with lifestyle advice and medical therapy (if needed) can be initiated.
Most cardiovascular diseases can be prevented by addressing behavioral risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity and harmful use of alcohol. However, it is also important to check blood pressure, blood glucose and cholesterol levels, as these are major risk factors for coronary artery disease and are usually not associated with any symptoms per se. Therefore, we would generally recommend people to undergo a full cardiovascular health check from the age of 40 years and these simple checks can be repeated annually or every two years depending on the results.
Patients with a family history of premature coronary artery disease or sudden cardiac death, should seek a thorough cardiological assessment at any age. Certain inherited cardiac abnormalities, including those causing potentially fatal heart rhythm problems, can often be diagnosed with a simple electrocardiogram (ECG) performed in childhood. Early diagnosis in these cases will enable potentially life-saving therapies to be offered.
It is a popular belief that chest pain is the only way to know if you are suffering from a heart attack. Does this myth have any scientific basis?
Oxygen is transported in the body by red blood cells. When a muscle does not receive enough blood, and therefore oxygen, it will start to ache. When the heart muscle aches, a patient will experience chest pain. Therefore, chest pain (angina) is the predominant symptom of significant coronary artery disease.
Angina is often described as a heaviness or pressure or squeezing discomfort in the centre of the chest, sometimes radiating to the neck or down the left arm. Stable angina usually occurs with exertion and is eased by rest. However, unstable angina can occur at rest and this is a worrying sign. Severe angina at rest with associated sweating and nausea is the most common presentation of a heart attack.
Are there any warning signs or red flags one should be aware of?
Any patient experiencing chest pain must visit a doctor, particularly if the pain is precipitated by exertion and eased by rest (stable angina). Severe chest discomfort at rest with associated sweating and nausea should alert a patient to call an ambulance as an emergency as this might be the presentation of a heart attack.
If a young, healthy individual has recovered from a cardiac arrest/heart attack, does he/she have a higher risk of suffering from another again?
Unfortunately, any patient that has been diagnosed with a heart attack or has recovered from a cardiac arrest, is at higher risk of suffering a recurrent event. Therefore, it is imperative that patients remain under the care of a cardiologist so that medical therapy can be optimized to improve the long-term prognosis. In many cases, invasive strategies such as coronary revascularization (with coronary artery stenting or bypass surgery) or implantation of cardioverter defibrillators, can save lives.
Can individuals continue with their daily activities (including exercising and playing sports) after suffering from a heart problem?
The aim of medical therapy is to restore a patient’s quality of life back to normal. In most cases, this is achievable with modern optimal medical therapy, invasive therapies when indicated and cardiac rehabilitation. However, in certain rare instances, it might not be advisable for patients to resume high intensity competitive sports.
What can the youth do to prevent or reduce the risks of suffering from a heart ailment?
Maintaining a healthy lifestyle is the best way to avoid cardiovascular diseases. Maintaining a normal body mass index prevents obesity and lowers the risk of developing diabetes and high blood pressure.
Consuming a low salt and low sugar diet, avoiding tobacco use and keeping physically active are all proven ways of maintaining good heart health.
Conversely, sedentary lifestyles, high salt and sugar diets, and high rates of smoking are some of the main reasons why cardiovascular disease is so common in the UAE and mortality from cardiovascular disease is higher locally than in Europe.
Activating emergency medical services by calling an ambulance at the earliest opportunity is of paramount importance in a heart attack/cardiac arrest situation. After that, basic life support skills can provide lifesaving care for the patient but must be performed by competent individuals.
In my opinion, basic life support skills should be taught in schools and universities so that as many people as possible are familiar with these life-saving techniques.
Lifestyle tips to maintain a healthy, well-functioning heart
Never smoke. Exercise regularly. The minimum amount of exercise to maintain good heart health, as recommended by the European Society of Cardiology and American Heart Association, is 30-60 minutes of moderate intensity exercise, 5 days per week.
Diet is also very important for cardiovascular health. A low-salt diet will help to maintain normal blood pressure. A low-sugar diet will help to moderate blood glucose levels and avoid diabetes mellitus. Reducing consumption of red meat, processed foods and dairy products such as cheese, will minimize the dietary intake of saturated fats and lower harmful cholesterol levels in the blood. Similarly, eating more fish like salmon, wholegrains, nuts like almonds, vegetables and fruits like avocado, will not only lower harmful cholesterol but also increase good, protective cholesterol levels in the blood.