Fig 1. Teammates formed a shield around Erikson
Though we do not yet know what caused Christian Eriksen to collapse during the recent football match between Denmark and Finland in the ongoing Euro 2020, there are many lessons we have learnt from this scenario. One could see how Medical Staff were quick to attend to him while his teammates, opposition and coaching staff were visibly stricken by the scenes unfolding at the Parken Stadium.
As policy researchers, we conducted an extensive literature review to examine the incidence rate of Sudden Death in Sporting activities globally using search engines with the keyword Sudden Sports Death. We found that the case of Christian Eriksen is not the first time such a situation has occurred. There is the need for Sport Administrators, Policy Makers, football clubs, the Ghana Football Association (GFA) and the Ministry of Youth and Sports to consider this as public health concern and formulate policies to address this in Sporting activities in Ghana.
Christian Eriksen’s collapse has set the stage for Cardiopulmonary Resuscitation (CPR) training for footballers and the general public as well. Interestingly, after the incidence, a publication in Daily Mail, (2021) indicates that footballers in Italy could be asked to take basic first-aid courses during the ongoing Euro 2020. Eriksen’s stable condition was attributed to the three minutes of CPR after suffering a cardiac arrest. The world hailed Denmark captain Simon Kjaer’s basic knowledge in CPR as they waited for the medics to arrive.
CPR is a lifesaving technique that is useful in many emergencies, such as a heart attack or near drowning, in which someone’s breathing or heartbeat has stopped. In this article, we examine the incidence rate of Sudden Cardiac Death in Sporting activities. We found that, the case of Christian Eriksen is not the first time such a situation has occurred. One article in the Guardian, (2012) found that more than 80 footballers have died suddenly while playing, all young men, all otherwise apparently fit and healthy.
Additionally, for football lovers, many will remember the collapse of Bolton Wanderers star Fabrice Muamba in 2012. But the big question we asked ourselves is why seemingly healthy and fit footballers would suffer such conditions. We also know that Physical activity is regarded as a faithful reflection of the state of health and quality of life of a society. As researchers, we find it hard to understand how an apparently healthy young person can die while showing great vitality in his or her usual athletic activities.
Cases of sudden death fill the headlines of the sports press, especially when they occur in well-trained athletes with an excellent athletic performance. Unfortunately, these athletes did not know that they were silent carriers of potentially lethal cardiovascular diseases, in spite of undergoing numerous medical controls in the course of their athletic career.
What is sudden death?
Sudden death refers to an unexpected demise occurring over a short period of time, usually within 1 hour of symptom onset. It is predominantly caused by abnormalities of the heart and affects both those with known and unknown cardiac disease. For this reason, it is commonly known as Sudden Cardiac Death (SCD). Cases of SCD are tragic and often receive a large amount of public attention, particularly when young, previously healthy athletes are affected. Fortunately, SCD is rare in athletes.
According to Michael Campbell (MD), the decision of whether or not an athlete may return to vigorous physical activity after surviving a sudden cardiac event is very individualized. He notes: “Knowing the exact diagnosis that caused the event is crucial in making these decisions”. He further opined that, Athletes with known arrhythmias who have received ablation treatment to correct the arrhythmia may be able to return to their previous activity level.
He further explained that athletes with known structural heart diseases should not participate in vigorous physical activity, but may participate in selected low-intensity, low-impact activities. “Some athletes may return to intense activity after receiving an implantable Cardioverter Defibrillator for certain conditions. Ultimately, the best decision is made after a discussion of the involved risks between the physician and the athlete,” he concluded.
Incidence of sports sudden cardiac death
We reviewed some studies on this as health policy researchers. One study conducted by Higgins & Andino, (2013) places the incidence of SCD at 1-2/100,000 per year, with athletes at 2.5 times higher risk. A previous study by Kramer et al., (2010) also revealed an incidence rate of 1:65,000 to 1:200,000 athletes in USA. Harmon and Drezner, (2007) equates this to 1 Sudden Cardiac Arrest every 3 days. Corrado et al., (2003) also found Cardiac Arrest to be 2.5 times higher in athletes than in non-athletes. A similar prospective population-based study by Corrado et al., (2005) in the Vento Region of Italy reported that 2.3 per 100,000 athletes per year die from all causes, while 2.1 per 100 000 athletes per year die from cardiovascular diseases.
A more recent study by Malhotra et al., (2018) in the United Kingdom also screened 11,168 adolescent athletes with a mean age of 16 years (95% of whom were male) in the English Football Association (FA) cardiac screening program, which consisted of a health questionnaire, physical examination, electrocardiography, and echocardiography from 1996 to 2016. The study found 42 athletes (0.38%) to have cardiac disorders that are associated with sudden cardiac death.
Post screening, there were 23 deaths from any cause, of which 8 (35%) were sudden deaths attributed to cardiac disease. The mean time between screening and sudden cardiac death was 6.8 years. On the basis of a total of 118,351 person-years, the incidence of sudden cardiac death among previously screened adolescent soccer players was 1 per 14,794 person-years (6.8 per 100,000 athletes).
Another study in Spain by Suárez-Mier and Aguilera, (2002), reviewed cases during sports activities from 1995 to 2001 in the registries of the Institute of Toxicology of Madrid, (Ministry of Justice). The series included 61 cases ranging in age from 11 to 65 years; 59 males and 2 females. The sports most frequently involved were cycling (21), football (13), and gymnastics (5).
In Croatia, a study by Duraković et al., (2012) which covers the period of 27 years: from January 1, 1984 to December 31, 2010 noticed 69 sudden and unexpected cardiac deaths during physical exercise in Croatia.
A more recent study by Leonid Makarov (2020), conducted between 1980 and 2011 in Sudden Death among Young Athletes Registry in the USA, recorded 2,406 observed in 29 diverse sports. The study found 80% of all sudden deaths occurred in high school/middle school or collegiate student athletes, and 20% were engaged in organized youth, postgraduate.
Statistical data vary greatly in different countries: Sudden Cardiac Death incidence rate in the USA is 7.47 and 1.33 per 1,000,000 exercising male and female school-age athletes respectively, whereas in Italy, the rate is 2.6 cases in men and 1.1 in women per 100,000 individuals per year who are involved in active competitive sports. The European Heart Rhythm Association (EHRA) position paper concluded that as an overall estimate, 1–2 out of 100,000 athletes between of age of 12 and 35 years old die suddenly each year.
Studies indicate that sports appreciably increase the risk of suffering sudden death during intense athletic activity (Deporte, 2002). Deporte, (2002) further explained that cardiovascular disease is the most frequent cause of sudden death, as in persons who do not practice sports. Between 74% and 94% of non-traumatic deaths that occur during athletic activities are due to cardiovascular causes.
For instance, young, seemingly fit athletes have hearts that are a little different from most people. Their well-exercised heart muscle has been reshaped to adapt to the stress of regular, vigorous training. This remodeling of the heart is useful, as it helps to pump blood more effectively round the body. But in certain conditions such as Hypertrophic Cardiomyopathy (HOCM), a genetic abnormality causes the muscle wall of the heart to grow far thicker than it should. Repeated training makes the problem worse; the muscle wall can become so thick that it stops the normal flow of blood going in and out of the heart. This is where things get dangerous.
A heart that cannot pump blood properly causes problems that usually affect far older and far less healthy people. An athlete with HOCM might seem very fit but have a heart which is struggling like that of an unwell 80-year-old. Sudden strain, like a football match, demands overwhelming effort. If he is lucky, the presence of shortness of breath or chest pain will indicate that something is wrong. But often the first signs of trouble are collapse or what doctors call sudden cardiac death. The heart’s ability to pump has been compromised so severely that it cannot beat in a coordinated way anymore.
As a result, the Italian FA President, Gabriele Gravina, after the event, has indicated his readiness to roll out mandatory first-aid courses across the game immediately. He notes: “We will do an in-depth study of what happened, but we will also look at another factor; quick and effective first aid on the pitch.” said Gravina. He further added: “We are working on developing these courses in time for when our clubs return for pre-season. We plan to start during the national team’s training camp.” According to Deporte, (2002), Sudden Death correlates with age. However, in persons under the age of 35 years, the risk is exceptionally small, with an incidence of 1/200 000/year, whereas in persons over the age of 35 years the risk of suffering sudden death is 1/18 000/year
- Although physical activity is beneficial for health, it carries an increased risk of sudden death.
- Athletes more likely to experience sudden cardiac arrest during racing, soccer, hockey
- An Emergency Action Plan is necessary to ensure a speedy response to a collapsed football player at our various football Centers
- All members of football teams in Ghana should be trained in at least hands-only CPR.
- It is a necessity to place a mobile defibrillator on the sideline of the football field during a match.
- Hands-only CPR is recommended as the initial on-field CPR technique for first responders, until defibrillation can be undertaken.
(Raphael Nyarkotey Obu, ND, DBL, MBA, ChMC, PhD, LLB(student) is an honorary Professor of Naturopathy Holistic Medicine, chartered Management Consultant, Author, Science Writer, Researcher, President, Nyarkotey College of Holistic Medicine; Association of Naturopathic Physicians(ANGP); Chief Editor of Ghana Alternative Medicine Journal(GAMJ) and Lawrencia Aggrey-Bluwey, BSc, PGDE, MPhil, is a Clinical Nurse, Health Services Manager and an Assistant Lecturer with the Department of Health Administration and Education, University of Education, Winneba and a PhD student in Health Policy and Management, University of Ghana, Legon. Contact: 0241083423/0541234556
- Higgins, J. P., & Andino, A. (2013). Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review. Journal of sports medicine (Hindawi Publishing Corporation), 2013, 967183. https://doi.org/10.1155/2013/967183
- Kramer E, Dvorak J, Kloeck W(2010)Review of the management of sudden cardiac arrest on the football field. British Journal of Sports Medicine ;44:540-545.
- Harmon KG, Drezner JA(2007)Update on sideline and event preparation for management of sudden cardiac arrest in athletes. Curr Sports Med Rep ;6:170–6
- Corrado D, Basso C, Rizzoli G et al(2003)Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol ;42:1959–63.
- Corrado D, Pelliccia A, Bjornstad HH, et al(2005)Cardiovascular preparticipation screening of young competitive athletes for prevention of sudden death: proposal for a common European protocol. Consensus Statement of the Study Group of Sport Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. Eur Heart J ;26:516–24.
- Neil Malhotra, Harshil Dhutia, Gherardo Finocchiaro, Sabiha Gati, Ian Beasley et al 2018. Outcomes of Cardiac Screening in Adolescent Soccer Players. N Engl J Med; 379:524-534
- Paz Suárez-Miera and Beatriz Aguileraa, 2002 Causes of Sudden Death During Sports Activities in Spain. https://www.revespcardiol.org/en-causes-sudden-death-during-sports-articulo-13032016
- Leonid Makarov, 2020. Sudden Cardiac Death in Young Athletes. https://www.intechopen.com/books/sudden-cardiac-death/sudden-cardiac-death-in-young-athletes