Why should a young adult be worried about heart disease? In an otherwise healthy person, one who is not born with a heart defect, what is the risk of heart disease? In general there are two concerns for the young adult. One is the risk of sudden cardiac death. This is of special concern to the student athlete, as many deaths occur on the field of play or in gym class. In New Jersey, there have been several cases of high school athletes with sudden cardiac death, most recently in a football and track star from Franklin. Attention was focused nationally on sudden cardiac death in athletes when a 26 year old football player for the Chicago Bears and a 21 year old college basketball player recently died a few days apart. The second concern for the young adult is the risk of developing coronary artery disease, the major cause of heart attacks and deaths in older adults, but a disease whose process begins in childhood.
Sudden cardiac arrest is caused by ventricular fibrillation (an irregular heart rhythm from the lower chambers of the heart). When the heart’s ventricles are fibrillating, they cannot pump blood to the brain and vital organs. If not treated promptly, this leads to death. Sudden cardiac arrest occurs in athletes and the incidence is estimated at 1 in 200,000 in high school athletes. Young athletes have an increased risk of sudden cardiac arrest compared to their non-athletic peers. The combination of extreme physical exertion and an underlying heart disorder can trigger cardiac arrest. The most common causes include hypertrophic cardiomyopathy (a thickened heart muscle), coronary artery anomalies (the heart arteries arising from the wrong location), right ventricular dysplasia or myocarditis (a weakening of the heart muscle), aortic stenosis (a thickened, malfunctioning heart valve), rupture of the aorta (the main artery from the heart) and diseases of the heart’s electrical system.
The best way to prevent sudden cardiac arrest in athletes is to screen them for these heart abnormalities. Certain factors in the history or physical exam should alert the doctor that the athlete is at risk for sudden cardiac death. In the United States, a history and physical is recommended prior to athletic competition, but not an electrocardiogram (a recording of the electric activity of the heart) or an echocardiogram (an ultrasound of the heart). Many colleges and pro sports teams, however, do these more specific tests to screen their players. In Italy, a more comprehensive and mandatory screening program was begun due to a high rate of sudden cardiac death in athletes. In addition to a history and physical, each athlete is given an electrocardiogram. If the athlete is felt to be at risk, an echocardiogram is performed. The screening is conducted by doctors who undergo special training to recognize the subtle findings associated with patients at risk for sudden cardiac arrest. Using this simple, noninvasive method, the rate of sudden cardiac death dropped 89% from 3.6 cases per 100,000 people to 0.4 cases per 100,000 people over 25 years. The Cardiology Department at Somerset Medical Center has instituted a voluntary screening program for high school varsity athletes in the area based on the Italian model. Each athlete is examined by a board certified adult or pediatric cardiologist and an electrocardiogram is performed. In those at risk, an echocardiogram is done and read immediately.
Coronary artery disease is the leading cause of death in the United States and is due to atherosclerosis or build up of plaque in the heart’s arteries. The exact cause of atherosclerosis is not known, but it is known that the process begins in childhood. The fatty streak is the earliest sign of atherosclerosis and it can be detected in the aorta of teenagers. Atherosclerosis progresses from the fatty streak to a cholesterol-laden plaque. Autopsies performed on servicemen who died in combat in Korea and Vietnam confirmed atherosclerotic plaque in these asymptomatic men in their teens and twenties.
Atherosclerotic plaque continues to build up over the next ten to twenty years until the plaque blocks a significant amount of blood flow, causing chest pain. Alternatively, a plaque may rupture, causing the blood to clot, obstructing blood flow and a heart attack occurs.
Risk factors for developing atherosclerosis are the same in both adults and children. These risk factors include obesity, diabetes, high blood pressure, hyperlipidemia (high cholesterol), sedentary life style and smoking. Initiating life style modifications in childhood, before fatty streaks or atherosclerotic plaques develop, should improve cardiovascular health in adult life. Another goal of the student athlete screening study at Somerset Medical Center was identifying these risk factors. Each athlete had fasting labs for cholesterol and blood sugar, to screen for hyperlipidemia and diabetes. Blood pressure recording help screen for hypertension. In addition, a bioimpedence device measured each student’s BMI (body mass index) and percentage of body fat. These measurements can identify if a patient has obesity. All of these measurements were given to the student in summary form, counseling was performed and any abnormalities or warning signs were identified and advice given for future follow up.
Healthy young adults often do not seek medical care while they are in their teens, twenties and thirties. The only reason they may seek a physician is for a sports physical or pre-employment examination. When they are seen by a doctor, special care must be taken to screen for causes of sudden cardiac death, especially in those young adults who are athletes or who engage in vigorous physical activity. In addition, risk factors for coronary heart disease must be identified, so a healthier life style can be initiated and, hopefully, future cardiovascular problems avoided.
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