'Dead' for 78mins: What caused footballer Muamba's collapse?

Bolton Wanderers' Fabrice Muamba has made a miraculous recovery after being "in effect dead" for 78 minutes following his cardiac arrest in Saturday's FA Cup quarter-final, doctors said on Wednesday.

The Premier League club's doctor Jonathan Tobin told the BBC that 15 defibrillator shocks had failed to get the 23-year-old's heart beating in the hour after he collapsed on the pitch at Tottenham Hotspur.

"We were fearing the worst and didn't think we'd get the recovery we had. It's incredible," he said.

"It was 48 minutes when he collapsed to reaching hospital and a further 30 minutes after that. He was, in effect, dead at that time."

Tobin said he had gone out into the corridor and cried when the situation sank in after Muamba had arrived at the London Chest Hospital.

By Tuesday evening, however, the midfielder was sufficiently recovered to tell Tobin that he was feeling fine.

"I went to see Fabrice last night. I went in and he said 'Hi, doc.'," Sky television quoted Tobin as saying. "I asked him how he was and he said 'Fine'."

Andrew Deaner, a consultant cardiologist at the London hospital who was at White Hart Lane as a spectator and ran on to the pitch to help, said he had also been astonished by the player's recovery.

"If I was ever going to use the term miraculous it could be used here. He has made a remarkable recovery so far," he told the BBC.

"Two hours after (he had regained consciousness) I whispered in his ear, 'What's your name?' and he said, 'Fabrice Muamba'. I said 'I hear you're a really good footballer' and he said 'I try'. I had a tear in my eye."

Deaner said Muamba's life was not in danger now but it was too early to say whether he would be able to play again. Sam Mohiddin, the cardiologist looking after the player, said however that "normal life is within the spectrum of possibility."

The match against Tottenham was abandoned at 1-1 just before halftime and has been rescheduled for next Tuesday.

The Sun newspaper quoted a family friend reporting that Muamba had asked who won the match when he regained consciousness.

"He was told the match was called off while the two teams were drawing 1-1," said Aime Esalo. "Fabrice asked why they had stopped it and his father said 'Because of you'."

Cause: Excessive exercise or hidden heart time bomb?

Reports say experts are as of yet uncertain as to what could have cause Muamba's heart to just suddenly stop beating on Saturday.

However, experts have speculated that it could have been that Muamba suffers from an underlying heart problem which was compounded by the vigorous physical exertion football players undergo on the field.

The Associated Press quoted Dr William McKenna, director of inherited cardiac diseases at University College London that "exercise could be a trigger for a cardiac event."

Cardiac arrests are different from a heart attack, in that it occurs when a person's heart just stops doing its job - pumping blood around the body. Heart attacks are when one of the arteries supplying blood to the heart is blocked, thus starving the heart muscle of oxygen.

Experts say that although sudden cardiac arrests can occur in health individuals with no known health problems, the risk is higher for those with pre-existing heart issues.

Dr Reginald Liew, Deputy Director of the Research and Development Unit at the National Heart Centre Singapore (NHCS), told YourHealth that for a 23-year-old like Muamba to suddenly collapse on the field, an underlying cardiac problem is often the cause.

He said the possibilities include:

a) An underlying heart muscle disorder, such as the abnormal thickening of heart muscle;
b) an underlying electrical problem, such as inherited heart rhythm disorder affecting cardiac ion channels;
c) a weakened heart muscle do to an infection (e.g. certain types of viruses) or an unknown cause;
d) congenital abnormality of the coronary arteries, as some people are born with anatomical abnormalities of the main blood vessels that supply the heart muscle with blood.

"The first two of these options often have a genetic predisposition, meaning they may be related to certain mutations," he said.

For some cases, a family history of sudden death can be found, although patients may have genetic mutations not necessarily connected to a family history of sudden death, he added.

He further elaborated that these scenarios generally results in ventricular fibrillation, where the heart rhythm goes haywire and becomes incompatible with cardiac output. This may result in the heart suddenly stopping.

Another heart abnormality could also have been an abnormal origin of heart arteries, which may have caused impaired flow during exercise, said Associate Professor Terrance Chua, the Chairman of the Board of Directors of the Singapore Heart Foundation.

It could also have been a heart attack, due to the rupture of fatty cholesterol deposit in the wall of the heart arteries and a clot formation blocking the artery, he said.

However, he highlighted that without more information being provided through in depth testing, it is difficult to pinpoint the exact cause.

Not the first time

Not the first time

Prof Chua said that its is not the first time he has seen such a case.

Indeed, just last year a 22-year-old Singaporean runner collapsed and died an hour later during the Standard Chartered Marathon Singapore 2011.

Mr Malcolm Sng Wei Ren, collapsed at the finishing line at the Padang at about 8.30am and was sent to the Singapore General Hospital (SGH).

However, he died an hour later.

Mr Sng, who was a first-year business management undergraduate at the Singapore Management University, did not declare any pre-existing medical conditions to the organisers.

He had completed the run in 1hr 53min 20sec, which is considered a decent time for an amateur runner.

Other previous sudden death incidences include:

2005: Mr Ho Wai Piew, 40, had an existing arterial problem and attended his first triathlon - the New Balance Corporate Triathlon. He suffered a heart attack during the swim leg and drowned.
2006: Singapore Armed Forces Colonel Bernard Tan, 39, died while participating in the Singapore Biathlon at East Coast Park in March. He collapsed 600m from the 10km finish line after completing a 1.5km swim. He reportedly died of a sudden cardiac arrest.
June 2007: National triathlete Mr Thaddeus Cheong, 17, suffered a heart failure and died after finishing third in a SEA Games triathlon selection trial.
August 2007: Army officer Mr Ho Si Qiu, 25, completed the half-marathon at the Singapore Bay run. Shortly after, his heart stopped and he died.

Prevention is better than cure

Prevention is better than cure

To help guard against sudden cardiac arrest, Prof Chua advised athletes to:

1. Avoid exercise if feeling unwell, having flu or fever.

2. Drink plenty of water to avoid heat stroke in Singapore.

3. Lead a healthy lifestyle and avoid risk factors for heart attack such as smoking, lack of exercise, obesity, diabetes, high cholesterol and high blood pressure.

4. Know the symptoms of heart disease such as chest discomfort on exercise, and always see a doctor if you have these symptoms.

Dr Liew added that there are screenings available for the detection of heart muscle diseases and heart electrical disorders. For example, using an echocardiogram for the former, and 12-lead ECG for the latter.

A cardiac CT scan can also be done to look for congenital abnormalities of the coronary arteries, althought this is not routinely done.

If you have been identified to have a heart abnormality, it may be advisable to refrain from competitive sports and have further tests to look for the underlying problem.

Your doctor may recommend that you be started on medication, or in very high risk individuals, they may be recommended to have an implantable cardioverter defibrillator (ICD) inserted, he said.

This device shocks the heart back to normal if it develops a dangerous heart rhythm, such as ventricular fibrillation.

Are you at risk?

Are you at risk?

There are many risk factors for heart disease.

They are broadly classified into those that are modifiable (can be changed) and those that are non-modifiable (cannot be changed).

What are the non-modifiable risk factors?

These are risk factors that you have no control over. They are:

Age
The older you are, the more susceptible you are to heart disease. For women, the effects of menopause - particularly the loss of natural oestrogen - appear to increase their risks of coronary heart disease and stroke.

Gender
Men are 3 to 5 times more likely to have coronary heart disease than women. However, the risk for women increases after menopause. By about 5 to 10 years following menopause, the risk for coronary heart disease for women increases to almost the same level as men.

Ethnicity
Risk for coronary heart disease varies with different ethnic groups. A study done in Singapore shows that the likelihood for coronary heart disease is highest amongst South Asians, i.e. Indians, Pakistanis, Bangladeshis, etc. South Asians are 3 times, and Malays are 2 times more likely than Chinese to suffer from coronary heart disease.

Family History
Certain risk factors tend to run in some families. If there is a history of heart disease in your immediate family (parents, siblings, children), you should try very hard to control your modifiable risk factors.

This section of the article was contributed by National Heart Centre Singapore (NHCS).

Risk factors you can change

What are the modifiable risk factors?

1) High blood cholesterol

"Bad" cholesterol increases the build-up of fats in the arteries. This causes hardening of the arteries so that they become narrowed. The result is that the blood flow to the heart becomes blocked or reduced.

"Good" cholesterol carries cholesterol from the arteries back to the liver, thus preventing the build-up of fats and formation of plaque in the arteries.

High blood cholesterol does not cause symptoms. It is therefore important to check your cholesterol levels regularly. This means once a year for a normal person wishing to monitor his cholesterol.

2) High Blood Pressure / Hypertension

You should check your blood pressure at least once a year.

Like high blood cholesterol, hypertension usually occurs without any symptoms. If left untreated, it can result in damage to the heart and blood vessels, eventually leading to stroke, heart attack or renal failure. Occasionally, when one's blood pressure is extremely high, the person may experience headaches, dizziness or alterations in vision.

Normal blood pressure may vary from 90/60mmHg to 120/80mmHg in a young healthy person. Hypertension is present when a person's blood pressure is persistently above 140/90mmHg.

If you have diabetes or kidney disease, try to keep your blood pressure at around 120/80mmHg. This is because even a marginally higher blood pressure will increase your risk of developing complications.

This section of the article was contributed by National Heart Centre Singapore (NHCS).


3) Diabetes mellitus and abnormal blood sugar levels

People with diabetes are 2 to 4 times more likely to develop coronary artery disease and stroke. Maintaining a healthy weight, a balanced diet and a regular exercise routine can prevent the onset of diabetes mellitus.

4) Menopause

Before the onset of menopause, many women appear to be partially protected from coronary heart disease, heart attack and stroke by natural oestrogen.

Women lose their natural oestrogen as they age and this may contribute to a higher risk of heart disease and stroke after menopause.

Routine hormone replacement for women who have undergone natural menopause does not prevent heart disease.

5) Obesity and being overweight

People who have excess body fat, especially located around the waist, are more prone to developing heart disease and stroke even if they have no other risk factors.

Excess weight increases the strain on the heart and raises blood pressure, blood cholesterol and triglyceride levels, while lowering "good" cholesterol) levels. It is also linked to the development of diabetes mellitus.

6) Physical inactivity

Regular physical activity helps prevent heart and blood vessel disease. Regular exercise may also lead to improvement in other cardiovascular risk factors, such as weight loss, lower blood pressure, decreased stress and improved cholesterol level.

While the risks of exercise are minimal, people with known coronary artery disease or those above 40 years of age who have been inactive should seek medical advice before starting a regular exercise programme.

7) Smoking

Smokers have two to three times the risk of non-smokers of sudden cardiac death. In fact, smokers account for about 40 per cent of deaths caused by heart disease in patients who are younger than 65 years.

When a person smokes, the nicotine in the smoke speed up his heart rate, raise the blood pressure and disturb the flow of blood and air in the lungs.

The carbon monoxide in the smoke lowers the amount of oxygen carried in the blood to the rest of the person's body, including the heart and the brain. Smoking also causes a decrease in "good" cholesterol.

8) Stress

Your blood pressure goes up momentarily when you get angry, excited, frightened or when you are under stress. If you are constantly stressed over a prolonged period, you may be at a higher risk of developing high blood pressure.

Prolonged stress may contribute to a heart attack. Emotional stress and tension also cause the body to produce adrenaline, which makes the heart pump faster and harder, and may also cause the blood vessels to narrow down.

This section of the article was contributed by National Heart Centre Singapore (NHCS).

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