Getting to the heart of cardiac problems
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The leading executives and medical staff of more than 170 countries gathered in Zurich on 17 and 18 October for FIFA's first Medical Conference. A wide range of subjects that have been explored by the FIFA Medical Committee and the FIFA Medical Assessment and Research Centre (F-MARC) over the last 15 years were discussed, including football at different altitude, the observance of Ramadan, the fight against doping and, as FIFA.com now highlights, FIFA's initiative to prevent ‘sudden cardiac death' (SCD).

Sometimes, even the worst of tragedies can serve as a catalyst for progress. The shocking death of Marc-Vivien Foe from SCD during a FIFA Confederations Cup match on 26 June 2003 undoubtedly helped push the football community to find ways of preventing further such incidents on the pitch, and that was the point laid out by Prof. Jiri Dvorak, FIFA Chief Medical Officer and Chairman of F-MARC, in his opening address. The Cameroonian player's autopsy revealed that he suffered from congenital hypertrophic cardiomyopathy of the left heart chamber, one of the major causes of SCD in sportsmen, and further changes of the muscle of the right heart.

Studies have been carried out to investigate the most likely causes of such incidents and, above all, to improve and implement preventive measures. In a pioneering initiative of a sports governing body, F-MARCdeveloped a football-specific pre-competition medical assessment (PCMA) and consequently every player of the 32 teams participating in the 2006 FIFA World Cup Germany™ took these tests to detect possible underlying cardiac disease.

Dr. Fernando Di Paolo then reported on a study in northern Italy where the regular examination of all competitive athletes is required by law, leading to large number of athletes being investigated. What he found out was that while competing, for example playing football, at the highest level can provoke (trigger) SCD when the heart is already weakened by so far undetected disease, it can in no way be taken as the underlying cause of such incidents.

"Above all, we asked ourselves how we could best fight against young athletes dying like this," he said. "We identified two main approaches: prevention through PCMA, and reaction when it happens by an effective emergency response including defibrillation." The Italians ordered a specific examination for all athletes: "Including a resting electrocardiogram in the regular examination of a largely Caucasian population causes the rate of SCD to fall considerably," explained Dr. Di Paolo. A quick and effective reaction in the wake of a cardiac arrest is paramount when it wasn't prevented in the first place, but the survival rate still remains terribly low at just 16 to 17 per cent.

Standardising prevention
FIFA clearly favours prevention through PCMA and the results so far have been encouraging."It was important to see in 2006 that the teams who qualified for Germany actually adhered to this programme, ," added Dr. Bert Mandelbaum, a FIFA Medical Committee member and physician with the United States team. "Since then, we apply it as much as possible and we want to widen its usage. FIFA has accepted its responsibility towards players' health by putting PCMA into practice."

What exactly is PCMA? It represents a whole battery of medical tests designed to make it possible to detect eventual cardiac problems, among other things. The FIFA PCMA includes not only a resting ECG, but also an echocardiography of the heart to maximise possibilities of detection. The goal now is to standardise a preventive system in football and see it applied everywhere and to everyone as indicated. That, for example, is exactly what Dr. Yacine Zerguini has been able to do in his native Algeria. "There were multiple challenges," he said. "To make the examination obligatory, we made it a condition of obtaining the licence necessary to take part in competitions. After that, we needed to stock information on 150,000 players in a database while making sure to respect patient confidentiality. We were able to do that, which is proof that standardised PCMA is possible on a large scale." 

The Chairman of the FIFA Medical Committee, Dr Michel D'Hooghe, also believes in this prevention being effective, but he feels everyone will need to work to see it implemented across the board. "There are 260 million players in the world and we know very well that it will be difficult to apply PCMA to all of them," he said. "FIFA is committed to applying it at the highest level, but the member associations will have to follow that example and put in the same effort."

However, the PCMA may also be implemented in stepwise manner, starting with simply history taking and physical examination and escalating only if any suspicious findings are detected, thereby reducing costs and infrastructure requirements. Despite still being in its infancy, though, this preventive approach clearly represents an important advance in the struggle to avoid seeing another Marc-Vivien Foe, Miklos Feher or Antonio Puerta die before their time while playing the sport they love.