There have been a number of athletes with heart disease–in a variety of sports–who’ve captured the nation’s attention because of sudden, unexpected death in recent years. Often these deaths have occured during training or competition. From time to time, I’ll take a look at one of these athletes and describe their heart problems. There’s probably something to learn in these examples about living (and exercising or training) with heart disease or preventing sudden cardiac death.
I was having dinner with some friends last weekend and the group included several runners and a couple doctors. We got to talking about heart disease in athletes and somebody asked me if I knew why Ryan Shay died.
To set the stage, Ryan Shay was a runner for most of his life. He grew up in Michigan where he was a multi-year high school state champion in the 1600m and 3200m events. He went on to college at Notre Dame, where he competed in both cross country and track. He was the NCAA champion at 10,000m in 2001 and was a 9-time All American. After college, he would go on to be the USATF marathon champion in 2003 and the USATF half marathon champion in 2003 and 2004. He finished a disappointing 23rd at the 2004 Olympic Trials, but had high hopes for the 2008 Trials.
Ryan Shay died in New York City on November 3, 2007, collapsing suddenly in Central Park, at mile 5.5 of the 2008 U.S. Olympic Marathon Trials. He received medical attention immediately, was taken to Lenox Hill Hospital, and was pronounced dead. An autopsy report was released several months later, describing the cause of death as “cardiac arrhythmia due to cardiac hypertrophy with patchy fibrosis of uncertain etiology….natural causes.”
Interestingly, Ryan Shay was known to have heart disease since he was a teenager. After an automobile accident, he had a chest x-ray which showed that, compared to an x-ray done 3 years earlier when he had pneumonia, showed his heart had enlarged appreciably. I’m not certain if any further diagnostic testing was undertaken, but the problem didn’t seem to hamper Ryan.
Of course, there’s probably no way to be absolutely certain what caused Ryan Shay’s death. But I think the information that’s available suggests a likely scenario. When the pathologist describes “patchy fibrosis,” she is referring to scar tissue that has developed in the heart….due to injury of some sort, just like scar tissue develops elsewhere in the body. Fibrosis in the heart in a young person is very unusual, though. In an older individual, fibrosis can develop commonly after injury like heart attack. But Ryan had no evidence of the coronary artery disease that causes heart attacks. Much more likely, Ryan had an episode of myocarditis, a viral infection of the heart that occured during childhood. In the aftermath of that infection, his heart enlarged and there was scarring in the heart muscle.
Ryan Shay’s heart obviously was strong in terms of its pumping function. No elite runner could achieve Ryan’s accomplishments without a “strong” heart. Unfortunately, the fibrosis in his heart was a “set-up” for the event that occured on the day of his death. The heart’s ordinarily highly organized electrical activity (that causes the various chambers to contract in the correct sequence) can become irregular because of areas of fibrosis in the heart walls. This can result in suddenly disorganized electrical activity (that we call an arrhythmia–likely ventricular fibrillation) that leaves the heart unable to contract and pump blood effectively. The blood pressure falls to zero and unless the electrical activity is returned to normal within minutes (using a defibrillator), the individual dies.
As we explore the spectrum of heart disease in athletes in the weeks and months ahead, we’ll see that the development of an arrhythmia is often the common final pathway that leads to sudden death in athletes. But there are many disorders besides myocarditis that can lead to this problem.