Cardiac care for athletes

“We know exercise is medicine”, says Jonathan Kim, MD, Associate Professor and Founding Director of Sports Cardiology at Emory University, Atlanta, USA, and Team Cardiologist for Georgia Tech, the Atlanta Falcons, Hawks, and Braves. He encourages people to exercise as much as they can—while he also aims to ensure that exercise enthusiasts are engaging in their sport safely.

Albeit rare, there are instances where professional athletes have suffered from sudden cardiac arrest. Recent examples include the collapse of professional soccer player Nabil Bentaleb of OSC Lille, France, and the tragic death of 17-year-old Chinese badminton talent Zhang Zhijie while playing the Badminton Asia Junior Championships.
Former German soccer player Daniel Engelbrecht also had a cardiac arrest on the pitch. His cardiac condition, myocarditis, has been linked to an infection he had several months before the cardiac event during the game. Engelbrecht was 22 years old when the life-threatening event occured—and felt “great that day, in the form of my life. I was in such a good shape. And I had no idea that there was something wrong with my heart.”

Even after he had collapsed, no one thought something was wrong with Engelbrecht's heart. During his next game three weeks later he signaled the coach to be substituted, then he was taken to the emergency room. The heart muscle inflammation (myocarditis) was finally diagnosed with the help of magnetic resonance imaging (MRI). "The doctor said I was lucky that my heart hadn't stopped beating anytime while I was alone at home, or during training. I was lucky to be still alive."

Professor Kim urges to take any warning sign seriously: "During exercise, chest pain, chest pressure, shortness of breath out of proportion to what you are doing, irregular heartbeats... And then a critical one, if you almost pass out or pass out during exercise—if an athlete sees me with this complaint, I tell them they can't train until we figure out what is going on."
While myocarditis is on the differential, risk factors for the younger athletes also include congenital heart diseases such as genetic cardiomyopathies or genetic arrythmia syndromes. To help ensure young athletes can engage in their sport safely, Kim first follows the respective American College of Cardiology (ACC) and American Heart Association (AHA) recommendations and begins with a cardiac specific pre-participation history and physical. While not currently required by the guidelines, a screening electrocardiogram (ECG) can also be included, but this requires careful consideration of the expertise involved for ECG interpretations and the downstream resources available for further assessment(s) of an abnormal ECG finding.

"One important challenge is that we don't have truly robust data to clearly show that ECG screening, beyond anything else that we do from a screening standpoint, improves outcomes," Kim sums up the current research. He warns that a cardiologist without expertise in the interpretation of an athletic ECG may lead to more false positives when reading an athlete's ECG data. In addition, unless the appropriate downstream resources are in place with more intensive screening practices, young, aspiring athletes may not be able to get the necessary follow-up tests depending on their insurance status or expert availability. Kim is passionate about the need for thoughtful planning when developing cardiac screening programs that include ECG, particularly in regard to available physician expertise and downstream resources in order to ensure equitable outcomes for all athletes.

Kim is also an avid advocate for emergency action plans in the case of a cardiac event on the pitch—or anywhere else: "Ensure access to automated external defibrillators (AEDs), learn cardiopulmonary resuscitation (CPR), so when a catastrophe occurs, we save the life of this young person, whether it's an athlete or a non-athlete at a school!"

Kim refers to Damar Hamlin, the Buffalo Bills' safety who suffered a cardiac arrest during a game on January 2, 2023, caused by commotio cordis. This cardiac trauma is triggered by a direct blow to the chest above the heart during a very narrow window within the cardiac cycle that can cause ventricular fibrillation and cardiac arrest. In fact, it is one of the known causes of sudden cardiac death in athletes [1], and no screening whatsoever can prevent it. Emergency action plans, immediate CPR and AED availability support survival rates, so Hamlin today is a strong public advocate to make these available at schools, especially in underserved neighborhoods.

While Damar Hamlin is back on the football field, Daniel Engelbrecht eventually had to give up his childhood dream of being a professional soccer player. After four heart surgeries, including one where a defibrillator was implanted, Engelbrecht returned to the pitch in November 2014 as the first professional football player with an implanted defibrillator in Germany. Today, Engelbrecht calls that defibrillator his "guardian angel" because it has already brought him back to life several times. The recurrence of his heart problems was the reason why he finally retired from professional sport: "It was the most difficult decision for me to stop playing football because it was the thing I loved the most. Still, I know, it was the right decision."

Engelbrecht still goes to gym regularly and also plays some tennis to ensure his mental wellbeing but makes sure he takes days off to recharge his batteries. With his personal experience in mind, he strongly advises young athletes to pay attention to their own body: "You are responsible for your health, not your parents, not your coach, not your club—you are responsible for yourself. If you're not feeling good, stay at home and take your time and give your body the time to recover. Listen to your body because you only have this one health."

Hear more from Dr. Kim and listen to Daniel Engelbrecht give a first-hand account of his collapse and recovery in our podcast episode. You will also learn how exercise can help patients with cardiovascular disease get back on their feet faster.