19 Mar 2012

Could tests have picked up Muamba heart problem?

Fabrice Muamba, who suffered heart failure during a match at the weekend, is showing signs of improvement. But, asks Channel 4 News, would a different heart testing regime have picked up his illness?

The latest update on the condition of Fabrice Muamba, the Bolton Wanderers footballer who collapsed during an FA Cup tie against Tottenham Hotspur on Saturday, is that he is able to “breathe independently” and has “been able to recognise family members and respond to questions”.

Earlier a spokesperson for the London Chest Hospital hospital said the footballer’s long-term prognosis “will remain unclear for some time. He is still critically ill and will continue to be closely monitored and treated.”

Muamba’s manager, Owen Coyle, has thanked medical staff for their hard work and prompt action in treating the Bolton midfielder.

Mere mortals

The fact remains, though, that the cardiac arrest suffered by Congo-born midfielder has stunned footballers, football supporters and the wider community. We assume that our sporting heroes, whose focus in life is the achievement of physical excellence, are immune to the ailments that beset mere mortals.

We assume that our sporting heroes are immune to the ailments that beset mere mortals.

How was it, then, that someone who had trained as a footballer from an early age, who was regularly subject to the physical programming and body tests which all professional athletes undergo, succumbed to cardiac failure?

The most common cause of sudden death is hypertrophic cardiomyopathy, which results from a thickening of the heart muscle. It has been identified as the cause of death of several elite sportsmen over the past decade, including that of Cameroon footballer Marc-Vivien Foe during a match in 2003.

Defective cell membranes

But Dr Leonard Shapiro, a cardiologist at Papworth Hospital and medical adviser to the Football Association, believes hypertrophic cardiomyopathy did not cause Fabrice Muamba’s heart to stop working for two hours on Saturday afternoon.

We can exclude 95 per cent of the causes, but there’s a 5 per cent that we can’t exclude. Dr Leonard Shapiro

“It’s very unlikely because he was screened, I think, four times,” Dr Shapiro told Channel 4 News. “It would be very unlikely that that would be missed.”

More probable, he suggests, is that Muamba’s illness was caused by defective cardiac cell membranes – called ion channels – which are almost impossible to detect.

“They can have lethal consequences. You can’t detect or check most of them by screening or any other method unless you catch the person during the event.

“Of the things we screen for, we can exclude 95 per cent of the causes, but there’s a 5 per cent that we can’t exclude – and it includes these sorts of problems.”

Physical exercise tests

Dr Amanda Varnava, consultant cardiologist at St Mary’s, Imperial college, agrees that Muamba’s heart problem may have been undetectable.

An electrocardiogram (ECG) is frequently used as a cardiac diagnostic test to assess the heart performance at rest, and can assist in determining a range of heart conditions.

But Dr Varnava believes a “resting” ECG (i.e. with the patient not moving), if used on Muamba, may not have been adequate to reveal cardiac abnormality.

“Sometimes abnormalities, such as long QT syndrome [producing irregular heartbeats], have to be unmasked by physical exercise tests,” she told Channel 4 News. However, the standard protocol in all countries does not include an exercise test on athletes unless they’re 35 or older. We don’t put people on a treadmill here.”

Nationwide testing

The issue of cost touches on the question of what sort of heart-testing regime there should be for those involved in competitive sport.

Sometimes abnormalities have to be unmasked by physical exercise tests… But we don’t put people on a treadmill here. Dr Amanda Varnava

In Italy, the death from heart failure of Renato Curi, a footballer with Perugia, during a professional game in October 1977, prompted the institution five years later of a nationwide testing programme.

That programme, which is still running today, is unique in developed countries because it stipulates that any person between the ages of 12 to 35 who is engaged in ongoing, competitive sporting activity should be regularly tested for heart disease.

The test, which includes a questionnaire, an analysis of family history, and an ECG, has reduced the incidence of sudden cardiac death within the age group by 90 per cent since its introduction in 1982.

Major undertaking

Whether such a regime could have picked up Fabrice Muamba’s heart problem is impossible to say at this stage. Dr Leonard Shapiro’s belief that he would have been tested at least four times since his mid-teens – as a member of the England squad at several levels, as an Arsenal academy player, and with Bolton Wanderers – suggests the midfielder’s problem may have been hard to detect.

But arrangements in the UK appear not to be mandatory in the manner of the Italian system.

The FA Handbook states that it is a requirement that an academy player aged 9-16 should undergo a medical examination, including “cardiovascular system assessments” and a “cardiological assessment test… where there are clinical indications following medical examination”. Under-17s are “to be given the opportunity to undergo cardiological assessment free of charge”.

The problem now for football in the UK, not just at the highest level but across the board, is that the game is simply too popular. It would be a major undertaking to introduce across-the-board testing along Italian lines.

It is to be hoped that Muamba makes a recovery, that his illness was indeed virtually impossible to anticipate, and that the incidence of such thankfully rare events continues to diminish.