Deaths During Sport and Recreational Activities in Istanbul

Sudden deaths can be simply explained as the rapid loss of heart functions of the individuals and recently an increase in sports-related sudden deaths is observed in forensic practice in Turkey. Reported here are six cases of sports-related sudden deaths to emphasize the pathological mechanisms with optimal screening strategies where a detailed postmortem examination were carried out for all. Except for one case, all cases occurred while playing soccer where coronary artery disease was established as the cause of death in four cases and as arrthymogenic right ventricular dysplasia in the other case. Toxicological analyses revealed 60 ng/ml benzodiazepine concentrations in one case. Sports activities should be undertaken cautiously, particularly in the presence of risk factors. Beside professionals, screening of the recreational athletes is also important. By this way, early diagnosis of most cardiovascular abnormalities can be provided. Address for correspondence: Tolga Saka, MD Associate Professor Department of Sports Medicine, 340093, Istanbul, Turkey Telephone: 790 533 335 86 83 E-mail: [email protected] INTRODUCTION Regular physical exercise is known to reduce the coronary incidents, but it is also well known that effort can also be a triggering factor for sudden death (SD) (Hull et al. 1994; Thompson et al. 2003; Turk et al. 2008). Heavy physical activity can eventually have fatal consequences including myocardial ischemia, infarction, ventricular tachyarrhythmia or SD (Candinas and Podrig 1990; Cobb and Weaver 1986; Hauer et al. 2000; Mead et al. 1976; Siscovick et al. 1984). In contrast to adults where physical activity appears to reduce the overall risk of SD by preventing or delaying the progression of atherosclerotic coronary artery diseases, physical exercise in young athletes with occult cardiovascular disease may increase both exercise and non-exercise-related SD (Corrado et al. 2006). Although the descriptive criteria for “sudden” death in sports usually differs among various studies, it is suggested that the description should be standardized as “sudden cardiac arrest or sudden cardiac death occurring during or within a short period in relation to participation in sport” by the Sport Cardiology Section of the European Association for Cardiovascular Prevention and Rehabilitation (Solberg et al. 2015). Even differences in methodical aspects on definitions result in large variations in the reported incidences of sudden death in sports, between one and three in hundred thousand should be considered as an accepted value (Berdowski et al. 2013; Borjesson and Pelliccia 2009; Harmon et al. 2014). Aetiology of sudden cardiac death (SCD) in sports, especially in young people is a wide spectrum with underlying congenital, inherited and acquired cardiovascular abnormalities (Corrado et al. 2005; Maron et al. 1996; Van Camp 1995). The leading causes include diseases of the myocardium, cardiomyopathy either arrhythmogenic right ventricular cardiomyopathy or hypertrophic cardiomyopathy, anatomic abnormalities of coronary artery, premature coronary artery disease (CAD), cardiac ion channellopathies (Brugada syndrome, catecholaminergic polymorphicventricular tachycardia or long and short QT-syndrome), Marfan’s syndromes complications, and acquired disorders, acute myocarditis and commotio cordis (Corrado et al. 2009; Sheikh and Sharma 2011). However, the primary cause of SCD in master athletes is CAD (Burke et al. 1991; Kim et al. 2012). The number of people involved in recreational physical activity is growing and it is not uncommon for a medical examiner to encounter sports-related SD (Fornes and Lecomte 2003). Despite death during sport representing a small 352 ÇAGLAR ÖZDEMIR, HASIM ASIL, TOLGA SAKA ET AL. proportion of unexpected sudden deaths, yet it still remains a major medico-legal problem (Tabib et al. 1999). This paper aims to highlight the pathological mechanisms and optimal screening strategies as well as to emphasize the prevention of these sudden deaths in the light of autopsy data. MATERIAL AND METHODS Data of the Morgue Specialization Department of the Council of Forensic Medicine is reviewed in this paper. The age and sex of the deceased, the site and the manner of the incident, any findings in regards to the postmortem examination and eventually the cause of death have been analyzed from the records in all autopsied deaths occurred during or shortly after any sports or recreational activities between January 2006 and December 2008. Coronary thrombosis, acute myocardial infarction, any extensive infarction scars, or more than seventy-five percent reduction of the lumen by an atheroma plaque in at least one of the main epicardial coronary arteries are accepted as diagnostic criteria for CAD as the cause of death (Burke et al. 1991; Suarez-Mier and Aguilera 2002). Arrhythmogenic right ventricular dysplasia (ARVD) was diagnosed when there was gross or histologic evidence of regional or diffuse full thickness replacement of the myocardium of the right ventricular free wall by fat and fibrous tissue, in the absence of other known cardiac or non-cardiac causes of death (Corrado et al. 1998; Thiene at al. 1988).