Check Up: Dr. Mona Osman El Hage, assistant professor of clinical specialty at AUBMC’s Department of Family Medicine

by MainGate Staff
Fall 2021

Dr. Mona Osman El Hage, Assistant Professor of Clinical Specialty at the Department of Family Medicine

Q. What is a sudden cardiac arrest and how is it different from a heart attack?

A. In layman’s terms, one might say that a heart attack is a plumbing problem, while sudden cardiac arrest is an electrical one. It’s not that the heart becomes clogged, it’s that it stops pumping altogether. You can think of it like a sudden power outage. The system just shuts down. You collapse. There’s no pulse, no breathing, no consciousness. In the case of a heart attack, you might have time to get to the emergency room. In the case of sudden cardiac arrest, you need immediate attention.

Q. And why does it occur? What causes it?

A. Heart problems are the most common causes. However, that depends on age. A massive heart attack due to coronary artery disease could be the cause, whereby the arteries have become clogged with cholesterol and other deposits. In young people, hereditary heart problems, whether structural or electrical in origin, can lead to sudden cardiac arrest; these are the more dramatic, newsworthy cases, like that of Danish pro footballer Christian Erikson who collapsed on the field during the Euro 2020 game against Finland. An enlarged heart, when the heart’s muscular walls stretch, enlarge, and thicken, leading to arrhythmias, is a structural problem. Congenital heart irregularities in the heart’s electrical circuitry may also lead to arrhythmia.1 Arrhythmia usually precedes sudden cardiac arrest.

Q. It has been said that sports or exercise could lead to sudden cardiac arrest. Is that true?

A. Exercise and sports do not cause sudden cardiac arrest, but they might trigger it in people with cardiovascular diseases. A person could be predisposed electrically or structurally to sudden cardiac arrest and not experience any symptoms or an event until they begin playing sports. There is evidence that sudden cardiac arrest is more common in athletes as compared to nonathletes (two to three times more common). However, nonhereditary factors can sometimes result in sudden cardiac arrest. For example, the use of performance-enhancing drugs might cause it. In others, loud noise or fear could aggravate the problem. Sometimes a viral infection that affects the heart, like myocarditis, could cause it. It could also be caused by a sudden trauma to the chest. That’s called commotio cordis.

Q. And how common is it?

A. Out-of-hospital sudden cardiac arrest is a leading cause of death worldwide, resulting in around seven million deaths annually. Most cases occur at home. In the United States, there are between 230,000 and 325,000 cardiac arrests occurring outside of hospitals annually. Only 7.6 percent of people will survive. In Lebanon, we do not have stats for aggregate incidence, but we know that around 4.8–5.5 percent of out-of-hospital incidences will survive. The incidence of sudden cardiac arrest is rare in young people, around one to three per 100,000. Still, it remains one of the most common causes of death in young athletes.

Q. What do treatment and recovery look like?

A. A person can recover immediately from sudden cardiac arrest, same as it happened with Erikson. You just have to get the electricity back on fast enough before any long-term damage occurs. It really depends on how fast a person is resuscitated. Resuscitation must begin as soon as possible. Every second that the heart remains “offline” is precious. After two minutes, brain damage can occur. After nine minutes, that damage becomes irreversible.

It is important to start cardiopulmonary resuscitation (CPR) as soon as possible, ideally within a minute or two of the collapse, and to use a defibrillator (an electrical device that restores normal heartbeat through electric pulse) on the patient in less than five minutes. A person’s chances of survival drop by 10 percent every minute post-cardiac arrest. In 2018, there was a student at Hostler who experienced a sudden cardiac arrest. He was playing basketball. The staff who are trained in CPR and use of automated external defibrillators (AEDs) immediately resuscitated him and he survived.

Treatment of the underlying conditions that might cause the sudden cardiac arrest is also available. This can be a medication or a simple procedure. Sometimes, patients that are predisposed to an event might have a defibrillator implanted so when an event occurs, the defibrillator kicks on like a back-up generator and restores the normal flow of electricity. Erikson, the footballer, was outfitted with a defibrillator.

Q. How can it be prevented?

A. Prevention of sudden cardiac death is possible through awareness, screening, early detection, and preparedness. We aim to detect heart problems early. Both the US and EU recommend cardiac screening for athletes. The American Heart Association recommends that everyone assess their family history and get a physical in order to diagnose potential problems. The EU recommends an electrocardiogram
(EKG) as well. This is based on Italy’s experience. In Italy, all athletes must be screened. Italy found that when screenings included an EKG, sudden cardiac arrest incidence decreased by 89 percent. In the US, they don’t recommend an EKG for all athletes because of cost-related issues. Another important aspect of prevention is the availability of AEDs in public places and training people (potential bystanders) on CPR and the use of AEDs.

Q. What is being done in Lebanon about this?

A. In Lebanon and after our tireless advocacy efforts, the Ministry of Public Health (MOPH) and the Ministry of Youth and Sports recommended conducting cardiac screening for athletes. Moreover, the MOPH issued a memo in 2019 calling for the mandatory availability of AEDs in public places, schools, universities, and sports fields.

Here at AUB, we have the Champs Fund, which I founded in honor of my son, Hicham, who passed away from sudden cardiac arrest while practicing with his football team in high school. It was caused by an undiagnosed hypertrophic cardiomyopathy. We conduct cardiac screenings of athletes at AUB, as well as at schools, other universities, sports clubs, and professional teams around Lebanon. In 2014, it became mandatory for athletes to be screened. If you want to represent AUB on a sports team, you must be screened. COVID-19 brought the screenings to a halt at AUB and around Lebanon, but we’ve since restarted at some locations and will resume with AUB athletes in the fall semester hopefully. We also train people, at AUB and elsewhere, on how to do cardiopulmonary resuscitation (CPR) and use an AED. And we donate AEDs.

1. The term “arrhythmia” refers to
abnormally fast or slow heart rates and
to irregular heart rhythms.