“Female athletes’ hearts are very different from men’s”
Athletes who suffer cardiac arrest during competition are increasingly in the news. A medical examination of the heart could prevent a cardiac arrest, although this test sometimes misses the mark, according to sports cardiologist Nicole Panhuyzen-Goedkoop. “Our data comes largely from young white men.”
News about soccer players collapsing on the field and cyclists dying of cardiac arrest or ending their careers prematurely is appearing more and more often. Yet cardiac arrest in elite athletes is not a recent phenomenon, says Nicole Panhuyzen-Goedkoop, sports cardiologist and PhD candidate at Amsterdam UMC. On Thursday, she will receive her doctorate from the UvA for a dissertation on medical cardiac examinations for athletes.
The first story of cardiac arrest dates back to 490 BC, when the Greek messenger Pheidippides ran over 40 kilometers from the town of Marathon to Athens to announce that the Greeks had defeated the Persian army. Upon arrival, he dropped dead. “Over the years, there has been increasing publicity of sudden death from cardiac arrest in sports,” Panhuyzen-Goedkoop said. “In the newspaper and social media, resuscitations on the soccer field are in the spotlight. These cases were previously known to occur, too, but were never really talked about.”
How does cardiac arrest occur during sports?
“In athletes under 35, there is often hereditary or congenital heart disease. Often people do not know they are carrying that disease. The first symptom can be cardiac arrest. The cause in athletes older than 35 is often a heart attack, due, for example, to the clogging of coronary arteries. When an athlete with heart disease continues to play sports, it can lead to a life-threatening situation.”
“Viruses can also infect the heart muscle, such as covid or another flu virus. The muscle pain you feel throughout your body with the flu can also be in your heart muscle, which you don't always feel. That's why you shouldn't play sports with the flu. In rare cases it can trigger a fatal arrhythmia.”
So is intensive exercise actually that healthy?
“There is nothing wrong with intensive exercise, and an athlete’s heart—enlarged ventricles, thickened heart walls, and a lower resting heart rate heart due to physical exertion—is also healthy. Only in combination with underlying heart disease can exercise become fatal. This does not occur often. Annually, just 2 to 10 in 100,000 athletes die of heart failure. That number could be reduced by making preventive sports cardiac screening possible for all athletes in the Netherlands. This is already the case in Italy, where all amateur athletes are required to undergo an examination biannually. Presumably, sports testing in Italy has ensured that athletes there die of cardiac arrest less often than non-athletes.”
Can you prevent cardiac arrest in athletes with an examination?
“I have researched that, but the evidence for it is very weak. That's because these are rare diseases so you can't prove how high the risk of cardiac arrest is during intensive sports. Unfortunately, the examination also produces false positive and false negative results. Some athletes are wrongly rejected and other athletes still die of cardiac arrest during sports.”
“The examination is currently conducted via a questionnaire, physical examination, and a cardiac video (ECG). If there are any abnormal findings, you have to look further. The knowledge we now have about cardiac imaging is largely from white men under 35 who exercise more than eight hours a week. We hardly know anything about people from other ethnic backgrounds, older people, or women. So I conclude in my dissertation that we need to move away from mass testing and make testing more customized.”
“Also, the examination should not only be available for athletes younger than 35. There are marathon runners who are older and athletes well into their 70s who are working with heart rate monitors and training schedules to keep improving themselves. A physician must then know to look at other diseases in this target group. The same goes for women and other ethnic groups.”
Nicole Panhuyzen-Goedkoop (1957) studied medicine at the UvA, and after a brief foray into surgery, continued her training as a cardiologist at Utrecht University Medical Center. In 2005 she opened the first outpatient clinic for sports cardiology in the Netherlands at Papendal. Until then, (elite) athletes with heart problems could only go to their general practitioner.
In 2006, together with the Dutch Society of Cardiology and the Dutch Society of Sports Medicine, Panhuyzen-Goedkoop set up the first examination specifically for the heart: the Lausanne protocol.
Does an athlete’s heart work differently in women than in men?
“Yes, we studied that in a group of male and female rowers who trained for nine months for the Olympics. Before and at the end of that period, we mapped out what the heart's adaptations are when you're already well-trained and whether the heart can adapt even further. And it can, which is incredible. In all rowers, after nine months of training, the left ventricle had increased in size. It was striking that in the women that increase was greater than in the men.”
How could that be?
“One thing I know for sure, women train much harder than men. This is the same in all sports disciplines that I have seen and experienced. In addition, of course, women not only have a different physique, muscle development, strength capabilities, and endurance than men, but the heart is also different. And therefore the adaptations of the athlete's heart are also different.”
“Hormones also play a role in this. For example, we saw a thickening of the heart muscle in male rowers that we did not see in female rowers. This is because men build muscle mass much faster and more easily than women due to the hormone testosterone. This also applies to the heart muscles.”
“At the same time, the number of women who die suddenly when exercising is very small; men are nine times more likely to experience cardiac arrest. So you can also question whether you should vet women. But we need to research that first.”
Nicole Panhuyzen-Goedkoop will receive her doctorate on Thursday, March 14th, at 4:00 p.m. for her dissertation, “The athlete’s heart – towards tailored clinical decision-making on athlete screening.” The defense will take place in the Agnietenkapel and is free to attend.
