When The Rhythm Breaks and Causes Sudden Cardiac Arrest (SCA)

It can be shocking to witness athletes collapsing and dying on the sports field. The sports world bore witness to such tragic occurrences several times, and Malaysia went through this heartache when its very own national cager Jacky Ng Kiat Kee passed away while on an invitational tournament in China.

The cause of his death was sudden cardiac arrest (SCA), which is a leading cause of death among young athletes globally. What makes cardiac arrest scary is the element of surprise. It can affect anyone at any time and can happen without any warning signs. Even young athletes who are supposedly fit and healthy can die from SCA, as has been the case numerous times.

According to Dr Koh Kok Wei, consultant cardiologist at Subang Jaya Medical Centre (SJMC) and Malaysia Heart Rhythm Society chairperson, an SCA victim's life can only be saved if cardiopulmonary resuscitation (CPR) is started immediately. 

"Having said that, the fact remains that CPR alone cannot revive the victim. It can only ensure that the oxygen supply to the brain is not hampered. To save the victim, getting him to an automated external defibrillator machine (AED) within five to 10 minutes is crucial because only an AED machine can restart the heart," he elaborates.

In a case that happened in Penang last year, a 49-year-old man was revived by five teenagers with the help of CPR and AED, 12 minutes after he suffered cardiac arrest while playing football.

The question is what causes SCA and is there a way to prevent it?

Arrhythmia: Getting the rhythm right

According to Dr Koh, SCA happens when the electrical system of the heart malfunctions, causing erratic or irregular heartbeats, or arrhythmia. However, arrhythmia is not a disease itself, but a manifestation of an underlying problem.

Some of the causes of arrhythmia include coronary artery disease or heart blockage and injury to the heart from a previous heart attack; but the most common cause is hypertrophic cardiomyopathy, which is the thickening of the heart muscles.

Sometimes, there are prior symptoms, such as palpitations but there are usually no warning signs before the heart suddenly stops beating. Dr Koh says the best and only way to prevent SCA is to diagnose the underlying heart problem that might cause a cardiac arrest and treat it.

How to detect arrhythmia

"There are many diagnostic procedures to detect arrhythmia, with the first step being an electrocardiogram (ECG). The problem with ECG is that it is much like taking a picture that captures the heart rhythm at one particular instant and the person's heart might just be beating normally then.

"If someone has a family history of sudden deaths or has risk factors related to heart diseases, such as diabetes and hypertension, they are advised to go for a more thorough heart screening, which includes an echocardiogram, treadmill stress test and Holter monitor," elaborates Dr Koh.

Sometimes, even these tests cannot detect arrhythmia, but Dr Koh emphasises that it does not completely negate the possibility of people with risk factors, especially those with a family history of heart disease, getting SCA.

"In such cases, a diagnostic procedure is undertaken whereby healthcare professionals induce SCA within the hospital. Yes, many people get scared when they hear that their heart will be stopped deliberately, but it is better to see if there is a problem within a controlled medical environment where the doctors and cardiologists are already prepared to restart the heart, than have it happen somewhere else," he assures.

However, there are instances when there is no detectable underlying cause of arrhythmia, or an uneven heartbeat cannot be diagnosed at all. In such cases, the only preventive measure is to get an implantable cardioverter defibrillator (ICD).

"An ICD can detect a malfunctioning electrical system and can send out shocks to restart the heart or bring the rhythm back to normal," says Dr Koh.

However, he says that since ICDS are expensive, not many Malaysians can afford it, adding that high ICD prices is a contributing factor to the low survival rate of SCA victims in Malaysia.

Knowledge of CPR for cardiac arrest can save lives

"There is a dire lack of awareness regarding SCA," says Dr Koh, who also believes the lack of knowledge leads to many people not receiving the primary care needed in emergency situations."

Many Malaysians confuse SCA with a heart attack when they are completely different. Heart attacks can lead to SCA but there are other things that can cause it, too. This lack of awareness causes people to ignore the necessity of taking safety training such as CPR.

"Every public place should have AED machines and there should be clear instructions as to its location. There should also be a professional available at all times to assist in using the machine because most people do not know how," he adds.

Based on Dr Koh's comments, taking lifesaving training in CPR that also teaches you how to use AED should be made mandatory in schools, universities and workplaces, because these techniques are the only thing that stands between life and death.

The life after sudden cardiac arrest (SCA)

The survival rate for sudden cardiac arrest (SCA) is extremely low in Malaysia. For the very few people who survive, the fight for their life does not end there.

Since the heart has stopped pumping blood, the victim's brain does not receive enough oxygen to work. Different kinds of medical issues can crop up depending on the length of time the brain does not receive sufficient blood, ranging from memory loss to partial paralysis to psychological problems, such as post-traumatic stress disorder.

SCA survivor Jasmine Wylie describes the after-effects, "I have roughly three years missing from my memory - a few weeks before the attack to a few years after. It is like I am a different person now. There are fundamental things that are very different from who I was before the attack, such as the way I think, how I perceive the world and how I store and retrieve information in my brain." Wylie is part of an SCA survivors support group on Facebook.

Lynn Cassano Russell, a member of the same group, says she experiences frequent seizures. "I also had a mild anoxic brain injury. I have severe fatigue and weakness that don't seem to get better with time. Although I can function and do tasks such as take showers and do my hair, it takes me twice as long as it did before and tires me out.

"Sometimes my head feels like it is spinning and only laying down helps. Daily life is such a struggle that I have been put on permanent disability because of the lasting effects," she adds. 

Wylie believes that the mental health side of recovery is mostly ignored by the medical community and having support groups to turn to can help victims as well as their loved ones.

"The knowledge and wisdom of other survivors have made such a huge impact on how I have dealt with things and I am very thankful to live in a time where I can belong to an online community, as you don't meet very many SCA survivors in regular life," she shares.

There is a lack of awareness about SCA in Malaysia and because of that, there is not a single support group for local SCA survivors as well as their families.

These shortcomings emphasise the need for Malaysia to not only focus on widespread life-saving training but building a solid support system for people affected by SCA.

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