Marathon runner Adrian Lehmann died at the weekend as a result of a heart attack. The tragic case shows that young people can also develop fatal heart diseases.
The unexpected death of marathon runner Adrian Lehmann shocked the sports world. How is it possible for a young, healthy man to suffer such a fate? A heart attack that seems to come out of the blue and ends fatally? And that one day before the Zurich Marathon, where Lehmann wanted to qualify for the Olympic Games in Paris.
The tragedy contradicts everything we think we know about heart attacks. It starts with age. In Switzerland, it is primarily older people over 50 who develop a heart attack, as a look at the figures from the Swiss Health Observatory shows (see table below). But the statistics also show that heart attacks do occur in the 19 to 34 year old age group. Young men are affected slightly more often than young women.
But that such a young person dies from the heart attack? This is also very rare in Switzerland, but not completely ruled out, as the data from the Health Observatory also shows. The risk of dying from a heart attack increases with the patient’s age. As with the frequency of heart attacks, heart attack mortality is also slightly higher in young men than in young women.
In addition to classic heart attacks, there are also atypical heart attacks
What ultimately triggered Adrian Lehmann’s heart attack and why the athlete died in the hospital two days later is still unknown. Only an autopsy of the body can provide answers. The consequences of the heart attack turned out to be more serious than initially expected – that is the only thing the Swiss Athletics Association announced on Sunday about the tragic progression of the disease. The association does not want to provide any more information, citing the family’s privacy.
But what can actually trigger a heart attack in such a young person? In most cases it is the same for a 34-year-old athlete as for a senior with a heart attack, says sports cardiologist Christian Schmied from the University Hospital of Zurich and the Hirslanden Clinic.
Such a “classic” heart attack is usually a two-stage process. First, accumulations of fat and calcium build up in the coronary arteries over the years. This process, called atherosclerosis, slowly narrows the blood vessel. However, a heart attack only occurs when parts of these plaques come off and acutely block the blood vessel, explains Schmied. The muscle tissue cut off from the blood vessel is now deprived of oxygen and will die without treatment.
Studies show that the known risk factors for a heart attack, such as smoking or elevated cholesterol and blood pressure levels, are already relevant in young people under the age of 40. But what is striking is that younger heart attack patients often have close family members with a similar fate. This suggests that some of the risk of heart attack may be inherited.
In rarer cases, however, the heart attack has an atypical trigger. This includes a spontaneously torn coronary artery. During such a dissection, the blood flow in the artery is acutely blocked, as in a classic heart attack. According to studies, this cause of heart attack tends to affect younger people under 50 and women.
A “paradoxical embolism” is also an atypical cause of a heart attack. This involves flushing a blood clot through a hole in the wall between the heart chambers. If the clot then gets into a coronary artery, it can block the vessel and trigger a heart attack. Such an embolism also tends to affect younger heart attack patients.
Risk genes can also trigger a heart attack at a young age. This is known from a coagulation disorder called the factor V Leiden mutation. People with this gene variant form blood clots relatively often and therefore have a significantly increased risk of heart attack.
The heart attack can throw the heart out of rhythm
In all types of heart attacks, the blood supply to the heart muscle is ultimately interrupted. Many patients experience this as typical chest pain. Now every minute counts. A large-scale infarction can quickly lead to cardiovascular failure.
To prevent this, the cardiologist or heart surgeon must urgently remove the obstruction in the coronary artery. The blood vessel is then usually stabilized with a metal mesh (stent). A stent is also used as a vascular support if the blood vessel wall is torn.
But that’s not always enough. Complications that can occur immediately or only after a few days or weeks are also feared in the case of a heart attack. Particularly sensitive is the potentially fatal cardiac arrhythmia, such as that suffered by professional footballer Christian Eriksen at the European Football Championship in 2021. Without any external influence, the 29-year-old collapsed during a game in front of the cameras.
Eriksen was lucky. He was resuscitated on the field and the cardiac arrhythmia was stopped with an electric shock. To protect against further such episodes, doctors later installed an automatic defibrillator in the athlete’s heart.
What triggers a heart attack or sudden cardiac death in individual cases cannot be predicted exactly or completely prevented. In addition to the cardiovascular risk factors mentioned, you can also identify possible abnormalities in the heart that increase the individual risk of cardiac arrest. These include certain heart muscle diseases (cardiomyopathies), calcified coronary arteries and inherited syndromes in which the electrical conductivity of the heart is changed. All of this is associated with an increased risk of life-threatening arrhythmias.
Such arrhythmias can be triggered by great physical exertion. Overall, cases of cardiac death occurring during sport are very rare. Estimates range from less than one event per year to almost 7 events per 100,000 athletes. According to Schmied, studies of marathon runners show that among the dead there are a striking number of overly ambitious male amateur athletes over the age of 40. Death often occurs in the last ten kilometers when it comes to “biting through”.
Danger threatens with nine hours of hard training per week
This is also consistent with recent findings that very ambitious male elite athletes sometimes have more calcified coronary arteries than one would expect for their age. For them, sport had harmful effects on their health. But where is the limit beyond which it becomes unhealthy? It cannot be defined exactly, says Schmied. In general, however, we recommend no more than nine hours of high-intensity training per week.
The physiological and hormonal changes in the body that occur during extreme performance are considered possible fatal triggers. According to Schmied, scarring in the heart often plays a role, as can occur with inflammation of the myocardium. Such inflammation is triggered by a variety of viruses, says the doctor. The corona vaccination, which is repeatedly blamed, is much less suspected.
In order to minimize the risk of scarring of the heart, Schmied recommends not only top athletes but also amateur athletes to avoid sport in the event of a viral infection. Because during the acute infection there is a high risk of dangerous arrhythmias, explains the doctor. In addition, any scars would increase the risk of fatal cardiac arrhythmias for life. In many tragic cardiac deaths in recent years, such scars following inflammation of the heart muscle have been detected in the autopsy.
In addition to the ban on sports in the event of viral infections, Schmied recommends that all ambitious athletes undergo regular preventive examinations. These are now established among squad athletes in many sports. This includes a resting ECG. This is particularly important for younger athletes, says Schmied, who worked on international guidelines on the topic. With the ECG you can detect over 90 percent of congenital anomalies in the heart.
According to the cardiologist, for older athletes – although in competitive sports you are considered “older” at the latest at the age of 35 – it is crucial to assess the risk of atherosclerosis in the coronary arteries. “An ECG is not enough for this, and a bicycle or treadmill test is also not sufficiently reliable,” emphasizes Schmied. Rather, the risk assessment must take into account various factors such as cholesterol levels, but also the athlete’s individual stress level.
Despite all the potential dangers, one should not lose sight of the health-promoting effects of sport, emphasizes Schmied. Physical exercise is so healthy that doctors now only advise against exercise in absolutely exceptional situations due to illness. Even people with stable narrowing of the coronary arteries – where the heart muscle only receives too little oxygen under greater stress – are recommended to exercise regularly at a moderate intensity.