Andy Hunter
Thursday August 30, 2007
The Guardian

Football was last night mourning the death of a third player in the space of 10 days after Chaswe Nsofwa, a former Zambia international, collapsed and died of heart failure during a training session with his Israeli club side, Hapoel Beersheba. The tragedy came less than 24 hours after Clive Clarke, the Leicester City player on loan from Sunderland, suffered a heart attack during Tuesday's League Cup tie at Nottingham Forest. Clarke was recovering in hospital yesterday.

On Tuesday afternoon the Spanish side Sevilla said their left-back, Antonio Puerta, had died after suffering "five cardio-respiratory stoppages". Little more than a week earlier Walsall's 16-year-old youth-team player Anton Reid inexplicably collapsed on the training ground and died. It is unprecedented that the sport should lose three players in such a short period and it prompted a demand that compulsory heart screening be brought in for all professional players in Britain.

Andy Scott, whose 13-year career was ended by heart problems, called on the Football Association and Professional Footballers' Association to introduce mandatory cardiac testing for all players.

"There is clearly no reason why a young person should die when they are in the prime of their career," said Scott, Brentford's assistant manager. "It's complete ignorance that this has not been taken further. This is an ideal opportunity now to make it compulsory for all players to be screened. How many times is it going to have to happen? Everyone knows it's going on but it's getting someone at the top to get off their backsides." The FA described such a move as a "strategic decision for the whole game". No one at the PFA could be contacted last night.

Nsofwa, a 27-year-old striker, was training in temperatures approaching 40C when he collapsed. Rescue workers spent several minutes trying to restart his heart before paramedics arrived. Attempts to revive Nsofwa, including using an external pacemaker, proved unsuccessful and the player was pronounced dead when he arrived at Soroka hospital.

Stuart James
Thursday August 30, 2007
The Guardian

Andy Scott, the former Leyton Orient striker who was forced to quit football two years ago after being diagnosed with a serious heart condition, has urged the Football Association and Professional Footballers' Association to support compulsory cardiac screening for players.

Scott's proposal came after Clive Clarke collapsed at half-time during Leicester City's Carling Cup match with Nottingham Forest on Tuesday night. Clarke was said to be making progress in hospital last night, having required a defibrillator to keep him alive 24 hours earlier.

The 35-year-old Scott, who made more than 400 appearances across all four divisions before it was found he was suffering from hypertrophic cardiomyopathy - the same heart condition that killed the Cameroon international Marc-Vivien Foé and Terry Yorath's son, Daniel - believes that Clarke's double heart failure at the City Ground, following the recent sudden deaths of Walsall's Anton Reid and Sevilla's Antonio Puerta, necessitates urgent action from football's authorities.

Yesterday another player died. Chaswe Nsofwa, a 26-year-old Zambian striker, was taking part in a practice session with his Israeli club, Hapoel Beersheba, when he passed out. Medics tried to restart his heart before taking him to hospital, where he was pronounced dead.

"If all the players were looked at by the proper people and there was proper screening done, all these people would still be alive or at least have the chance to be alive because it would be found out," said Scott, whose condition was diagnosed after he collapsed in the Orient dressing room with severe chest pains in 2005.

"The medicals are nowhere near stringent enough. The fact of the matter is that everyone should be tested. How many times are people going to die? Is it going to take a Wayne Rooney or a David Beckham to keel over before anyone sits up and takes notice? It's getting ridiculous now.

"There is clearly no reason why a young person should die when they are in the prime of their career and fitness. It's complete ignorance that this has not been taken further. This is an ideal opportunity now to make it compulsory for all players to be screened. There have been three cases in the last [10 days]. How many times is it going to have to happen? Everyone knows it's going on but it's getting someone at the top to get off their backsides.

"I think it should be an FA initiative, backed by the PFA. There are mobile screening units who go around and can identify any slight imperfection in the heart that could indicate sudden death syndrome and that can be investigated. These mobile screening units could go around and do one club every day. It needs a sweep now of all the players that are under contract. It would only take 10 minutes to check a player."

Since 1995 the FA, together with the PFA, has funded a scheme that ensures "every 16-year-old associated with a professional club is being offered the chance to have full cardio-screening".

Walsall confirmed last night that Reid, who collapsed and died on the training ground 10 days ago, had been tested. It was not possible to ascertain whether Clarke, on loan at Leicester from Sunderland, had undergone cardiac screening but it is understood players at the Stadium of Light are routinely tested. That is also the case at Fulham although Craig Panther, the Premier League club's chief medical officer, said the system was not flawless. "As with any screening test there will be one or two who seem to have a structurally normal heart, who seem to have a normal ECG but go on to have a cardiac death," he said. "It is rare but in theory it could happen. Any screening programme doesn't abolish risk. It just reduces it."

Panther does believe, however, that testing "should be mandatory" at all professional clubs. The FA, conscious that such a scheme would present ethical issues in terms of forcing players to undergo testing, said: "That's more of a strategic decision for the whole game."

Scott said: "To screen every single player would probably cost less than £1,000. You spend that on a couple of scans for a bad knee or bad ankle. It's £1,000 to make sure that your club will not be experiencing what people at Leicester, Walsall and Seville are going through now."

How can young footballers at the peak of their athletic prowess suffer heart failure? Glenn Moore reports
Published: 30 August 2007

Antonio Puerta was buried yesterday, in Seville, the city where he lived, loved and died while playing football. As he was interred, the family of Clive Clarke was at Nottingham's Queens Medical Centre, giving thanks for escaping a similar tragedy.

Clarke, a Sunderland defender on loan to Leicester City, collapsed during City's Carling Cup match at Nottingham Forest on Tuesday night. He is understood to have suffered two heart failures and was treated with a defibrillator in the dressing room.

Puerta collapsed 35 minutes into Saturday's match with Getafe. He died of multiple organ failure brought on by a series of prolonged cardiac arrests. More than 10,000 fans, of local rivals Real Betis as well as Seville, paid their respects last night, filing past his coffin at the club's Sanchez Pizjuan Stadium. Puerta, Seville born-and-bred, leaves a wife who is seven months pregnant.

Puerta was 22, five years younger than Clarke. He was the latest in a tragic line of young footballers, and other athletes, to die of heart failure in what ought to be their peak years of fitness. Much younger players have been affected, notably Anton Reid, the 16-year-old Walsall apprentice who died while training last week, and Daniel Yorath, son of Terry and brother of Gabby Logan, who died in 1992 at 15 while having a back-garden kick-around. He was on Leeds United's books.

To the average supporter, who likes a pie and a pint, who never warms up for his weekly five-a-side game but only suffers a bit of stiffness afterwards, the incidents do not make sense. These, after all, are fit guys, professional athletes. "It's nothing to do with fitness," said Dr Craig Panther, of Pure Sports Medicine who has worked with Fulham. "There will be some underlying heart problem, something they were born with, have developed, or are suffering as a consequence of a viral illness. It can happen at all levels, we just hear about the professionals."

Indeed, the charity CRY (Cardiac Risk in the Young) estimates eight under-35-year-olds a week die of Sudden Cardiac Death, or Sudden Death Syndrome. Earlier this year it launched, in conjunction with Philips, Save Our Athletes, a five-year screening programme for British athletes seeking involvement in the 2012 Olympics. "Everyone is potentially at risk and the only accurate means of diagnosis is through expert cardiovascular assessment," said Professor Greg Whyte, chairman of CRY and Professor of Applied Sport & Exercise Science at Liverpool John Moores University.

The hearts of young footballers are screened when they come into the game under a joint initiative by the Football Association and the Professional Footballers' Association, which dates back a decade. Premier League regulations, and common sense, dictate that clubs continue to monitor players' health. But an ECG screening will not pick up every abnormality. It did not save Reid and it would probably have not, for example, have picked up the enlarged right ventricle of Marc Vivien-Foé, the former West Ham and Manchester City player, who collapsed while playing for Cameroon in Lyons in 2003. Nor would it necessarily have spotted that Puerta had arrhythmogenic right ventricular cardiomyopathy. This leads to arrhythmias (abnormal heart rhythms) and occurs in about one in 5,000 people, around two-thirds of whom will have no family history of the condition.

The tragedy of most conditions associated with Sudden Cardiac Death is that were the victims not exercising hard, and so pushing their bodies, they would probably not have had an attack. Then again, even people with sedentary lifestyles have occasional bursts of energy.

The risk needs to be kept in perspective. Dr Brian Aarons, formerly Wimbledon's club doctor, who now works with the FA's disability teams, said: "We are not talking about conventional heart attacks - smoking, high blood pressure, high cholesterol. These are very rare conditions, a number of different ones, but all of them very rare. Four hundred deaths sound a lot, but think of how many people are involved in sport every day. More than 100,000 Britons a year die of conventional heart disease." Exercise remains a good idea.

One footballer who survived is Andy Scott. In March 2005 the former Sheffield United, Brentford and Oxford forward was playing for Leyton Orient against Cheltenham when he felt abnormally drained. Scott has recalled: "Twenty minutes into the game I was struggling to breathe and my legs felt really heavy. I came off and got seen by the doctor."

He was sent to a specialist, who told him: "You're going to have to hang your boots up or else you could die." Scott added: "I'd been playing for so long and everything had been fine, I'd just assumed I'd be back, but it wasn't to be."

Scott, then 32, had made 348 League appearances, including all 39 that season. He recognises how fortunate he was and campaigns for better cardiac screening of players with CRY.

Given his age, it is not clear whether Clarke had been screened, but as noted, an ECG test will not spot everything. Yesterday Clarke's agent, Gary Mellor, said the player was "sitting up and talking" and awaiting the results of further tests. Mellor added: "It appears Clive's heart stopped twice and mouth-to-mouth didn't work, so the paramedics had to use a defibrillator. His family are very upset, especially after what happened with Antonio Puerta dying. We just hope he's going to be OK."

Leicester are due to play again on Saturday, at Plymouth. Seville, who postponed Tuesday's Champions League qualifier at AEK Athens, will resume playing tomorrow night in the European Super Cup against Milan in Monaco. Players will wear black armbands, stadium flags will be flown at half mast and there will be a minute's silence in addition to a short film recapping the player's career before the match.

Given the rarity of such deaths, Puerta was, extraordinarily, the second Seville player to die after collapsing on the pitch due to a heart condition. Pedro Berruezo, who died in 1973, was also 27, and his wife was also pregnant. Their son. Pedro, is now a professional footballer with the Segunda B side Ceuta.

Sudden Death Syndrome Footballers who have suffered heart failure

* David Longhurst, 25. A striker who began his career in the Nottingham Forest youth team, Longhurst suffered a heart attack playing for York City in 1990. York later named one of the stands at Bootham Crescent after him.

* Robbie James, 40. The former Swansea City, Stoke City and QPR star died on the pitch playing for Llanelli AFC, where he was player-manager, in 1998. James won 47 caps for Wales.

* Marc-Vivien Foé, 28 (right). On 26 June 2003, Foé collapsed near the centre circle playing in the Confederations Cup semi-final for Cameroon against Columbia. The death was said to be caused by an enlarged right ventricle. He played for Lens and Lyons and had Premier League spells with West Ham United and Manchester City. Foé scored the last City goal at Maine Road. City retired the No 23 shirt he wore in 2002-03 .

* Miklos Feher, 24. Feher died playing for Benfica against Victoria Guimaraes in january 2004. The player collapsed after receiving a yellow card and died later that night from a confirmed cardiac arrest.

* Anton Reid, 16. On 20 August this year, Anton Reid passed away during training with his club Walsall on their Aston training pitch. He was in his first year with the youth team.

The death yesterday of a third footballer in the past ten days has focused attention on the care given to players by the game's authorities, but while the screening of players in England has never been more comprehensive, a leading heart specialist has called for more effective cardiovascular testing.

Chaswe Nsofwa, a Zambian player with Hapoel Beersheva, of Israel, collapsed during training yesterday and died in hospital. Antonio Puerta, of Seville and Spain, died on Tuesday, three days after collapsing in a league game. Last week, Anton Reid, a 16-year-old Walsall trainee, died after a training session. Clive Clarke, of Leicester City, is recovering after collapsing at half-time during a Carling Cup tie away to Nottingham Forest on Tuesday.

Yesterday Dr Dorian Dugmore, the director of the adidas Wellness centre and a member of the European Society of Cardiology, advocated a more rigorous testing programme using electrocardiograms (ECG) to assess heart function during sporting activity.

According to Dugmore, existing screening is often inadequate because the ECG is taken while the athlete is at rest. "That doesn't tell you what's happening when a player is pushing himself to exhaustion," he said. "People should be stress-tested to their maximum . . . they [the authorities] should seriously consider doing this with all players on a regular basis."

New regulations relating to the emergency care of players at Barclays Premier League matches came into effect at the start of this season, with an ambulance at every game purely for the use of players and officials, along with two fully equipped paramedics. By next season club doctors and physiotherapists must have completed an advanced resuscitation and emergency aid course. Every Football League match must be attended by a registered medical practitioner and at least one paramedic.

The FA and Professional Footballers' Association (PFA) fund a scheme, in its tenth year, that gives every 16-year-old at a professional club a comprehensive cardiological screening. "Our programme has picked up one or two instances each year, which can be a real disappointment to the player and the parents, but we feel duty-bound to say 'You need to know this and then it is your decision,' " Gordon Taylor, the chief executive of the PFA, said.

Conditions that develop after that age may not be detected, while the large number of players entering the game from abroad will not have passed through the scheme and their medical records are sometimes not available.

"All Premiership footballers should have cardiac screening and it is in the Premier League rules for the first time this season," Dr Nigel Sellars, Ports-mouth's club doctor, said. "It sounds as if the lad at Walsall was unlucky, because we screen all our players at 16. Paul Hart, our new academy director, would like it to be 14. And then you think should it be 11, or should it be 9? I have heard that Puerta had not only been screened but had a full cardiological work-up so, if that is true, it's even more scary that he died.

"As a club doctor, it makes you think about whether you are doing everything correctly at your own club.

Our players wear heart monitors for every training session and software puts the information straight on to a laptop so that every player's heart record can be charted. The right things are happening - but it has been a freakish ten days."

Taylor acknowledged that the increased demands of the modern game could be a factor. "I think because the game has become more competitive than ever, while there has been improvement in diet, physiology and training techniques, at the same time there can be pressures that reveal a weakness that wouldn't be detected under less demanding circumstances.

"Marc-Vivien Foé [who died in 2003] was at the end of a long season and had played a number of games [in the Confederations Cup] and you wondered whether it was one game too many. So we have to keep monitoring 52 weeks of the year. We have made some progress, but it is incumbent on us to keep moving forward."

Living in Paris I kept coming up against a guy on the poker circuit who never said anything and always looked ill, with huge black rings under his eyes. He never showed much emotion whether he won or lost. One day we had a coffee and he told me that his sports-mad son had collapsed and died playing football, and since then, everything in his life seemed irrelevant, trivial.

I've played in games where players have suffered serious injuries, though not to the heart. Once, in France, a player swallowed his tongue. He fell in a heap, unable to control his body, like he was in a coma. I forgot all about the ball. Panic sets in - you wave on the physio, feel helpless as the medical staff crowd around the body and tension drifts around the stadium. It's hard to get on with the game after a shock like that. You lose all your focus, drift aimlessly until the 90 minutes are up. There's no spirit, no "come on, let's win it for him!" More like "let's just get changed and get out of here". Teams are like families, there's a special bond.

If more players are developing cardiovascular problems, then on one level it doesn't make sense because medicals these days are more thorough than ever, with the top clubs conducting detailed health checks, from toes to teeth. But are heart problems in professional football on the increase? That's not logical unless something about the sport has changed. A growing drug problem? I doubt it. So you've got to wonder if the pace and demands of the modern game are putting lives at risk. Whether football is evolving to a point where players are being pushed beyond their limits.

It could be just a horrible coincidence that Clive Clarke has heart failure the day that Antonio Puerta dies, that several players have passed away from cardiac problems in recent years. People drop dead. It doesn't matter whether they are footballers, farmers or shop-fitters. It's pure dumb luck. But it's also a numbers game. And while exercise can reduce illness, overexercise can cause it.

If players are fitter than ever, that means their workload is heavier than ever. Training is more tiring and matches are faster. We know that the modern game is more intensive and more hectic than it used to be. Clubs want athletes, players who run quicker and longer. Naturally, they want to push players to their limits. When anything is operating at its maximum, be it a factory, a car or a human being, it's more likely to break.

Players spend a lot of time in the gym now, but you ask yourself if that makes some parts of their bodies more developed than others and what effect that might have. We're all different, but outfield players tend to do the same training exercises for the same amount of time. In this team sport, clubs don't optimise sessions for individual benefit, even though athletic ability can vary widely. Goalkeepers, who do the least cardiovascular exercise, seem less likely than outfield players to suffer heart problems.

The heart, after all, is just a muscle. If Michael Owen and Kieron Dyer can have repeated leg-muscle injuries, why shouldn't the same logic be applied to the heart? But logic and reason don't do anything to ease the pain of a tragedy such as Puerta's death.