Autopsy provides answers, but little solace
Posted on Sunday, April 13, 2008
URL: http://www.nwanews.com/adg/Sports/222681/
The news that Adam Nickel died after completing the Little Rock Marathon because of the confluence of an extremely rare and difficult-to-detect medical condition and very unlucky timing gave race director Bill Torrey closure, but no comfort.
Nickel, 27, a graduate student at the University of Wisconsin, finished 18 th in the March 2 race after completing the 26. 2 miles in 3 hours, 2 minutes, 26 seconds, which is considered an elite time. He had a heart attack at the finish line and died moments later.
Autopsy results from the Arkansas Crime Lab, released Monday, indicate that Nickel had a vascular disease known as “multifocal small coronary artery fibromuscular dysplasia,” which means he had small heart arteries that restricted the flow of blood. The small arteries were near a critical part of the heart that regulates electrical impulses.
That, combined with abnormal electrolyte percentage levels that many distance runners experience, including raised potassium percentage levels, led to a significant heart arrhythmia that proved fatal.
“I’m glad we have some sense of closure or at least know what the problem was,” Torrey said. “It helps us understand what happened, even though I don’t see any way to have prevented this. But it doesn’t comfort me to know that; I haven’t looked at it that way at all. The biggest thing is thinking about Adam and his family, thinking about their loss.
“ What it’s done for us is made us aware it could happen. We have to take whatever precautions to make sure our medical staff is ready for the maximum. We were ready, but it was an eye-opener, even for the medical staff. They know it can be the extreme end, not just blisters and occasional dehydration. You could have a heart attack.”
It would have been difficult for anyone to see Nickel’s heart attack coming.
Nickel was an experienced runner and had completed five marathons before coming to Arkansas. His family said he had not had any medical issues related to running since he took up the sport in high school.
“He was the healthy one of the family,” said his mother, Cynthia.
Dr. Charles Kokes, the crime lab’s chief medical examiner, said an electrocardiogram could have detected Nickel’s condition, but a physical alone would not.
Many runners might have Nickel’s condition, not know it and still feel fine, Kokes said. In Nickel’s case, the fact that the affected arteries were so near nodes in the heart that control electrical impulses led to the fatal event.
But most catastrophic was the timing.
Although Nickel was an experienced runner, Kokes said Nickel likely had his vascular condition for some time. The heart vessels were deteriorating as each day passed.
“The only thing that makes sense is that by this time in his life these vessel changes had progressed to the point that they had narrowed enough to precipitate the arrhythmia,” Kokes said.
But even with the progressed vascular disease and the location of the affected arteries, Kokes said Nickel likely would have survived a shorter training run, one that did not place as much stress on his heart and where the electrolyte percentages — which also affect a heart’s electrical signals — were not so severely out of balance.
A shorter run would have led to a less severe arrhythmia, and Nickel could have been treated. As it was, Nickel’s severe heart attack killed him in seconds.
Kokes said it is likely that Nickel’s final kick to the finish line pushed his heart’s stress level over the top.
“I would put [this death ] in the very uncommon to rare category,” Kokes said. “Obviously a lot of people run marathons and survive. To have someone collapse and die right after race is very uncommon.”
Kokes compared Nickel’s death to the death of Antony Hobbs III, the 17-year-old Little Rock Parkview basketball player who collapsed and died during a Jan. 2 game. Hobbs died of hypertrophic cardiomyopathy, an enlarged heart. But Kokes, who also conducted Hobbs’ autopsy, saw similarities in the way the two athletes died, if not the exact cause.
“It’s painful when the first time we realize there is a heart condition, the first manifestation of it was sudden death,” Kokes said. “That’s unusual. Most patients will not present that way. They will faint multiple times, have chest pain — something that will alert you. It’s very unfortunate for both these young men.”
Several experienced runners said Nickel’s death, while certainly tragic, should neither alarm other runners nor dampen their enthusiasm for the sport.
Amby Burfoot, the winner of the 1968 Boston Marathon and the editor at large for Runner’s World Magazine, has extensively reported on the death of Ryan Shay, who collapsed during the U. S. Olympic Marathon Trials on Nov. 3. Shay’s autopsy indicated he died from cardiac hypertrophy, which is an irregular heartbeat caused by an enlarged heart.
“I think when someone is as young and fit and fast as [Nickel ], almost the same as Ryan Shay, there’s always an underlying cause,” Burfoot said. “But it is simply a reflection of the vast number of people running these days. We know that running is a very healthy sport. Some people have bad genetics and get knee injuries, and some have an underlying heart condition and die. But it wasn’t running that caused death. It only takes one death to be a tragedy, but it’s not a reflection of running in particular.”
Glen Mays is an associate professor and chairman of the department of health policy and management at the Boozman College of Public Health at UAMS in Little Rock, as well as the winner of the 2004 Little Rock Marathon. He said deaths like those of Shay and Nickel are anomalies not specific to runners.
“It does concern me that these events can diminish enthusiasm for the sport and unnecessarily raise concerns,” Mays said. “These are rare heart conditions. Running might trigger an event like this, but any kind of activity may have. It’s really unfair to think about running even adding to that risk. There’s a risk any time you have an underlying heart condition, whether you are mowing the lawn or walking the dog.
“ Ultimately [Nickel’s death ] is not a reflection of the risks of the sport. For most of us, running is going to dramatically improve cardiovascular health.”
The Arkansas running community has certainly taken notice of Nickel’s death, Torrey said, but most are not slowing down. Nor is there a reason to, Torrey said. Nickel’s death was tragic, but very difficult to prevent.
Instead, runners and the marathon organizers can learn from it. Torrey said they have.
“The enthusiasm is still there,” Torrey said. “I don’t see anyone backing off doing anything. That comes on a 1-to-1 personal basis. I don’t think Adam’s death affects how they’ll train. Their own personal experience makes them determine if they want to run or not run.
“ There are things you learn. As race director, we need to be prepared for a simple blister to a heart attack and everything in between. As a runner, the thing you learn from this is make sure you are healthy before running a marathon.”