The tendency, in the wake of the sudden death of a young athlete, is to demand answers, to look for reasons for how it could have happened.
How could Bears defensive end Gaines Adams, an apparently otherwise healthy 26-year-old, succumb to cardiac arrest or sudden cardiac death (SCD)?
Preliminary findings show he had an enlarged heart, which sounds scary and awful and surely the cause of death. It also sounds like it could have been detected early to prevent such a tragic event.
But it is not that easy. Nor is it entirely accurate.
While it could take weeks, even months, for any sort of conclusive resolution on Adams' death, the variables are endless and an enlarged heart is not a diagnosis.
Speaking in general terms and not about Adams' case specifically, Dr. Robert Bonow, chief of cardiology at Northwestern Memorial Hospital, said an enlarged heart in an athlete is "a normal response to the extra work they do. That's normal."
But an enlarged heart can also be an indication of many serious conditions, including hypertrophic cardiomyopathy (HCM), a condition in which heart muscles thicken that is a leading cause (accounting for 26 percent) of sudden death among athletes.
As part of the collective bargaining agreement, every NFL player undergoes an annual physical exam that includes an electrocardiagram (EKG) to detect heart abnormalities, typically during the May minicamp. But stress testing and an echocardiogram -- an ultrasound which allows the doctor to study the size of the heart and strength of the heart muscle, but is also more costly -- are typically only done if abnormalities are detected in the EKG.
"Over the last 25 years, the NFL has been doing EKGs when players are drafted and specifically looking for issues [such as HCM]," said Dr. Christine Lawless, on the faculty of the University of Chicago and certified in both cardiology and sports medicine. "It will be interesting to see if when [Adams] went through [the NFL draft] in 2007, whether an echocardiogram was done? This is the general NFL approach it may provide some clue as to what happened to Adams."
Beginning in the 2006-07 season, the NBA became the first major sports league to standardize its physical exams, which included EKGs and echocardiograms, in the wake of the 2005 death of Atlanta center Jason Collier, 28, from an abnormally enlarged heart. Collier's relatives said they had been unaware of any heart problems.
Two weeks prior to Collier's death, the Bulls traded Eddy Curry to the Knicks because of concerns that he might be predisposed to a potentially fatal heart condition after two instances of irregular heartbeats and Curry's refusal to undergo further genetic testing. The Knicks concluded, after consulting numerous cardiologists, that he was not at risk.
In February 2006, before the NBA had announced their upgraded testing, then-Knicks center Channing Frye told ESPN why some players might object. Previously, each team was allowed to determine its own level of testing.
"I think it should be freedom of choice to have it done," Channing said at the time. "Because if you want it done, that means you are going to want it known, that means you are liable for it. But more guys will say, 'I just don't want to know,' and I understand why they say that. More guys have heart problems than what they lead on. If they find out, how are you going to put food on your table, not only for you, but for your family, your uncles, your aunts, your grandma?"
The Bears cannot comment on Adams' physical at the time of his trade from Tampa in October because of the HIPAA privacy rule, but again commenting in general terms, Bonow said that typically a condition such as HCM would have not developed over the course of only a few months.
Bonow said a microscopic specimen taken during the autopsy could determine whether Adams died of a condition such as HCM or other abnormalities, including myocarditis, an inflammation of the heart which is usually caused by viral infection. Pathology results would reveal evidence of any other substances in the blood that could have caused his death, Bonow said.
Lawless, the team doctor for U.S. Figure Skating and a cardiology consultant to Major League Soccer, said that taking a regular history and physicals of athletes may only detect a disease such as HCM "2 to 6 percent of the time."
"The next step, the EKG, can pick it up 50 to 80 percent of the time, but that can open up a hornet's nest for several reasons," she said. "Can we improve on our already low rate of sudden death in athletes here in the U.S.? Who will pay for the EKGs to be done? Professional teams can afford to do so, but it may be more difficult for the collegiate or high school athletic population."
In Europe, and particularly Italy, Lawless said, universal EKGs are performed on athletes and are heavily promoted as having reduced the incidence of sudden death.
"The Italians did this for 20 years and concluded that doing EKGs reduced the sudden death rate in young athletes by 89 percent," she said. "However, after 20 years of using EKGs, they ended up finding that there is roughly a 1-out-of-every-200,000 chance for a sudden death in the young athlete population [under age 30]. Those are the numbers [the U.S.] ended up with from routine preseason physicals."
Lawless presented research to the American Heart Association in November supporting the AHA's belief that universal EKG tests may result in a high rate of false-positive results, prompting unnecessary follow-up tests.
In the case of Adams, hopefully some helpful information can come in the form of a conclusive finding from the autopsy. But if we're looking for rationale for the death of a 26-year-old, it's not likely.
Melissa Isaacson is a columnist for ESPNChicago.com