Fatal collapse reopens diagnostic debate


Reggie Lewis' fatal collapse on a practice court was sure to rekindle a bizarre medical debate that arose last spring after he received conflicting advice after passing out during an NBA playoff game in April.

Initially, a team of cardiologists at the New England Baptist Hospital concluded that he suffered from a life-threatening heart abnormality -- focal cardiomyopathy -- that ruled out any further exertion. His career appeared over.

Apparently unhappy with the advice, Lewis sought a second opinion at the Brigham and Women's Hospital in Boston, where Dr. Gilbert Mudge performed further tests and concluded that Lewis had "a normal athlete's heart."

Mudge said he had a fairly benign condition called neurocardiogenic syncope. It meant that a confusion in the electrical signals running between the brain and the heart was causing the heart to slow down at inappropriate moments.

The result was a fainting spell -- but nothing more serious than the spell that could be produced by a sudden fright. And with proper medication, there was no reason why he could not resume play, Mudge said.

To many heart specialists, the diagnosis was unusual, even stunning considering the circumstances of Lewis' collapse.

Dr. Michael Gold, director of electrophysiology at the University of Maryland Medical Center, said such fainting spells ordinarily occur in precisely the opposite situation -- when someone is at rest.

"It's a complex question," he said. "Neurocardiogenic syncope is not a life-threatening condition and it does not mandate that people change their activity. But I should point out that it does not occur while playing basketball. It typically occurs when you're at rest, while under some stress but it rarely occurs while being active, particularly when you're vigorously active."

Mudge submitted the athlete to a "tilt table" test in which a patient is suddenly switched from a horizontal to a standing position. In people with neurocardiogenic syncope, this sudden switch can produce the symptoms.

But the test, he said, has its problems. A quarter of the people who don't have the condition will show the symptoms. And 20 percent of the people who do have the syncope won't show any symptoms at all.

If Lewis indeed suffered from cardiomyopathy -- a weakening of the heart muscle -- he certainly should not have engaged in sports, Gold said. The disease can produce abnormal heart rhythms that are more likely to occur with extreme exertion. It is a classic cause of sudden death.

Dr. Kenneth L. Baughman, a heart specialist at the Johns Hopkins Hospital, said an autopsy is probably the only way now to learn whether he had the problem.

Ordinarily, he said, the diagnosis can be made without much problem when the patient goes to the hospital with his initial symptoms. What puzzled Baughman is that he was examined by excellent physicians in both cases.

"We have to assume that there's something very peculiar about his findings and about his studies that made it problematic," he said of Mudge, who is certain to be the object of much second-guessing.

"It's so uncharacteristic for Gilbert Mudge to go out on the limb with advice like this, I'd have to assume that the evidence was strong that it was neurocardiogenic syncope. We'll have to wait for the post-mortem."

But Dr. Mark Estes, a member of the original cardiology team, said Lewis' death confirmed their diagnosis of cardiomyopathy. "Yes, this means we were right," Estes said.

But he stressed "this is going to be a very difficult time for everybody -- for Lewis' family, the Celtics, fans and physicians involved in his care. The wrong thing to do is point fingers and assess who's responsible."

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