Spain yet to discover the root of cardiac problems among players

When the final whistle blew, the cameras closed in as the two men embraced. These were not adversaries recognizing each other's merits after the most honorable of contests. Nor were they teammates sharing the spoils of victory. In fact, they weren't footballers at all. But they were heroes. Together, the two doctors, José Ignacio Garrido and Tomás Calero, had just saved someone's life. Live on TV.

It all started in the 61st minute of a Second Division match between UD Salamanca and Real Betis on Sunday. In the middle of the pitch, Miguel García stumbled a couple of yards and then fell forward, flat on his face. Motionless. Suddenly, there was a commotion. Panic took hold. Players' heads were in hands, there were tears and terrified looks. García's heart had stopped. Fortunately, with Garrido and Calero running on the pitch, García was resuscitated with the aid of a heart defibrillator.

"He was dead for 25 seconds," Calero said.

As he came around, relieved footballers made thumbs-up gestures to García's terrified family in the stands. Everyone had feared the worst. The same names had come into everyone's minds: Antonio Puerta and Dani Jarque.

Seville defender Puerta died of a heart problem after collapsing on the pitch during a match with Getafe in 2007; Jarque, the Espanyol captain, died because of heart failure during the preseason in 2009. They weren't alone. Ruben de la Red collapsed while playing for Real Madrid in 2008 and has not been able to return. Sevilla's Sergio Sánchez, who had surgery for a heart condition earlier this year, also remains sidelined.

García has been told that he almost certainly will not play again. But at least he is still alive. It may not feel like it to them, but García, Sánchez and de la Red are, on one level at least, the lucky ones.

In total, seven professional players in Spain have died because of heart problems in the last decade, the most recent being Jordi Pitarque, from Third Division side Reus, last month. That compares unfavorably to one during the 1970s, two during the 1980s and one during the 1990s.

There have been six cases in the last three years alone: Puerta, Jarque, Pitarque, de la Red, Sánchez and García. Until 2002, according to the sports daily Marca, there were just four cardiopathological episodes; since then, there have been 10.

That also compares unfavorably to other countries. According to the latest figures from the Spanish Cardiology Society, Spain has about 40,000 fatal cases a year. Proportionately, the number is higher among footballers. In the last decade, there have been only a dozen fatal cases for pro players worldwide -- and Spain accounts for a large proportion. On Sunday, the country feared another.

All of this leads to a series of questions:

Why are there so many cases in Spanish football at the moment?

First, one caveat: Although the cases appear similar, there are differences and they should not necessarily be lumped together. Puerta died because of a dysplasia, a defect in the generation of cells in the heart, which creates an uneven heart rate. His case is similar to those of Pitarque and De la Red. García, on the other hand, had a heart attack caused by a buildup of cholesterol in the artery walls -- normally suffered by much older people.

Javier Ceballos, the doctor at Racing Santander, believes the apparent increase could be, at least in part, a statistical anomaly. Although Ceballos admits that, at an average of one case in 300,000 people, the figure is "high" and should not simply be dismissed, there is not a single scientifically convincing reason. More research is certainly needed. Dr. Villacastín, chief of Arrhythmia at the Madrid Clinic, told Marca that the number is "notable, especially among elite footballers." But López Farré, who runs the center for Cardiovascular Research in Madrid, said, "That is skewed by the sheer numbers that play football compared to other sports."

Is modern football too demanding? Are players training too hard? Is their diet too strict? Could that explain the increase?

"When I played, things like this never happened," Rayo Vallecano coach Pepe Mel said. He suggested that changes in the game might have caused the increase and hinted at other, extraneous factors.

"Football has to reflect on this. It never used to happen and now it seems to happen every so often," he said. "We have to analyze the causes. I don't know why -- if it is because of nutrition, training sessions, stress, the demands of the competition. There are so many games."

One First Division club doctor, though, dismisses that suggestion. Spain's Cardiology Association recently pointed out that footballers have bigger hearts than the average, but the strain on the heart is still relatively low compared to that demanded of athletes in resistance-based sports, such as cycling, rowing or marathon running.

"The intensity demanded of professional football is nothing, virtually a joke," the doctor said. "There are so many clichés said about football -- players can't play two matches a week, they can't cope with the pace, etc. It's a myth. The physical demands made on footballers are not that great in medical terms."

The doctor gives equally short shrift to Mel's suggestion that changesd in diet may play a part. "Back then, you would have a steak and chips before the game," the doctor said. "Now it seems like that's not allowed, that's total rubbish."

What about drugs?

Mel's suggestion seemed to hint at the awkward question that many have raised. Could this be an indication of drug use? Some have pointed the finger at the Operación Puerto doping case in Spain. All 34 sportsmen named were cyclists, but that is only a fraction of the 200 athletes thought to have been "treated" by Dr. Eufemiano Fuentes. "There were well-known football players who visited him," cyclist Jesús Manzano said. Elsewhere, there is a suspicion that Spain does not pursue drug abuse with sufficient intensity.

Again, though, doctors are skeptical. There is a fear that within players' entourages the potential exists, in isolated cases, for someone to gain a footballer's confidence and "convince him that so-and-so supplement or so-and-so drug will help him, even when it won't -- they are complete charlatans," a club doctor said. But one doctor maintains that drug use is low, saying he has seen no cases in more than 20 years in the game; unlike in other sports, he reasons, performance-enhancing substances are not decisive in football, notwithstanding the unscrupulous behavior of some hangers-on. Besides, he adds, the evidence to link drug use to heart failures is patchy, although it is true that some substances do increase heart rates dangerously.

More important, in the vast majority of cases, tests following episodes have revealed long-term pathologies. Preexisting heart defects have been discovered, as was the case with de la Red and Pitarque. García had suffered blood clots while at Zaragoza B. The Spanish Cardiology Association has asked for access to all the autopsies so it can investigate fully and seek connections. The focus is very much on prevention, on not allowing risky cases with existing pathologies to play football. Genetics, rather than environmental factors, are currently considered to be the key.

So, is enough being done to discover preexisting heart problems?

Sánchez's dilated aorta was found thanks to tests by Seville. But the Italian newspaper Gazzetta dello Sport says the tests are still not stringent enough. Madrid correspondent Filippo Ricci underlines the difference between the tests in Italy, where heart defects were uncovered in players like Nwanko Kanu (who continued playing) and Khalilou Fadiga. Tests begin younger, take into account family histories and are more intensive. There has been just one death in Italy since the 1970s.

Heart problems are extremely difficult to detect, but Spain could perhaps do more. Doctors in Spain confirm that the problem is not so much a medical one as a footballing one -- it is often a question of priorities and resources. Spain's cardiologists are among the best in the world but they are rarely involved. There is neither the time nor the resources to carry our full screening on young children involving echograms and artery scans. And without the very best cardiologists, detection is virtually impossible.

"When clubs sign players, they are far more focused on getting the paperwork done than anything else," one insider said. "There's a sense of, 'Here, sign this, we'll do the medical stuff later.' It gets done but not always by the best people. Footballing haste, footballing needs, take precedence over medical tests."

Said Racing Santander's Ceballos: "Tests are expensive and difficult. Maybe there needs to be a change of culture and commitment in that sense; we have to do this with the best cardiologists, specialists in their field. We need to be a bit more rigorous, there need to be echograms and full tests. And we need to get that right together. We must be a little more committed."

Are things improving?

The good news is: Yes. For Puerta and Jarque, for the seven players who have died since 2002, it is too late. It is also an unpleasant truth that nothing forces improvements into the game more than tragedy. And nothing underlines that more clearly than last weekend.

Since Puerta's death, every club in Spain's professional league is required to have very specific medical kit. The kit costs $6,000 and includes 22 items. One of them is a defibrillator, the instrument that restarted García's heart after 25 seconds. Spain's clubs have had the kits only since 2007, after the tragic death of the Seville defender. As Dr. Tomás Galero of Betis put it: "Puerta saved García's life."