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Commotio Cordis and Sudden Cardiac Arrest: Interview With Matthew Martinez, MD
EP Lab Digest talks with Matthew Martinez, MD, Director of Sports Cardiology at Atlantic Health System and Morristown Medical Center in Morristown, New Jersey, about commotio cordis and the risk for sudden cardiac arrest.
Please introduce yourself.
Dr Martinez: I am Matthew Martinez, MD, Director of Sports Cardiology at Atlantic Health System and Morristown Medical Center in Morristown, New Jersey.
What is commotio cordis?
Dr Martinez: Commotio cordis is sudden cardiac death secondary to a blunt or nonpenetrating blow to the chest. It is really a primary arrhythmic event, but it is important that the chest blow does not cause direct structural damage to the heart itself. It actually is timed like an R-on-T phenomenon, where it lands during that vulnerable portion of the heart. At the time of that T wave, if it lands during that segment, it puts the heart into ventricular fibrillation (VF) and is a known cause of sudden cardiac death in young athletes.
How common is commotio cordis as a cause of sudden cardiac death in athletes?
Dr Martinez: It is listed as one of the known causes of cardiac death in athletes, but in general, we would consider it a diagnosis of exclusion and somewhat of a rare cause. There are at least 200 confirmed cases of commotio cordis based on publications, but it is reasonable to consider that this underestimates the entire number of events, because you have to link a chest blow with a cardiac arrest afterwards, and then identify no structural cause. So it may end up falling into that category in a lot of publications as an unknown cause of sudden death, because either people did not witness this or make the connection between the blow to the chest and the event for sudden death. It usually affects young people. We typically think of this as being more common in the teenage years, with an average age of 15 years old, based on the National Commotio Cordis Registry. About 10% of cases occur in those older than age 25. We often think about this as mostly occurring in sports with a projectile involved, like baseball, lacrosse, or hockey, where there is a high-velocity object that lands in the middle of a chest, timed at that important part of the cardiac cycle that leads to VF. But it has absolutely been reported in other contact sports such as football. It seems to be predominantly men—over 90% of cases are in male athletes, and about 75%-80% occur during competitive sports compared to recreational sports.
Discuss the importance of increased awareness of commotio cordis as well as CPR training and widespread access to automated external defibrillators.
Dr Martinez: I think maybe the most important message is recognition of a traumatic chest wall impact can lead to sudden death. The only method to undo a cardiac arrest is a defibrillator that can shock the heart back into normal rhythm. So, the importance of an emergency action plan and automated external defibrillator (AED) cannot be overstated, and it is important to recognize that no matter what we do, there will never be a completely successful screening program that will eliminate the risk for sudden death. That is because commotio cordis actually occurs in structurally normal hearts. They have no known history of myocardial or electrical disease or anomalous coronary arteries in this younger group. It is a structurally normal heart. You would expect that any prescreening assessments to be normal. It is really bad luck, since it lands at that inappropriate time in a normal heart, so there is nothing to identify ahead of time. By definition, afterwards there is no residual damage to the heart for commotio cordis. The only way to improve outcomes is recognition that commotio cordis occurs, that there are particular sports—such as projectile sports—that are higher risk, and that any trauma to the chest that leads to a fainting episode should be considered cardiac arrest or cardiac death until proven otherwise. So, executing an emergency action plan with early action of an AED is the best process to ensure safety of athletes, whether it is a high school athlete, college athlete, or professional athlete. It is the most important part of a plan for the health and safety for athletes, no matter what age, sport, or venue.
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