By Dennis Read
Dennis Read is an Associate Editor at Training & Conditioning.
Training & Conditioning, 14.5, July/August 2004, http://www.momentummedia.com/articles/tc/tc1405/heartstops.htm
It can happen anywhere at anytime. Sometimes there’s a sign of what’s to come, often there’s not. During the past year it occurred in settings as disparate as a lacrosse game in upstate New York and an empty basketball arena in Texas. But whether sudden cardiac death occurs from a traumatic injury or an underlying condition, people are left asking what can be done to prevent it from happening again.
The sad reality is that these deaths are sometimes not preventable. However, people around the country are taking steps to try to reduce the risk of sudden cardiac death, from identifying those athletes most at risk to developing equipment that might better protect the heart.
When George Boiardi died on March 17, the shock waves reverberated from one college campus through an entire sport. A senior captain on Cornell University’s men’s lacrosse team, Boiardi died after being struck in the chest by a shot late in a game against Binghamton University. If Boiardi had a chance to survive, everything was in place to make that happen: Athletic trainers responded immediately, an on-site AED was used, and EMTs arrived minutes later. Yet none of these efforts could save Boiardi.
Unfortunately, the lacrosse world was already familiar with this type of scene. Boiardi was the third collegiate lacrosse player in five years to die after being hit in the chest by a ball. A high school player also died the same way during that span.
The exact cause of Boiardi’s death will never be known. At the request of his parents, no autopsy was performed. But the dangers of a blow to the chest are no secret. The three previous lacrosse deaths were blamed on commotio cordis, which occurs when a non-penetrating blow to the chest directly over the heart during a very narrow phase of the heart beat causes ventricular fibrillation, or other types of arrhythmia, in an otherwise healthy heart. In an article published in Progress in Biophysics & Molecular Biology, Mark S. Link, MD, of the New England Medical Center, Tufts University School of Medicine, reported that the vulnerable period lasts only 10- to 30-thousandths of a second.
Commotio cordis is believed to be rare, although the exact number of cases is not known. The Commotio Cordis Registry in Minneapolis has documented more than 150 cases since it formed six years ago and typically adds between five and 10 cases per year. But many past deaths likely went undiagnosed and other cases may still go undocumented.
The risk of commotio cordis extends far beyond lacrosse. Of the 128 cases recorded by the Commotio Cordis Registry through 2001, 62 percent occurred in participants in organized sporting events, ranging from youth to professional sports. Of those, 46 involved baseball or softball while 13 involved ice hockey. Five came in lacrosse. In most cases, the speed of the ball or puck was typical for the sport. At higher speed, physical damage to the heart also becomes a danger.
High school and youth athletes appear to be most at risk of commotio cordis. The average age of victims was 14 years and nearly 80 percent of cases occurred in people under 18. Some researchers have attributed this to younger athletes having a more pliable chest wall.
The search for ways to reduce the risk of traumatic heart death continues. Within lacrosse, both equipment and playing rules are being looked at with an eye toward reducing risk.
“We’ve got to do something,” says NCAA Lacrosse Rules Committee Chair Willie Scroggs, Senior Associate Athletic Director at the University of North Carolina, where he was previously the Head Men’s Lacrosse Coach. “We can’t just sit back and say, ‘I hope it doesn’t happen again,’ if there are things we can do rule-wise, technique-wise, or equipment-wise.”
The US Lacrosse Sports Science and Safety Committee has recommended changing the rules of the game to penalize players who intentionally try to block shots by stepping in front of the ball. US Lacrosse Executive Director Steve Stenersen sent letters to both the NFHS and NCAA rules committees asking them to consider a similar change.
Some college coaches, though, aren’t waiting for the rules to change. “Hockey players dive in front of the puck all the time, but I’ve taken that type of thing out of my coaching repertoire,” says Dave Urick, Head Men’s Lacrosse Coach at Georgetown University. “It’s not something we teach or encourage them to do anymore, and that’s a direct result of what’s happened to these young men. I just felt like it made sense from a safety standpoint.”
Efforts are being made on the equipment front as well. Under current lacrosse rules, only goalies are required to wear chest protectors, most of which are similar to those worn by baseball and softball catchers. Other players must wear shoulder and arm pads, but unlike the equipment worn by many hockey players, very few lacrosse pads offer chest protection. Scroggs says that equipment manufacturers are working with coaches, players, and medical experts to develop more protective equipment, but he doesn’t expect to see anything new introduced before next season because of the development and testing involved.
Equipment may not provide the full answer, anyway. Of the 79 athletic deaths recorded in the Commotio Cordis Registry by 2001, 28 percent happened to players wearing standard chest protection for their sport at the time. Although some football and hockey players suffered their injuries when they were struck directly in
the chest by objects that evaded the protective equipment, seven cases involved baseball catchers and hockey and lacrosse goalies who suffered commotio cordis despite having their chest protectors take the blow.
Link and his fellow researchers conducted an experiment with anesthetized pigs wearing commercially available chest protectors designed for youth baseball players. The pigs were hit in the chest with baseballs fired at 40 miles per hour. These researchers found that the likelihood of ventricular fibrillation in pigs wearing chest protectors was not statistically different from those not wearing chest protectors.
While chest protectors may not offer full protection from commotio cordis, some people believe they are still an important tool in reducing risk. In May, the NATA Age-Specific Task Force issued a statement on commotio cordis that suggested the use of all-purpose chest protectors during practices and games as a way to reduce the danger.
At the same time, researchers are looking for ways to construct chest protectors that offer more protection from commotio cordis. Most current equipment is designed to protect against physical trauma, including that which might directly damage the heart. The key will be finding a way to disperse the force of the impact over a larger area so that less of it is transmitted to the heart, reducing the chance of sending it into ventricular fibrillation.
“Research is finding that certain chest protectors don’t work,” says Keith Gorse, MEd, ATC, Clinical Coordinator and Instructor in the Department of Athletic Training at Duquesne University. “What we’d like to do within the NATA is work with US Lacrosse to research the newer chest protectors that are designed to disperse pressure away from the heart and see if they work.”
In the meantime, Gorse advises athletic trainers to decide what will work best for their athletes. “Chest protectors are a big question right now,” he says. “A lot of people are for them and a lot of people aren’t. The most important thing for athletic trainers to do is to research the different types of chest protectors that are out there before buying them.”
Link’s study did find some promising prospects for treating commotio cordis, as long as treatment can be provided quickly. Test animals who received defibrillation after one or two minutes of ventricular fibrillation survived 96 percent of the time while the survival rate fell to 46 percent after four minutes and 25 percent after six minutes. In real life events, the Commotio Cordis Registry reported that 25 percent of those who received resuscitative measures in less than four minutes survived, while in 38 cases of delayed resuscitation only one person survived. These figures emphasize the importance of quick and proper treatment.
“Determine what the problem is as soon as possible, start CPR, and get an AED on that person right away,” Gorse says. “There’s a better than 50-50 chance of survival if you start caring for the person within a minute. But this means making sure there’s an AED on site—it can’t be 400 yards away.”
While awareness of commotio cordis is relatively new, medical professionals have long been aware of the connection between athletic participation and sudden cardiac death from non-traumatic causes. The exact prevalence of sudden cardiac death in athletes is unknown, but estimates ranges from one death in 200,000 athletes to one in 300,000 per year.
The most common cause of sudden cardiac death in athletes is hypertrophic cardiomyopathy, which is a thickening of the heart. In a June 2004 article in The Physician and Sportsmedicine, Dennis Wen, MD, Associate Professor of Family and Community Medicine at the University of Missouri, says that fatal cases, hypertrophic cardiomyopathy usually causes arrhythmias, such as ventricular fibrillation (unsynchronized heartbeat) or ventricular tachycardia (rapid heartbeat). It can strike without warning, although some victims have histories of chest pains, fatigue, syncope, and palpitations.
Wen reports that echocardiography is considered the “gold standard” in diagnosing hypertrophic cardiomyopathy, but still has several limitations. First, hypertrophic cardiomyopathy may not be apparent until an athlete has reached full maturity, meaning a high school athlete may still be at risk, even if he or she has previously received a negative test. Second, some people with hypertrophic cardiomyopathy have very little risk of sudden cardiac death, but little is known about who is at risk and who is not. In addition, heart murmurs, once considered an effective screen for hypertrophic cardiomyopathy, are apparent in only a small number of people with the condition.
Electrocardiograms may show signs of hypertrophic cardiomyopathy, but they also may not. As a result the first symptom often is death.
Wen reports that the second most common cause of sudden cardiac death in athletes is coronary anomalies. These can lead to ischemia, arrhythmia, or low blood flow into the coronary artery.
These conditions may produce fatigue, chest pains, and syncope, but not always. Wen suggests coronary angiography as the most reliable means of finding these anomalies. Echocardiography, especially transesophageal echocardiography, is also helpful.
Other rare causes of sudden cardiac death include myocarditis and arrhythmogenic right ventricular dysplasia (ARVD). Myocarditis, which is an inflammation of the heart’s muscular wall, can result from a variety of causes including viruses and bacteria, and may be indicated through echocardiograms in some cases. ARVD affects the muscle in the right ventricle and can cause abnormal heart rhythms. Electrocardiography and echocardiography can both be helpful in detecting ARVD, however, some doctors consider MRIs to be more accurate.
To Screen or Not?
Since sudden cardiac death can and does occur without any prior symptoms, the focus has been on screening for those who may be susceptible to these diseases. Unfortunately, no single test will identify every athlete at risk for sudden cardiac death. These conditions can even go undetected in someone who receives a full battery of tests.
No matter how hard you look, you may miss one. And there’s a chance that you will misidentify some athletes who are not at risk. So the dilemma becomes how hard to look. The answers vary depending on where you’re sitting.
“You can add layers and layers of screening tests, but a few are still going to slip through no matter what you do,” Wen says. “The whole problem is that these are such rare conditions. Things that are rare require screening methods—whether they be histories or echos or whatever—that are both extremely sensitive and extremely specific. None of the things we do now even come close to the levels of specificity and sensitivity needed to be useful for something this rare.”
Many people liken the screening process to searching for a needle in a haystack. Researchers estimate that, on average, finding one person with a condition that may lead to sudden cardiac death requires screening 200,000 people, making the odds of finding one at any school very remote. In addition, there are the problems created by false positive and false negative results.
“So the question is, when does it become worthwhile to keep adding layers and layers of screening tests only to find a few more cases, when the majority will still slip through?” Wen says. “If you screen enough kids you’ll find a positive here and a positive there, but does that justify doing millions of tests? Some people say it is worth it to find that one needle in the haystack. Other people say it’s not. In my article, I chose to argue that it’s not worth doing all that testing just to find that one needle.”
Ramon Brugada, MD, Director of the Molecular Genetics Program at the Masonic Medical Research Laboratory in Utica, N.Y., which studies cardiac arrhythmias and cardiac disease, holds a different view. Brugada believes that every high school athlete should receive a cardiological exam. “In Japan, everybody gets an electrocardiogram before puberty, and in Italy every newborn gets an electrocardiogram,” he says. “The benefit of doing the electrocardiogram overshadows the concerns about cost and economical issues. Schools require vaccinations, so why not require an EKG to make sure that everything is fine? The reality is that 99 of 100 patients will be fine, but the single guy who drops dead at age 14 while running at school justifies the testing.”
Others aren’t so sure. Michael Koester, MD, FAAP, ATC, CSCS, Primary Care Sports Medicine Fellow at Vanderbilt University, served as a high school team physician in Oregon for the past five years and recommends against doing full cardiological exams on all athletes.
“In times of limited budgets and limited resources, I’m concerned that if people start doing EKGs and echos, it will become the standard of care,” he says. “Parents will think, ‘They’re doing this at that school, why aren’t they doing it at my kids’ school?’
“There’s no single test that we can do that will prevent every case of sudden cardiac death, and my biggest concern is the high rate of false positives,” he continues. “Even if you had a test that was close to perfect, you’re going to get thousands of kids who are going to test false positive. And what do you do with those kids? You can tell the parents the kid may be at risk of sudden cardiac death, then they go through test after test only to conclude that the kids is at a risk that is difficult to quantify.
“Or after scaring them half to death, you tell them, ‘Nope, that was a false positive and they aren’t at risk of dying suddenly during athletic participation.’ How much does that weigh on the parents, along with the financial cost of having to do more referrals?”
For schools that do opt for testing, there is some debate about which tests are the best ones to do. Echocardiograms check the blood flow in the heart and are better at catching heart abnormalities such as hypertrophic cardiomyopathy. Electrocardiograms, meanwhile, are more likely to find rhythm disturbances, such as Wolff-Parkinson-White or long QT syndrome.
Some schools are employing an outside company to administer echocardiograms to their student-athletes. These tests are provided at a flat rate, often around $60. In some cases, all athletes are tested. In others, athletic trainers simply make the testing available for those willing to pay for it.
In the Myrtle Beach (S.C.) school district, administrators considered adopting such a program before deciding to stick with the more traditional screening program they have been using. “We have nine high schools in our district with several thousand students who participate in athletics,” says Jim Berry, MEd, ATC, SCAT, NREMT, Director of Sports Medicine and Head Athletic Trainer at Myrtle Beach (S.C.) High School. “It was a situation where, if we offered it, who would take advantage of it? Since we couldn’t afford to cover the cost, was it fair to only test the kids who could afford to have the test done?
“We discussed scheduling a time and sending a letter out saying, ‘We’re offering this opportunity if you want your child tested,’” he continues. “But what if a kid gets tested, it comes back negative, and they drop dead two weeks later? What liability will we have? So the district and the athletic trainers decided at this point it wasn’t something we wanted to explore any further. We felt like the system we had in place was appropriate.”
Focus On Exam
Instead of expensive screening tests, Koester suggests that schools rely on good preparticipation physical examinations, including a thorough cardiac history, to help shrink the haystack by identifying athletes who should receive closer examinations. “The most important thing that they need to include are the guidelines set out by the American Heart Association, looking mostly at family history, the athlete’s own history, and physical exam findings,” he says. “There is a history form recommended by the American Heart Association, the American Academy of Pediatrics, the American Academy of Orthopedic Surgeons, and the American Academy of Family Practice Physicians, which is available in the Preparticipation Physical Exam monograph. It’s not perfect, but it’s as close to perfect as we have when you look at cost-to-benefit ratios.”
Koester feels strongly enough about the importance of a thorough preparticipation physical exam, including cardiac history, that he suggests funding those efforts first. “I think athletic trainers are being pushed in the direction of buying expensive pieces of equipment like AEDs,” says Koester. “AEDs are great, but number one, sudden cardiac death happens in about one in every 200,000 athletes, so the odds of having an athlete need an AED are slim. Number two, there is no great evidence that automatic external defibrillation is going to reverse the process of these kids who go into a terminal arrhythmia.
“I think having those devices is great, but the person you’re most likely to use them on is the referee or someone in the stands,” he continues. “I think funds can be pushed in that direction, but there won’t be a great return on them. The best thing to get is a thorough history and physical exam.”
Berry leans heavily on cardiac histories to identify athletes who may be at risk of sudden cardiac death. “What we’ve done, and what South Carolina has done through its official physical form, is to strengthen the cardiological part of the history form,” Berry says. “It used to be that a lot of physical forms would just ask, ‘Have you ever had chest pains?’ Well, chest pain can be caused by a lot of things. So now we have a separate cardiac history section with nine specific questions that the kids or their parents must answer about their cardiac history. The family history is important because there is such a strong relationship between what’s happened with the mother or father and what tends to happen with the children.”
Jody Jenike, MEd, ATC, Head Athletic Trainer at Xavier University, also relies on the cardiac history as a primary screening device. “We have a five-point questionnaire, and a certified athletic trainer will ask the student-athlete each of those questions to make sure they’re honestly answered,” Jenike says. “And we ask them these questions in addition to the form the family fills out in the summer, so there are checks and balances.”
Listen to the Heart
Jenike also emphasizes the importance of a thorough physical examination. One of her athletes was found to have an atrial septal defect—a serious, but not life-threatening, heart problem—through an echocardiogram, which is performed on all members of the school’s men’s and women’s basketball teams. But Jenike believes the condition should have been caught earlier when the player received a preparticipation physical exam.
“At the time, we were working with an internist who was very good at discerning a murmur as being a one, two, three, or four,” Jenike says. “In a quiet room, he could tell you where it was, and he worked alongside our cardiologist. At the time we did the player’s physical, the internist was running late and a physician’s assistant happened to listen to her heart. So she was halfway through the physical and onto the orthopedist when the internist arrived. Had we not done the cardiac exam we would not have picked this up.
“We don’t have a PA listen to the heart anymore,” she continues. “PAs can help with physicals, but my feeling is you should have an internist—who can be given a quiet room—listen to the heart. Everybody dreads the mass physicals and wants to get through them but I think it’s worth an extra two minutes per kid.”
Koester says that any primary care physician should be able to pick up murmurs, be it a pediatrician, internist, or family practice doctor. “In some states, physician assistants and nurse practitioners are licensed to do the PPE and I think that’s reasonable—if they have the appropriate training, which many of them have,” he says. “But I don’t think the chiropractors and naturopaths are able to show that they have the proper training in cardiovascular disease and cardiovascular physical exams to be able to perform the exam. If they can show that they have had training, that’s another thing, but with the standard level of training that they have in detecting cardiac disease, I don’t think they should be performing those exams.”
Koester also suggests putting some thought into who checks the athletes’ blood pressure. “One thing that is often overlooked is whether the people taking blood pressures know what they’re doing,” he says. “To get accurate measurements, make sure you have good cuff sizes, that you’re in a quiet area, and you have nurses or ATCs who are good at measuring blood pressure.”
In addition to taking a detailed history and having an internist listen to the heart, Jenike also screens athletes for risk of Marfan syndrome by measuring their arm span. Marfan syndrome is most often found in tall, slender people with unusually long arms and legs, and can result in a weakened aorta.
All athletes who raise any red flag through their physical exam or cardiac history are then sent to a cardiologist for a full cardiological evaluation. Koester recommends that, when possible, it’s best to send the athletes to a cardiologist who is familiar with sport medicine.
Preventing heart-related deaths is not straightforward by any means. But for each individual situation, the best strategy, Jenike says, is to keep up with the advances in detection techniques and keep moving your screening program forward.
“Everybody lives within their own comfort zone,” Jenike says. “Some schools are out in rural areas where there may not be a cardiologist nearby. But could they have an internist who is experienced listening to the heart brought in from a hospital on the day of the physicals and have the athletic trainer ask the history questions? I believe they can. And the kids who are at risk get sent for further evaluation.
“Comfort zones are influenced by money and time,” she continues. “You have to jump in the water somewhere before you can swim. You have to take a step and then improve it each year. If you keep saying you can’t do it because of this or that, you’ll never get there. I believe in having a one-year, three-year, and five-year plan, and you push each year to add things.”
You also need to pay attention to any signs or symptoms that can crop up when you least expect them to.
“It’s important to be aware that there are some signals the heart gives out that indicate something is amiss,” Brugada says. “If there is anything you don’t feel is normal, seek help. For example, passing out is not a simple thing. It’s a very complicated issue and because of the possible implications [of serious heart problems] it’s something that has to be taken extremely seriously. Athletes should not be passing out.”
But, in the absence of symptoms, Wen says it’s important for athletic trainers to explain to parents and other interested parties just how unusual these deaths are. “I think they need to stress the rarity of this and let people know that athletics are still safe and their sons or daughters on an athletic team are probably not at risk of dying,” he says. “We’re talking about an extremely rare thing. And sports and athletic activities—whether recreational or organized—are still very safe. There’s still a lot more to be gained from participating in athletics than not, so you shouldn’t be scared off by the publicity over athletic deaths.”
For more information on commotio cordis, go to www.la12.org/articles/med-research.htm. This page is part of the Louis J. Acompora Memorial Foundation Web site. Acompora was a 14-year-old high school lacrosse player from Northport, N.Y., who was killed by commotio cordis in March, 2000.
For more information on the American Heart Association recommendations for preparticipation physical exams go to www.americanheart.org and type “preparticipation” in the search window.