Prevention and Wellness

Answers to Athletes and Sudden Cardiac Arrest

Premier Health physicians and athletic trainers answers Frequently Asked Questions about Sudden Cardiac Arrest.

What is sudden cardiac arrest?

Dr. Michael Barrow discusses what happens to your body during sudden cardiac arrest. Click play to watch the video or read the transcript.

 

Sudden cardiac arrest is a condition where your heart suddenly and unexpectedly stops beating. It just stops. When this happens, there’s no more blood flow and organs start to die very quickly.

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Is sudden cardiac arrest the same as a heart attack?

Dr. Michael Barrow discusses the difference between sudden cardiac arrest and a heart attack. Click play to watch the video or read the transcript.

 

No, that is not the case. Sudden cardiac arrest is exactly that, when the heart just suddenly and unexpectedly stops. With a heart attack, you typically feel some symptoms. A heart attack is when there is a blockage of an artery somewhere in the heart that keeps blood flow from getting to the heart muscle itself. This damages the heart. You could end up with sudden cardiac arrest as a result of a heart attack, but the two are not necessarily linked.

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Does an individual feel any symptoms before a sudden cardiac arrest?

Dr. Michael Barrow discusses the symptoms people may or may not feel before a sudden cardiac arrest. Click play to watch the video or read the transcript.

 

This is a difficult question to answer because lots of times you don’t have any symptoms at all. All of a sudden you just collapse. If the sudden cardiac arrest is preceded by something else first, say you had a heart attack or you had some type of irregular heartbeat that was sustained, you might feel a fluttering in your chest or you might feel lightheaded or dizzy or pass out.

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Who is at risk for sudden cardiac arrest?

Dr. Michael Barrow discusses who is at risk for sudden cardiac arrest. Click play to watch the video or read the transcript.

 

Anyone with underlying coronary artery disease is the most at risk for sudden cardiac arrest. There are other things that put you at risk, such as if you have a history of irregular heartbeat or a previous sudden cardiac arrest. You are also at risk for sudden cardiac arrest if you have a congenital problem that affects the structure of your heart or if there are electrical abnormalities with your heart’s wiring. The greatest risk is really if you have underlying coronary artery disease with blocked arteries.

Can sudden cardiac arrest be prevented?

Dr. Michael Barrow discusses ways to prevent sudden cardiac arrest in people with known risk factors for the condition. Click play to watch the video or read the transcript.

 

Sudden cardiac arrest can only be prevented if you know you’re at risk for the condition and you address the underlying problems that put you at risk. If you have heart disease, blocked arteries or irregular heartbeats, you are at greater risk for sudden cardiac arrest. If you want to prevent sudden cardiac arrest, then you address the underlying problems.

How do you prevent sudden cardiac arrest in people with no underlying conditions?

Dr. Michael Barrow discusses the difficulty in preventing sudden cardiac arrest if you are not aware of any risk factors. Click play to watch the video or read the transcript.

 

At the end of the day, you can’t absolutely prevent it. All you can do is modify the risk factors that put you at risk for sudden cardiac arrest. But you don’t always know that you’ve got those risk factors. That’s one of the problems we run into in high school athletics. You’ve got a young, healthy population who wouldn’t normally be suspicious for having underlying problems, yet in fact they may have some, which puts them at risk for a sudden cardiac event.

How should sudden cardiac arrest be treated?

Dr. Michael Barrow discusses why using an AED (automatic external defibrillator) is the best way to treat sudden cardiac arrest. Click play to watch the video or read the transcript.

 

The only treatment we’ve got is an AED, the automatic external defibrillator. The AED is the best thing that we have to offer and it works very well, but it’s not 100 percent. Of course, for the AED to work, one needs to be nearby when you need it.

We want to have an AED. The phrase we use is that it’s really the “time to electricity” that makes a difference on how quickly and how well you can revive someone.

You can also do CPR. We don’t want to forget that. If you don’t have the AED immediately available or you’re waiting on the medics to get there, then you want to go ahead and do CPR to do what you can to keep the blood circulating in the body.

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If an athlete survives a sudden cardiac arrest, what are the risks of another incident?

Dr. Michael Barrow discusses the risks of another sudden cardiac arrest for an athlete with an underlying problem who survived a previous sudden cardiac episode. Click play to watch the video or read the transcript.

 

For athletes who survive a sudden cardiac arrest, the first thing we do is stabilize them and get them to a hospital. Then we do a work-up to find out why they had the sudden cardiac arrest and what we can to prevent that from occurring in the future. If there’s an underlying problem that we can fix, then we can substantially reduce, but not eliminate, the risks for recurrence.

Ultimately the athlete is released from the hospital. If there is an existing cause for the sudden cardiac arrest, the athlete may be unable to return to certain sports.

Structural problems with the heart often can be fixed to reduce the risk for a sudden cardiac arrest event. Electrical problems can be managed with an implanted defibrillator, which is a device like a pacemaker. A pacemaker emits a low-level shock on a regular basis to keep the heart beating properly. An implanted defibrillator gives more of a jolt to restart the heart. That’s what we use to prevent sudden cardiac arrest.

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Why is an EAP important?

It’s important to have an emergency action plan (EAP) in place at most facilities because it enables the staff to handle urgent circumstances that they would otherwise be unprepared to handle, according to the U.S. Department of LaborOff Site Icon (USDL).

Having an EAP in place means that different staff members are aware of their role in an emergency situation ahead of time, according to the National Institutes of HealthOff Site Icon (NIH). When and if an urgent situation does occur, staff members can transition to that role quickly. The NIH states that EAP preparation includes having necessary medical equipment on hand, such as Automated External Defibrillator(AED), which can be critical in an effective first response to a sudden cardiac arrest.

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Who does the EAP encompass?

An EAP would include a certain venue’s staff as well as any administrative or coaching staff when a sporting event is taking place, according to the National Institutes of HealthOff Site Icon (NIH). Players and/or parents and family members would not be involved in drills, as those participants vary at each venue, according to the NIH. It’s important to include outside participant in EAP drills and plans, according to the National Athletic Training AssociationOff Site Icon (NATA). Those groups who should be involved are those who would be expected to assist in an emergency situation, such as emergency first responders (EMTs), local law enforcement, and other public safety officials, according to NATA.

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How often should the EAP be reviewed and/or practiced?

Regular rehearsal of an EAP is essential to its success in the event that it’s needed, according to the National Institutes of HealthOff Site Icon (NIH). Many cardiac arrests take place outside of a hospital, so it’s important to have emergency planning in place and practiced for emergencies in which time is critical. Most organizations and venues have drills of their EAPs throughout the year, according to the National Athletic Training AssociationOff Site Icon (NATA). It’s recommended that each organization do a full practice run at least once a year, involving as many potential players as possible, including outside emergency responders and agencies, states the NATA.

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How does an EAP help with early defibrillation in a cardiac emergency?

In the event of a sudden cardiac arrest, live-saving intervention could mean having a response within minutes, according to the National Institutes of HealthOff Site Icon (NIH). As part of their EAP, many organizations and venues are equipped with an Automated External Defibrillator (AED), states the NIH. These devices can be of critical aid in the event of sudden cardiac arrest, as they are constructed for the layman’s use to bring one’s heart back to normal rhythm if they’re having a heart attack, according to the NIH.

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What are the survival rates with AED & EAP in place vs. without?

Survival rates can be very slim in cases where a person suffers a cardiac event without an emergency plan in place, according to the National Institutes of HealthOff Site Icon (NIH). With conditions like heart attack or stroke, time is critical in treating the patient and in keeping the problem from doing further damage, according to the NIH. When emergency plans are in place, survival rates can go up to more than 70 percent where there is an Automated External Defibrillator (AED) in place, according to the National Athletic Training AssociationOff Site Iconc (NATA)

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Athletes and Sudden Cardiac Events

Should cardiac screenings be performed as part of the pre-participation physical in athletics?

Dr. Jeffrey James discusses heart screenings for high school and college athletes. Click play to watch the video or read the transcript.

 

There’s no doubt that there should be a cardiac screen. The debate comes more on what kind of cardiac screen we should be doing. Prior to participating in athletics, everybody should have a physical exam. As part of that exam, what we currently do, and have done for a number of years, is a cardiac screen that involves taking a personal history, a family history and a cardiovascular exam. This exam includes checking cardiac auscultation (heart sounds) and pulses and blood pressure monitoring. The question is whether or not we should be doing EKG screening.  

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How frequently should a cardiac screen be done? How frequently should advanced cardiac testing be done?

Dr. Sean Convery discusses how frequently cardiac screenings and advanced cardiac testing should be done for high school and college athletes. Click play to watch the video or read the transcript.

 

What we like to see is a physical examination once a year while the athletes are younger, from high school down. In college, we do them every two years. The advanced or the more sophisticated cardiac screen, which would be an electrocardiogram (EKG), is now recommended just once, but we're trending toward doing it twice in high school, every two years, and once in college. I see that changing to every two years in college as well.

The reason is that the cardiac system in young athletes develops and changes over time and some of the conditions that exist that could pose a risk to their life may not be fully functional in those athletes until they're older.

So a kid with a normal EKG as a freshman in high school may have an abnormal EKG as a junior in college. The exact time frame or recommended interval for EKG testing is not yet agreed upon. Right now I think most people would agree that in high school a physical examination with a history should be done every year. An EKG should probably be done at least once, maybe every two years in high school. In college, physicals should be done every two years with an EKG done at least once – probably twice while in college.

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What types of cardiac issues can be identified with the current cardiac screening model? 

Dr. Jeffrey James discusses the types of cardiac issues that can be identified with the cardiac screening model used for high school and college athletes. Click play to watch the video or read the transcript.

 

We're trying to pick up a number of things. We're looking for any kind of structural heart disease, such as hypertrophic cardiomyopathy, that may cause heart murmurs or lead to sudden cardiac arrest. That's the biggest thing we're trying to prevent – sudden cardiac arrest or sudden cardiac death in athletes. There are a number of different disease entities that can cause that. Some of them are structural; some of them are genetic, like Marfan syndrome, which causes enlargement of the heart. There are other cardiac anomalies with the blood vessels or abnormal electric activity in the heart.

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Can you identify cardiac issues through auscultation, blood pressure and pulse rate? 

Dr. Jeffrey James discusses what heart sounds and basic screening can reveal for high school and college athletes. Click play to watch the video or read the transcript.

 

There are some findings, such as heart murmurs and abnormal pulses, that we cannot always pick up through the primary cardiac exam. We try to find those signs on the history that we get from the patient. Do they have any history of syncope or passing out during or after activity? Do they have any strong family history of cardiac disease? Do they have any family members who died suddenly of heart-related issues or unknown death, particularly at a young age — younger than 40 or 50 years old? Do they have any history of heart murmurs that a pediatrician or family doctor picked up in previous years? Do they or any family members have any history of abnormal heart rhythms or beats? There are a lot of different parts to the physical exam and the history that can help point us to some of these different pathologies. 

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What types of cardiac issues would be picked up with more advanced testing (EKG)?

Dr. Jeffrey James discusses the cardiac issues that can be uncovered with more advanced testing for high school and college athletes. Click play to watch the video or read the transcript.

 

With the advanced testing, such as electrocardiogram or EKG testing, it can increase the sensitivity in picking up structural or electrical problems in the heart. The difficulty comes with the interpretation of the EKG. Many times the test results are normal. The EKG is an objective test, meaning that it just gives you a print out. But the true activity going on in the heart — the interpretation — can be subjective among providers. If you don't have the adequate training to look at it, then it can be interpreted as normal, even if it's abnormal, or vice versa. It comes with the training and making sure that the right people are looking at it. 

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Who should be performing the EKG tests? 

Dr. Sean Convery discusses who should perform EKG tests for high school and college athletes. Click play to watch the video or read the transcript.

 

The question of who does the testing is currently in debate. It can be a mix of things. We really feel that the yearly physical examination should be done by the athlete's own caregiver who is familiar with their family history.

The EKG screening can be done in a number of different ways, either in the physician's office or by the school. If the school administers the EKG, the results should be reviewed by someone who knows the latest screening protocols, called the New Seattle Criteria. These criteria are different for athletes than they are for non-athletic individuals, as to what is normal and what is abnormal.

The EKG screening can be done at the school in a group setting because it doesn't involve questioning the athletes about things they might be doing, including social behaviors, that are an important part of the physical examination. 

Who is the most appropriate person to read EKG results for high school athletes? Collegiate athletes? Younger children?  

Dr. Jeffrey James discusses who should read EKG results for high school and college athletes. Click play to watch the video or read the transcript.

 

The EKGs are tricky because of who is qualified to interpret them and the differences between the different populations. For example, an EKG can be normal in a lot of instances in younger populations just because some of the pathologies don't seem to appear until age 18 or 20. So that's where it becomes tricky. By adding the electrocardiograms to screenings, we may get a normal result in a 12- or 14-, or even 16-year-old. Then as they get a little bit older, the results may turn abnormal. That's when we really worry about these pathologies popping up.

The other issue is that if you're not familiar with the electrocardiographic changes or electrical changes in the heart and the structural changes that happen with athletes, the EKG results can be seen as abnormal. But in reality they reflect normal physiologic changes or electric changes that happen in the heart. That can lead to a lot of false positives and that can cause a lot of extra time lost in their athletics. This can also cause emotional issues for the athlete and his or her family, just because they're out of their athletics. They're worried about heart disease and obviously the extra money it would take to go see a specialist or get extra testing that may turn out to be normal.

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What is the concern about interpreting results from EKGs performed on high school athletes?  

Dr. Sean Convery discusses existing concerns about how EKG results for high school and college athletes are interpreted. Click play to watch the video or read the transcript.

 

The question of false positives is always a concern, because we don't want to inappropriately withhold someone from participation when they really have a normal EKG. A pediatric cardiologist is used to reading pediatric heart rhythms. If someone is unfamiliar with the Seattle Criteria, they may be unfamiliar with what pediatric or adolescent cardiac tracings look like.

It's really important that the right people are interpreting the EKG data. The data is no good if the person doesn't interpret it correctly. That's one of the reasons we've gone to the revised Seattle Criteria. I don't think that a pediatric cardiologist necessarily has to be the one to read those. It would be great if they did, but quite frankly there are not enough pediatric cardiologists in this country to read all those EKGs. People trained in reading athletic EKGs can do that.

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If an athlete does get a positive EKG, what are the next steps? 

Dr. Jeffrey James discusses what happens next after positive EKG results are received for a high school or college athlete. Click play to watch the video or read the transcript.

 

If we get an abnormal EKG, we have procedures that we follow. We will recommend a follow-up visit with a special cardiologist trained in interpreting EKG results from athletes. The specialist will do an assessment and a physical exam. If he or she feels the EKG is abnormal and the athlete needs further assessment, additional testing may be done, such as an echocardiogram or an ultrasound of the heart or a stress test while monitoring the heart rhythms.

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Do athletes ever mask a condition or not tell their doctor about an issue because they're afraid they won't get playing time?

Dr. Jeffrey James discusses the usefulness of the personal medical history in diagnosing cardiac issues for high school and college athletes. Click play to watch the video or read the transcript.

 

Sure. Part of the debate about whether or not the history and physical exam is adequate enough is about whether the athlete is being truthful and honest. We base a lot of what we do and how we proceed in clearing athletes based on what they say is going on. So if they're not being truthful in their responses, or maybe they think it is normal for an athlete to get short of breath, or to get mild chest discomfort with their athletics, they might not say anything. If we don't know about an issue, it can lead to difficulties in diagnosing underlying cardiac diseases.

Should all athletes have more advanced cardiac screenings prior to participating in athletics, or only those athletes with red flags in their medical history?

Dr. Jeffrey James discusses the appropriate time to use advanced cardiac screenings for high school and college athletes. Click play to watch the video or read the transcript.

 

As far as screening all athletes for cardiac disease, they definitely need to have an adequate medical history and physical exam. The jury is still out as to whether doing advanced cardiac screening on every athlete is beneficial. There are too many “what if's” in this situation. There is tremendous cost involved in screening every single athlete. We don't know if the benefits outweigh the risks of screening everyone. The false positives can be too high. Then we might be removing a lot of athletes or kids from their competitions who may not truly have problems. 

Anyone who has red flags definitely should get advanced screening, such as an electrocardiogram and further evaluation with a cardiologist. Red flags include an abnormal family history, an abnormal personal history and any symptoms such as chest pain during exertion, fainting spells, passing out after or during competition or dizziness with competition. 

Dr. Sean Convery discusses the debate over when to use advanced cardiac screenings for high school and college athletes. Click play to watch the video or read the transcript.

 

The overwhelming concern is false positives and inappropriately holding kids out of sports and activities when they don't need to be out.

If the screening is done correctly, the false positive numbers can be reduced to a low and acceptable range. If you have an abnormal physical examination, an abnormal history or an abnormal EKG, you move into the more advanced testing, which involves a visit with a cardiologist who is knowledgeable in athletic heart conditions for a specific age group. More testing might follow, like an echocardiogram. If that's abnormal, you proceed to the next level, which could require a cardiac catheterization. That would be rare, but those are the steps to take.

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What started the debate about the need for EKGs?

Dr. Sean Convery discusses the how data supports the use of EKG testing for high school and college athletes. Click play to watch the video or read the transcript.

 

The concerns raised about sudden cardiac death in athletes have been going on for a number of years. Now we have more accurate data. We have more numbers. We have studies dealing with thousands of athletes — looking at hundreds of sudden cardiac deaths — in high school and college. Now we see that those numbers are troubling in certain populations. The most troubling would be in the collegiate African-American basketball player, who has the most risk for this sudden cardiac death.

Depending on what study you look at, a sudden cardiac death occurs once in every 3,000 to 5,000 athletic years. That sounds like a lot of years, but it's not when you look at how many people are playing. When you see numbers like that you realize that you have to do something at all the levels. Now that we have more accurate reporting and databases that can easily be shared, we can crunch all those numbers and say, "Hey, there's an issue here." Before, it was just a few reports here and there, anecdotal evidence. No one really wanted to pull the trigger on that. But now I think the numbers are a little overwhelming.

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How does an athlete with a cardiac abnormality serious enough to end his life play 25 or 30 basketball games and practice three times a week and not have any symptoms?

Dr. Sean Convery discusses how sudden cardiac events can occur in high school and college athletes. Click play to watch the video or read the transcript.

 

That's a good question. A lot of times people wonder how a kid plays basketball in junior high, high school and two years of college and then all of a sudden something happens? The answer is partly bad luck. The wrong thing happens at the wrong time. A rhythm disturbance might occur that the heart can’t recover from. Athletes’ bodies change as they go through high school and college and some of these inherited cardiac abnormalities don't really surface until certain things happen in the cardiac system. A lot of times it's the electrical system in the heart that matures to a point where it becomes an issue.

Take a guy like Pete Maravich, who died playing pick-up basketball after a long, relatively storied career in high school, college and the pros. He dies playing pick-up basketball because he had a fairly rare congenital cardiac abnormality — and things went wrong at the wrong time.

If you looked back at the history of someone with a sudden cardiac event, there may have been some evidence somewhere that wasn't quite right. But at the time the test was done, no one had a reason to chase it. And if you went and chased every little thing, you'd have nobody playing anything. The maturity — or degeneration —of the cardiac electrical system, bad luck and bad timing are often to blame.

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What is commotio cordis?

Dr. Jeffrey Rayborn discusses commotio cordis in high school and college athletes. Click play to watch the video or read the transcript.

 

Commotio cordis is a cardiac event from blunt force trauma to the chest, resulting in sudden collapse. It can also cause sudden cardiac death.

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Is commotio cordis preventable?

Dr. Jeffrey Rayborn discusses why commotio cordis is not preventable in high school and college athletics. Click play to watch the video or read the transcript.

 

Commotio cordis has no underlying factors that predispose someone from having it. So, in general, no, it's not preventable. This typically happens during a sporting activity. From a ball, or sometimes a fist. Or in mixed martial arts, it could be a kick to the chest. There is some evidence that chest protection may help. That's somewhat controversial. There's evidence suggesting that softer baseballs and softballs, with a softer core for youth sports, may help prevent this. But in general, it's not a preventable occurrence. There are steps that can be taken to help decrease the risk of death when a person experiences such a trauma.

    Are there any signs or symptoms of suspected commotio cordis?

    Dr. Jeffrey Rayborn discusses the signs and symptoms of commotio cordis in high school and college athletes. Click play to watch the video or read the transcript.

     

    There are no obvious signs or symptoms before the trauma takes place. Once the athlete is hit, typically from a ball, the collapse occurs. The individual may briefly regain consciousness and get up and throw the ball. Or they may have a crying episode before they go unconscious again. The impact to the chest often does not appear significant to bystanders. Unfortunately, it might seem the athlete just had the wind knocked out of them until someone recognizes that a much more serious event is taking place.

      How is commotio cordis treated?

      Dr. Jeffrey Rayborn discusses how commotio cordis is treated in high school and college athletes. Click play to watch the video or read the transcript.

       

      Commotio cordis treatment centers on quick, rapid response by bystanders to give appropriate CPR and defibrillation with an AED as quickly as possible. The quicker an AED can be obtained to shock the athlete’s heart back into a regular cardiac rhythm, greatly enhances survival. Studies show the window for action is about three minutes. The athlete has a much higher chance of survival if the CPR and shock treatment can be given within a three-minute time period from collapse.

      If an AED is not immediately available, call 911 and continue to administer CPR until emergency personnel can arrive to aide the athlete.

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      What is the progression of care for an athlete who experiences commotio cordis?

      Dr. Jeffrey Rayborn discusses the recovery process for high school and college athletes who survive commotio cordis. Click play to watch the video or read the transcript.

       

      If an athlete is properly treated and survives, there will be a follow-up visit with a cardiologist for cardiac testing. Most of the testing will return normal results, verifying that the episode was caused by commotio cordis and not some underlying abnormality. The return to play will vary depending on different factors, including the doctor’s opinion and the individual’s specific situation.

        Does commotio cordis cause permanent damage to the heart?

        Dr. Jeffrey Rayborn discusses how commotio cordis affects the hearts of high school and college athletes. Click play to watch the video or read the transcript.

         

        Typically there is no permanent damage to the heart after an event. And the testing will verify that by returning normal results.

        What is the most significant thing that helps an athlete survive an impact that causes commotio cordis? 

        Dr. Jeffrey Rayborn discusses how availability of an AED can help athletes survive a commotio cordis episode. Click play to watch the video or read the transcript.

         

        Having certified athletic trainers and other medical personnel and hopefully AEDs rapidly available at events greatly increases the rate of survival with an event such as commotio cordis.

        That is due to the quick response and obtaining the correct care within that three-minute window to shock the heart back into regular rhythm.

        How frequent is commotio cordis in athletics?

        Dr. Jeffrey Rayborn discusses the risks of commotio cordis occurring in high school and college athletics.  Click play to watch the video or read the transcript.

         

        Commotio cordis is a relatively rare event. There's a registry that started several years ago, and only 180 to 200 cases have been documented. That number is thought to be relatively low due to episodes being unreported or not knowing the cause of the event. Although it is rare, the risk of commotio cordis is higher in sports such as baseball, softball, martial arts. It can also occur in lacrosse, hockey, football and virtually any other sport.

        What would disqualify an athlete from being able to return to athletics?

        Dr. Jeffery James discusses why a high school or college athlete would not be able to return to sports after a sudden cardiac event. Click play to watch the video or read the transcript.

         

        If an athlete gets an abnormal screen and we're hoping to return them to play, they would have to go through a complete evaluation with a cardiologist and advanced testing. As far as return to play after that, it would depend on what is found on their advanced imaging and screening. If they have one of the underlying conditions, such as hypertrophic cardiomyopathy, it's likely that they could be disqualified from athletics completely. That would again depend on what's found. There are some other heart conditions that will allow an athlete to return to less vigorous athletics. The American Heart Association has guidelines based on what heart conditions are allowed to participate in what athletics, and that would be based on the clearance we would need from the athlete’s cardiologist.


        Source: Michael W. Barrow, MD, Samaritan North Family Physicians; American Heart Association; National Institutes of Health; Nik Berger, MS, AT, ATC, Premier Health Sports Medicine – Miami Valley Hospital South; Jeffrey James, DO, Premier Orthopedics; Sean Convery, MD, Premier Orthopedics; Jeffrey Rayborn, MD, Premier Orthopedics

        Content Updated: April 4, 2018

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