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Synopsis: A history of warning symptoms for commotio cordis should be obtained during the preparticipation physical exam to help reduce the risk of sudden cardiac death.
Source: Vincent GM, McPeak H. Commotio cordis. The Physician and Sportsmedicine 2000;28(11):31-39.
Commotio cordis, or cardiac concussion, is a rare cause of sudden death in athletes that results from "blunt, nonpenetrating, precordial chest impact that causes arrhythmias or sudden death without evidence of heart injury at autopsy". It has been most frequently reported in baseball, softball, and ice hockey. According to the U.S. Commotio Cordis Registry in Minneapolis, 70% of those affected have been younger than 16 years of age, 99% have been male, and 87% have been white. The precipitating event is generally a blow to the precordial area, but left-lateral chest trauma can precipitate an event as well. Young athletes are felt to be more susceptible to commotio cordis because of the narrower anteroposterior diameter of their thorax and the greater compliance of their chest wall. Other factors suggested for the increased susceptibility of young athletes include their lack of awareness of risk factors and their less frequent use of protective gear compared with collegiate and professional athletes.
The pathophysiology of commotio cordis is not well understood, but from experimental work in pigs and evaluation of survivors of this incident, it appears that a blow delivered at precisely the right time in the cardiac electrical cycle can result in a fatal arrhythmia. Ventricular fibrillation is the most common arrhythmia seen. The true incidence of this cardiac catastrophe from which only 10% survive, despite resuscitation efforts, is unknown, but 70 cases have been reported to the registry as of June 1998.
Prevention measures include chest protectors for those at risk, elimination of the on-deck circle in baseball, further evaluation of the effectiveness of softer-core baseballs, and education of players and coaches regarding these measures.
Fortunately, sudden death in athletics is extremely rare. The most common cause in athletes older than 35 is coronary artery disease; whereas, the most common cause of sudden death in younger athletes is inherited structural abnormalities of the heart (e.g., hypertrophic cardiomyopathy and structural malformations of the coronary arteries). Sudden death can also result from myocarditis triggered by a viral infection or cardiac abnormalities caused by drug abuse.
Unfortunately, most causes of sudden death in young athletes cannot be detected during routine medical athletic screening examinations. However, since many young athletes at risk for fatal cardiac events often experience warning symptoms during exercise, including questions in the preseason examination specific for these symptoms as well as questions pertaining to a family history of cardiac disease and a history of drug use by the athlete is mandatory. These warning symptoms include chest or stomach pain or discomfort, dizziness, palpitations, or fainting episodes. The physical examination should also include auscultation of the athlete’s heart with the athlete standing and lying and a seated brachial artery blood pressure.