Commotio Cordis

Now that the NFL preseason is firmly underway and fantasy football leagues are scrambling to sort out their draft picks, let's take revisit a moment from last football season that fans are unlikely to forget any time soon: The moment Buffalo Bills' defensive back Damar Hamlin collapsed on the field on live national television. Multiple specialists have since cleared Hamlin to return to football this season, ESPN reported in April. Officially, Hamlin was diagnosed with commotio cordis, a specific type of cardiac arrest. The American Heart Association describes commotio cordis as a very rare consequence of blunt force trauma to the heart at exactly the wrong time in the heart rhythm, causing the heart to stop beating. Aside from the trainers and first responders who rushed to Hamlin's aid, it could be argued that the MVP of that Jan. 2 game against the Cincinnati Bengals was the automated external defibrillator (AED) that helped save his life. Contrary to popular belief, defibrillators can only correct irregular heartbeat patterns, they cannot restart hearts. In Hamlin's case, the defibrillation delivered by the AED used by the team's trainer successfully converted Hamlin's rhythm to allow his heart to beat regularly again. Automated external defibrillators have become so common in public spaces that they may be easily overlooked. Brostock / iStock via Getty Images But there are many lessons to be learned from studying the evolution of the AED . AEDs are also an impressive example of voice prompts enhancing user interactions with a medical device. The latest-generation defibrillators use voice prompts to guide users through the numerous steps required to perform a successful rescue. Spoken instructions, such as "stay calm" and "check breathing," spare the rescuer from having to read textual or graphical instructions, which would be more time-consuming and could create confusion. The world's first portable defibrillator was launched by the Royal Victoria Hospital-Belfast in Ireland under the direction of doctors Frank Pantridge and John Geddes. “Pantridge’s vision in the 1950s was that a defibrillator should be beside every fire extinguisher,” Dewar Finlay, interim associate dean of the school of engineering at Ulster University, told MD+DI in an interview in March 2022. Although they had developed a mobile cardiac care unit, it was not convenient to use, as it weighed 110 lb. This was mainly due to the lack of miniaturized electronic components, particularly those required to power a defibrillator and provide the electrical energy needed to produce the required shock. The research team, which formed the company, HeartSine in 1988, now owned by Stryker, continued to refine the device to make it more lightweight and portable. Read on to learn the role that rapid prototyping and user-centric design played in the evolution of the automated external defibrillator.

WASHINGTON, June 20, 2023 /PRNewswire/ -- On behalf of the Association of Black Cardiologists (ABC), we extend our heartfelt well wishes and unwavering support to National Football League (NFL) player Damar Hamlin, who experienced a sudden cardiac event early this year. We recognize the gravity of this event and its impact on him, the NFL community, the country, and the world. Damar's strength and resilience are commendable, and his dedication to sudden cardiac death awareness is inspiring. While our team members were not directly involved in his evaluation, we agree that a diagnosis of commotio cordis is the most likely if a comprehensive cardiac evaluation was normal. Commotio cordis occurs when there is an untimely, focal, high-velocity impact to the chest wall during a narrow, vulnerable period of the cardiac cycle. This diagnosis is extremely rare, and can occur in a normal heart. The decision regarding the resumption of competitive sports should be predicated upon a meticulous appraisal of Damar's specific condition, the underlying etiology of the cardiac event, and the potential risks at stake. The ABC ardently advocates for the principles of shared decision-making in sports cardiology, wherein medical professionals collaborate with the athlete, their family, the organization, and a multidisciplinary team to ascertain the safest course of action regarding return-to-play. With appropriate medical care, rehabilitation, and understanding of risk, we support him returning to the NFL if he so wishes. Additionally, we pray that he receives the full support of the NFL and the nation for his psychological recovery. Sudden cardiac death (SCD) is a complex event with many potential underlying mechanisms that may lead to a sudden cessation of effective cardiac pumping and loss of pulse. In individuals predisposed to SCD, the pathophysiology involves a combination of structural abnormalities of the heart, inherited cardiac conditions, and electrical disturbances. In an attempt to detect cardiac abnormalities that increase an athlete's risk of exercise-related SCD, preparticipation evaluations (PPE) can be helpful. However, despite best efforts and screening, tragic events may still occur. Once abnormalities are identified on screening, appropriate downstream testing is required. It is crucial to acknowledge the disparities that exist in the diagnosis of predisposing conditions related to SCD. Specific populations, particularly Black individuals, face inequities in accessing comprehensive downstream cardiac evaluations, including imaging, stress testing, genetic testing, and advanced invasive diagnostic modalities. This can impede the identification of underlying cardiac conditions, thereby hindering targeted prevention strategies. Furthermore, disparities in sudden cardiac arrest and resuscitation outcomes have been observed, with lower survival rates among certain racial and ethnic groups. Epidemiological studies, including that by the National Collegiate Athletic Association (NCAA), have highlighted Black male athletes as the highest-risk individuals compared to white athletes. To date, there has been no biological explanation for these discrepancies. The ABC asserts that addressing adverse social determinants of health is necessary to achieve equitable healthcare and rectify these disparities to ensure the well-being of all athletes. It is essential to acknowledge the excellent, immediate resuscitation that Damar Hamlin received on an NFL field with athletic trainers skilled in cardiopulmonary resuscitation (CPR), automated external defibrillator (AED) use, and emergency medical transport. It exemplified the well-executed emergency action plan (EAP) that every sporting facility and organization is encouraged to have. Unfortunately, millions of student-athletes throughout this country are not afforded these resources, mainly in impoverished environments especially in Black and Hispanic communities. Lack of athletic trainers and functioning AEDs leads to less survival among these athletes. The ABC endorses and supports the Access to AEDs Act. This bipartisan bill will increase access to life-saving equipment, CPR education, and training for schools nationwide to improve outcomes of sudden cardiac arrest for all. The ABC remains unwavering in our commitment to raising awareness regarding sudden cardiac risk in athletes, promoting comprehensive cardiac evaluations regardless of socioeconomic background, and advocating for equitable access to cardiac care. We implore athletes, sports organizations, medical professionals, and the wider community to unite in mitigating the risks associated with sports-related cardiac events, thereby ensuring the safety and well-being of all athletes. Merije Chukumerije, MD; ABC member, Sports Cardiology specialist; Marlon E. Everett, MD, Co-Chair, ABC Communications Committee; Camille G. Frazier-Mills, MD, MHS, Co-Chair, ABC Electrophysiology Committee; Aubrey J. Grant, MD, ABC member, Sports Cardiology specialist; G. Mark Jenkins, MD, Co-Chair, ABC Advisory Group and Former ABC Board Member; Kevin F. Kwaku, MD, PhD, ABC Board Member and Co-Chair, ABC Electrophysiology Committee; Jayne Morgan, MD, Co-Chair, ABC Communications Committee; Anekwe E. Onwuanyi, MD, President of ABC; and Barbara Hutchinson, MD; ABC Board Chair. About ABC Founded in 1974, the ABC is a nonprofit organization dedicated to eliminating the disparities related to cardiovascular disease and achieving health equity such that all people can live long healthy lives. Membership is open to all interested in the care of people with or at risk for cardiovascular disease, including health professionals, lay members of the community (Community Health Advocates), corporate and institutional members. Today, the ABC's public and private partnerships continue to increase its impact in communities across the nation. For more information, visit and wearethefaces.abcardio.org or connect with ABC on Twitter, Facebook, Instagram, and LinkedIn. Contact: ABC Media Relations [email protected] 646-689-0659 SOURCE Association of Black Cardiologists

TUESDAY, April 18, 2023 (American Heart Association News) -- Damar Hamlin has confirmed the cause of his near-fatal collapse on "Monday Night Football" as commotio cordis, a rare event caused by a blow to the chest. "This event was life-changing, but it's not the end of my story," Hamlin said Tuesday. Hamlin, 25, a safety for the Buffalo Bills, spoke at a news conference after working out with the team. Earlier, general manager Brandon Beane said that multiple specialists had seen Hamlin and that he had been "fully cleared" to return to football. "I got a long journey to go, but I'm committed to it each day, day in day out," Hamlin said. "So I thank everybody for being on this journey with me." Hamlin's collapse after being hit in the chest while making a tackle on Jan. 2 left millions wondering how a run-of-the-mill play could stop an athlete's heart. Commotio cordis requires several things to go exactly right – or exactly wrong – said Dr. Gordon F. Tomaselli, the Marilyn and Stanley M. Katz Dean of the Albert Einstein College of Medicine in the Bronx, New York. He also is executive vice president and chief academic officer of Montefiore Medicine. Unless witnesses recognize it, start CPR, alert emergency medical services and use a defibrillator, "patients will not survive," said Tomaselli, a former president of the American Heart Association who specializes in sudden cardiac death and heart rhythm disturbances. Here are some basics about what commotio cordis looks like and what people should know about protecting themselves and their families. What is commotio cordis? Commotio cordis (pronounced ke-MO-she-o-KORD-is) comes from the Latin for "agitation of the heart." It was first described in the 1700s, but most of what is known about it has been learned since the 1990s. Put simply, it's a rare cardiac arrest immediately following a blow to the chest. The impact induces a potentially lethal heart rhythm disturbance, or arrhythmia, called ventricular fibrillation, Tomaselli said. What does it look like? What viewers witnessed when Hamlin collapsed was typical, said Dr. Barry J. Maron, a cardiologist at Lahey Hospital and Medical Center in Burlington, Massachusetts, who was watching the game. "I saw it in real time," said Maron, as Hamlin took what seemed to be a routine blow, then staggered, and collapsed. "That was a commotio cordis event." Maron, who has spent decades doing pioneering research on commotio cordis, was not aware of Hamlin's official diagnosis prior to Tuesday's announcement. But he said last week that after a blow to the chest, the person can tolerate the arrhythmia for a few seconds before collapsing. Maron said in one memorable case, a second baseman playing softball was struck by a line drive in the chest. "The ball dropped right in front of him. He reached down, picked up the ball and threw the runner out. And then collapsed. And died." How rare is it? There's no way to know exactly how common commotio cordis events are, said Maron, who helped found the U.S. Commotio Cordis Registry in 1995. Reporting cases to the registry is voluntary. "But they are for sure very, very rare." A scientific review just published last month in JACC: Clinical Electrophysiology identified only 334 cases dating back to 1980. Who is most often affected? In the recent scientific review, 94% of victims were male, and their average age was 19. A little less than two-thirds of the cases involved sports, and most of those involved a projectile such as a baseball or softball. Among the non-sports cases, about three-fourths involved assault, and 7% were from motor vehicle accidents. Commotio cordis has been caused by snowballs, sibling scuffles and falling off bikes. Children have died after being struck by toy bats, T-balls or plastic sleds. Younger people are more susceptible to commotio cordis because their chests are less developed and more pliable, Tomaselli said, and they're more likely to be doing something – such as playing sports – that could put them at risk. There's no data on whether physical differences might protect females, he said, and their lower rates are probably related to the fact that boys and young men, in the past, have been more likely to participate in sports. Overwhelmingly, Tomaselli said, commotio cordis occurs in people who have no underlying heart disease. What exactly has to go wrong for a seemingly simple blow to the chest to stop a heart? First, Maron said, "the blow has to be over the heart. If it's, for example, on the right side of the chest, it's not going to trigger the arrhythmia." Second, it has to occur during a precise moment in a heartbeat. "It's a very narrow time window," Tomaselli said. "Anywhere between 20 and 40 milliseconds." For comparison, an eyeblink takes as much as 300 milliseconds. Finally, the blow must be not too hard and not too soft, Tomaselli said. "It's kind of a Goldilocks phenomenon." If the blow is too intense, the heart gets bruised, and commotio cordis generally does not occur. A less-intense blow – even a soft one, Maron said – can trigger the problem. What sorts of safety measures are possible? "It would be very hard to protect oneself from commotio cordis," Maron said. People have died despite wearing chest protection; children have died from gently tossed balls that bounced off a glove. "It's a bizarre occurrence." But proper training in how to respond can make a huge difference. A 2015 AHA and American College of Cardiology scientific statement that Maron helped write showed that survival rates had increased in recent decades to nearly 60% by 2012. Tomaselli agreed that the best preventive measure would be to have more people able to recognize and respond to a cardiac arrest by calling 911, knowing how to perform effective CPR and making sure automated external defibrillators, or AEDs, are available for all sporting events. "It's not so much prevention as it is prompt treatment," Tomaselli said. What went right in Damar Hamlin's case? With any cardiac arrest, survival depends on people nearby acting to correct the problem within seconds to minutes, Tomaselli said. On Jan. 2, the chain of survival began with immediately activating emergency medical personnel, beginning CPR and using a defibrillator. "The reason he did so well was because he was in a situation where there was a prompt and effective response," Tomaselli said. He added that when there is no underlying heart condition, someone who has experienced commotio cordis should be able to return to their usual activities. Is there any overarching lesson we can learn from this? "It's reversible," Maron said. In theory, virtually any case of commotio cordis could be undone if people are trained to recognize it, have access to AEDs, and act. "Anybody can save a life," Tomaselli said. "And you can save a life by knowing how to do basic cardiac life support and CPR." American Heart Association News covers heart and brain health. Not all views expressed in this story reflect the official position of the American Heart Association. Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved. By Michael Merschel, American Heart Association News Posted April 2023