Thursday, December 9, 2010

There was a case in New Jersey this week where a 16 year old catcher died from commotio cordis. He was at baseball practice and was struck in the chest by a ball, causing SCD. This case is important due to three factors. One, the player was wearing a chest protector, which obviously didn't absorb the energy of the ball. Second, the accident took place in a school gym, not out on a baseball diamond. There was no mention of an AED being used and apparently the family is questioning whether one was available at the gym. Third, NJ legislators introduced a bill in 2008 that would require all public schools, recreation facilities and youth camps to have an AED. The bill has not been adopted, but it is time to get it passed as at least one life potentially would have been saved.

Monday, September 20, 2010

A busy weekend in sports and cardiology

2 items from the weekend caught my attention:
1) A high school football player in Oregon had sudden cardiac arrest. He was saved by a cardiac nurse who was in the stands, saw him collapse and, presumably, did CPR. He was diagnosed with an anomalous coronary artery and had successful heart surgery.
Anomalous origin of a coronary artery is a condition one is born with. It is a leading cause of cardiac arrest (approximately 20% of cases). There are many different coronary anomalies. The ones associated with cardiac arrest involve either the left anterior descending coronary or the right coronary arising from the opposite coronary cusp from normal. The artery then courses in between the aorta and the main pulmonary artery. Cardiac arrest can occur when the artery is compressed, causing ischemia (lack of blood flow) and either a heart attack or an irregular rhythm. Fortunately, the football player survived and had corrective surgery.
http://www.kgw.com/news/local/HS-football-player-prepares-for-heart-surgery-103283964.html
2) Michigan State's football coach, Mark Dantonio, suffered a heart attack hours after making an incredible call, faking a field goal, in overtime, to score a touchdown and win a big game against Notre Dame. Several hours after the game, the coach had chest pain and went to the hospital. He was taken to the cath lab, found to have blockage and a stent was placed.
We have known for years that stress can precipitate heart problems, including a heart attack or sudden cardiac arrest.  Stress will trigger a "fight or flight" response in the body, releasing adrenaline and cortisol. These hormones will increase the heart rate, increase blood pressure and make the body more prone to blood clotting. These responses may have been helpful in the jungle when we need to fight an enemy or a wild animal. but they are detrimental if someone has underlying heart disease. The hormones may constrict  a blocked heart artery, the increased heart rate and blood pressure increase the heart's demand for oxygen, which may not be met by a blocked artery and the propensity to clot can lead to a blood clot within a blocked heart artery. All of this may lead to a heart attack, followed by sudden cardiac arrest.
http://sports.espn.go.com/ncf/news/story?id=5592217 
Fortunately both cases turned out OK.

Wednesday, August 11, 2010

Sudden Cardiac Arrest in the Young Athlete

Why should a young adult be worried about heart disease? In an otherwise healthy person, one who is not born with a heart defect, what is the risk of heart disease? In general there are two concerns for the young adult. One is the risk of sudden cardiac death. This is of special concern to the student athlete, as many deaths occur on the field of play or in gym class. In New Jersey, there have been several cases of high school athletes with sudden cardiac death, most recently in a football and track star from Franklin. Attention was focused nationally on sudden cardiac death in athletes when a 26 year old football player for the Chicago Bears and a 21 year old college basketball player recently died a few days apart. The second concern for the young adult is the risk of developing coronary artery disease, the major cause of heart attacks and deaths in older adults, but a disease whose process begins in childhood.

Sudden cardiac arrest is caused by ventricular fibrillation (an irregular heart rhythm from the lower chambers of the heart). When the heart’s ventricles are fibrillating, they cannot pump blood to the brain and vital organs. If not treated promptly, this leads to death. Sudden cardiac arrest occurs in athletes and the incidence is estimated at 1 in 200,000 in high school athletes. Young athletes have an increased risk of sudden cardiac arrest compared to their non-athletic peers. The combination of extreme physical exertion and an underlying heart disorder can trigger cardiac arrest. The most common causes include hypertrophic cardiomyopathy (a thickened heart muscle), coronary artery anomalies (the heart arteries arising from the wrong location), right ventricular dysplasia or myocarditis (a weakening of the heart muscle), aortic stenosis (a thickened, malfunctioning heart valve), rupture of the aorta (the main artery from the heart) and diseases of the heart’s electrical system.

The best way to prevent sudden cardiac arrest in athletes is to screen them for these heart abnormalities. Certain factors in the history or physical exam should alert the doctor that the athlete is at risk for sudden cardiac death. In the United States, a history and physical is recommended prior to athletic competition, but not an electrocardiogram (a recording of the electric activity of the heart) or an echocardiogram (an ultrasound of the heart). Many colleges and pro sports teams, however, do these more specific tests to screen their players. In Italy, a more comprehensive and mandatory screening program was begun due to a high rate of sudden cardiac death in athletes. In addition to a history and physical, each athlete is given an electrocardiogram. If the athlete is felt to be at risk, an echocardiogram is performed. The screening is conducted by doctors who undergo special training to recognize the subtle findings associated with patients at risk for sudden cardiac arrest. Using this simple, noninvasive method, the rate of sudden cardiac death dropped 89% from 3.6 cases per 100,000 people to 0.4 cases per 100,000 people over 25 years. The Cardiology Department at Somerset Medical Center has instituted a voluntary screening program for high school varsity athletes in the area based on the Italian model. Each athlete is examined by a board certified adult or pediatric cardiologist and an electrocardiogram is performed. In those at risk, an echocardiogram is done and read immediately.

Coronary artery disease is the leading cause of death in the United States and is due to atherosclerosis or build up of plaque in the heart’s arteries. The exact cause of atherosclerosis is not known, but it is known that the process begins in childhood. The fatty streak is the earliest sign of atherosclerosis and it can be detected in the aorta of teenagers. Atherosclerosis progresses from the fatty streak to a cholesterol-laden plaque. Autopsies performed on servicemen who died in combat in Korea and Vietnam confirmed atherosclerotic plaque in these asymptomatic men in their teens and twenties.
Atherosclerotic plaque continues to build up over the next ten to twenty years until the plaque blocks a significant amount of blood flow, causing chest pain. Alternatively, a plaque may rupture, causing the blood to clot, obstructing blood flow and a heart attack occurs.
Risk factors for developing atherosclerosis are the same in both adults and children. These risk factors include obesity, diabetes, high blood pressure, hyperlipidemia (high cholesterol), sedentary life style and smoking. Initiating life style modifications in childhood, before fatty streaks or atherosclerotic plaques develop, should improve cardiovascular health in adult life. Another goal of the student athlete screening study at Somerset Medical Center was identifying these risk factors. Each athlete had fasting labs for cholesterol and blood sugar, to screen for hyperlipidemia and diabetes. Blood pressure recording help screen for hypertension. In addition, a bioimpedence device measured each student’s BMI (body mass index) and percentage of body fat. These measurements can identify if a patient has obesity. All of these measurements were given to the student in summary form, counseling was performed and any abnormalities or warning signs were identified and advice given for future follow up.

Healthy young adults often do not seek medical care while they are in their teens, twenties and thirties. The only reason they may seek a physician is for a sports physical or pre-employment examination. When they are seen by a doctor, special care must be taken to screen for causes of sudden cardiac death, especially in those young adults who are athletes or who engage in vigorous physical activity. In addition, risk factors for coronary heart disease must be identified, so a healthier life style can be initiated and, hopefully, future cardiovascular problems avoided.

Automatic External Defibrillator (AED)

The chance of success for resuscitation with an AED is dependent on how soon a shock is delivered to a person in cardiac arrest. The chance of success (leaving the hospital alive, neurologically intact) goes down 7-10% every minute.
This pitcher, a sophomore in high school, was hit by a line drive during an American Legion game. Fortunately, there were no cardiac problems and except for some bruising, there was no long term damage

Commotio Cordis

What is commotio cordis? The ping of the baseball bat is music to some, but it can also produce a projectile, which, if it strikes a batter's chest at just the right spot, at just the right time in the heart cycle, it can produce a deadly heart rhythm called cardiac arrest. Cardiac arrest caused by a blow to the chest is called Commotio Cordis (“Commotion in the Chest”) and is similar to the type of heart rhythm that can be deadly to people who are having heart attacks.
The exact incidence of commotio cordis is not known, but it is not uncommon. A 12-year-old pitcher from Wayne New Jersey was struck by a baseball in June 2006 and fortunately was able to survive.
Children and young adolescents are at greatest risk for commotio cordis because they have compliant chest walls that transmit the energy of the baseball to the heart. A baseball is the most common object that can cause commotio cordis, but other projectiles, like lacrosse balls, hockey pucks, footballs and soccer balls can also cause the arrhythmia.
The treatment for commotio cordis is prompt defibrillation, an electric shock to the heart that restores the heart to a normal rhythm. Unless defibrillation is provided within 10 minutes or less, commotio cordis is almost always fatal. Automatic external debrillators (AED’s) are small, portable devices that can provide an electric shock to a victim of cardiac arrest. AED’s have been used by bystanders in airports, casinos and other public places to treat cardiac arrest. AED’s are also deployed by policeman and other rescue workers. In an effort to prevent commotio cordis, various chest protectors have been developed. Unfortunately, none have proven to be effective and athletes are reluctant to use them as they can restrict motion.
Until new and improved chest protectors are invented, parents of young athletes should speak with their Little League governing bodies about obtaining an AED for their athletic fields.