On January 2 2023 in front of thousands of people at the stadium and millions on a national television broadcast, a Buffalo Bills player made a routine football play, stood up and then collapsed with sudden cardiac arrest. What is sudden cardiac arrest? What causes it? How is it treated? Can it be prevented?
Sudden cardiac arrest is an abnormal heart rhythm most often 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 affects 150,000 to 250,00 people in the US each year. Less than 20% of sudden cardiac arrest victims have their rhythm restored to normal and only 10% survive to ultimately leave the hospital.
The cause of sudden cardiac arrest depends on the age of the victim and the type of underlying heart disease. In patients over the age of 35, the overwhelming cause of sudden cardiac arrest is a heart attack. A heart attack occurs when the blood flow to the heart muscle is stopped completely. Usually there is a pre-existing plaque or blockage in a heart artery, the plaque breaks open, a blood clot forms and the blood flow is halted. It is important to realize that a heart attack and sudden cardiac arrest are not the same thing. A heart attack is one of the causes of sudden cardiac arrest and primarily a plumbing problem (the artery and the blood flow) while sudden cardiac arrest is an electrical problem (an abnormal rhythm). In those under age 35 and less likely in older victims cardiomyopathy (a primary heart muscle problem) can cause sudden cardiac arrest. This includes dilated cardiomyopathy (a weak, flabby heart), hypertrophic cardiomyopathy (an abnormally thickened heart muscle) and arrhythmogenic right ventricular dysplasia (fatty infiltration of the wall of the right ventricle). Primary rhythm problems such as Wolf-Parkinson-White syndrome (a bypass which circumvents the usual electrical pathway), Long QT syndrome and Brugada syndrome must also be considered. In young patients, especially young athletes, an anomalous origin of a heart artery can be seen in 12 to 19% of victims. The artery follows an abnormal course between the main artery (the aorta) and the lung artery (pulmonary artery). With exercise, the pressure in these arteries goes up, compressing the heart artery and interrupting blood flow to the heart. Another cause that has come to the forefront in recent years is myocarditis (inflammation of the heart muscle). Myocarditis can be due to infection (from various viruses including COVID), cancer chemotherapy agents (check point inhibitors) or idiopathic. All of these causes are due to an underlying heart issue but sudden cardiac arrest may occur in a normal heart as well. Commotio cordis occurs after a blunt impact to the chest (with a projectile such as a baseball). The energy of the impact is transmitted to the heart, disrupting the normal heart rhythm. The vulnerable period for a projectile striking the heart is only about 10 to 15 milliseconds long and represents one percent of the total heart cycle. It is a rare but not uncommon occurrence.
The successful treatment of sudden cardiac arrest demands prompt recognition, cardiopulmonary resuscitation (CPR) and defibrillation. Recognizing sudden cardiac arrest may not be easy. The patient cannot explain what is wrong and they are often first evaluated by nonmedical personnel. In addition, it may look like another process is occurring, such as a seizure. If sudden cardiac arrest is suspected, the initiation of prompt CPR has been shown to save lives. The American Heart Association now recommends hands only chest compression (no mouth-to-mouth) and pressing hard and fast. Sudden cardiac arrest need not be 100% confirmed to start CPR; if suspected start chest compressions. If the victim doesn’t have cardiac arrest they will ask not to have their chest pumped. Definitive treatment of sudden cardiac arrest is defibrillation, an electric shock to the heart that restores the heart to normal rhythm. The shock is usually provided by an Automatic External Defibrillator (AED), a small portable device that is brought to the victim’s side. The sooner the patient is shocked, the greater the chance of surviving. Fifty percent of victims of sudden cardiac arrest survive if shocked within two to three minutes, but only ten percent will live if the shock is more than ten minutes from the time of collapse. Timing is everything and having an AED as close as possible to potential victims is life saving. As such, there is a push to have AEDs placed in areas where there are large public gatherings (such as airports, schools, stadiums, sports complexes). AEDs have been successfully deployed by police, firemen, sports trainers, and bystanders. There is even a study exploring delivering AEDs by drones.
Sudden cardiac arrest is often the first sign that a person has heart disease, but there are steps that can be taken to prevent it. For those over 35 years old, following a heart healthy lifestyle is the first step (staying active, watching a good diet, not smoking, keeping weight under control, treating high blood pressure and/or high cholesterol). For those at higher risk (for example a family history of heart disease at a young age), speak to your doctor about additional testing. Lastly, don’t ignore symptoms such as chest pain, shortness of breath, nausea/vomiting or passing out. Studies have shown that 50% to 75% of sudden cardiac arrest patients had warning symptoms. Many of the symptoms are nondescript; when should you be concerned? If symptoms are new or unusually severe, then seek care immediately. For those under age 35 and who have high-risk characteristics, cardiac testing (EKG, echo, cardiac MRI) as well as genetic testing may be indicated. For people under age 35 not at high risk, screening for sudden cardiac arrest is controversial. Many professional athletes (especially football, basketball and soccer players) are screened before a contract is signed. In addition, Division 1 college athletes are screened.
The NFL routinely screens players for their risk of sudden cardiac arrest. In addition, NFL sideline training staff routinely practices responses to sudden cardiac arrest. Due to the prompt response, CPR, the use of an AED, and expert team work by the training staff and medical personnel the player was resuscitated on the field and was able to survive a near death experience.
The Cardiology Department at RWJ Somerset is conducting its annual screening of high school athletes on Saturday February 4 2023. The screening is free and open to athletes from 14 to 18 years of age.
For more information please check the website (rwjbh.org/cardiacathleticscreening) or call 908-685-1414 to reserve a time slot.
