Commotio Cordis Underrecognized, Undertreated Outside of Sports

Sudden cardiac arrest (SCA) due to commotio cordis occurs more frequently in non-sport-related settings than is commonly thought, resulting in lower rates of resuscitation and increased mortality, especially among young women, a new review suggests.

The condition is rare, caused by an often fatal arrhythmia secondary to a blunt, nonpenetrating impact over the precordium, without direct structural damage to the heart itself. Common causes in non-sport settings include assault, motor vehicle accidents (MVAs), and daily activities such as occupational accidents.

“We found a stark difference in mortality outcomes between non-sport-related commotio cordis compared to sport-related events,” at 88% vs 66%, Han S. Lim, MBBS, PhD, of the University of Melbourne, and Austin Health, Heidelberg, Australia, told theheart.org | Medscape Cardiology. “Rates of cardiopulmonary resuscitation (CPR) (27% vs 97%) and defibrillation (17% vs 81%) were considerably lower in the non-sport-related events.”

“Although still being male-predominant, of concern, we saw a higher proportion of females in non-sport-related commotio cordis due to assault, MVAs, and other activities,” he noted. Such events may occur “in secluded domestic settings, may not be witnessed, or may occur as intentional harm, whereby the witness could also be the perpetrator, reducing the likelihood of prompt diagnosis, CPR, and defibrillation administration.”

The study was published online March 22 in JACC: Clinical Electrophysiology.

Young Women Affected

Lim and colleagues searched the literature through 2021 for all cases of commotio cordis. Three hundred and thirty-four cases from among 53 citations were included in the analysis; of those, 121 (36%) occurred in non-sport-related settings, including assault (76%), MVAs (7%), and daily activities (16%). “Daily activities” comprised activities that were expected in a person’s day-to-day routine such as falls, playfighting (in children), and occupational accidents.

Non-sport-related cases primarily involved nonprojectile etiologies (95%), including bodily contact (79%), such as impacts from fists, feet, and knees; impacts with handlebars or steering wheels; and solid stick-like weapons and flat surfaces.

Sport-related cases involved a significantly higher proportion of projectiles (94% vs 5%) and occurred across a range of sports, mostly at the competitive level (66%).

Both sport-related and non-sport-related commotio cordis affected a similar younger demographic (mean age,19; mostly males). No statistically significant differences between the two groups were seen with regard to previous cardiac history or family history of cardiac disease, or in arrhythmias on electrocardiogram, biomarkers, or imaging findings.

However, in non-sport-related events, the proportion of females affected was significantly higher (13% vs 2%), as was mortality (88% vs 66%). Rates were lower for CPR (27% vs 97%) and defibrillation use (17% vs 81%), and resuscitation was more commonly delayed beyond 3 minutes (80% vs 5%).

The finding that more than a third of reported cases were non-sport-related “is higher than previously reported, and included data from 15 different countries,” the authors note.

Study limitations included the use of data only from published studies, inclusion of a case series limited to fatal cases, small sample sizes, and lack of consistent reporting of demographic data, mechanisms, investigation results, management, and outcomes.

Increased Awareness “Essential”

Lim and colleagues conclude that increased awareness of non-sport-related commotio cordis is “essential” for early recognition, resuscitation, and mortality reduction. Jim Cheung, MD, chair of the American College of Cardiology’s Electrophysiology Section, “completely agrees.” Greater awareness among the general population could reduce barriers to CPR and automated external defibrillator (AED) use, he said, which in turn, can lead to improved survival.

Furthermore, Cheung added, “This study underscores the importance of ensuring that non-cardiology-trained physicians such as emergency medicine physicians and trauma surgeons who might encounter patients with non-sports-related commotio cordis recognize the entity during the course of treatment.”

Because the review relied only on published cases, “it may not represent the true breadth of cases that are occurring in the real world,” he noted. “I suspect that cases that occur outside of sports-related activities, such as MVAs and assault, are more likely to be under-reported and that the true proportion of non-sports-related commotio cordis may be significantly higher than 36%.” Increased reporting of cases as part of an international commotio cordis registry would help provide additional insights, he suggested.

“There is a common misperception that SCA only occurs among older patients and patients with known coronary artery disease or heart failure,” he said. “For us to move the needle on improving SCA survival, we will need to tackle the problem from multiple angles including increasing public awareness, training the public on CPR and AED use, and improving access to AEDs by addressing structural barriers.”

Cheung pointed to ongoing efforts by nonprofit, patient-driven organizations such as the SADS Foundation and Omar Carter Foundation, and professional societies such as the American College of Cardiology, the American Heart Association, and Heart Rhythm Society, to direct public awareness campaigns and legislative proposals to address this problem.

Similar efforts are underway among cardiac societies and SCA awareness groups in Australia, Lim said.

No funding or relevant financial relationships were disclosed.

JACC Clin Electrophysiol. Published online March 22, 2023. Abstract

Follow Marilynn Larkin on Twitter: @MarilynnL. 

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