Correspondence

Sudden Death during Sports Activities

N Engl J Med 1995; 333:1784-1785December 28, 1995

Article

To the Editor:

Maron et al. (Aug. 10 issue)1 speculate that a blunt precordial blow may cause sudden death in young athletes by inducing ventricular dysrhythmias. This is not the only mechanism by which such a blow may cause severe cardiac dysfunction. We recently evaluated a 19-year-old man who had a massive myocardial infarction following minimal chest trauma. He sustained two blows to the chest during a game of tackle football. One hour later, severe chest pain developed, accompanied by nausea, diaphoresis, and dyspnea. At the hospital, he was noted to have congestive cardiac failure, with echocardiographic and electrocardiographic evidence of an acute anterior lateral septal myocardial infarction. Catheterization showed a total occlusion of the proximal left anterior descending coronary artery with thrombus, which was successfully recanalized by balloon angioplasty. The creatine kinase level peaked at 10,060 U per liter, with a 10 percent MB fraction. The patient had an uneventful hospital course after angioplasty and was able to resume his usual activities during the next year, with the exception of contact sports. He was evaluated extensively for abnormalities of coagulation, a well-recognized risk factor for unusual thrombotic events. The results of his blood and urine toxicology screenings on admission were unremarkable. Further investigation — including tests for lupus anticoagulant, anticardiolipin antibody, protein C, protein S, antithrombin III, α₂-antiplasmin, plasma plasminogen, and plasminogen-activator inhibitor type 1; a Russell's viper–venom test; measurement of the erythrocyte sedimentation rate; and screening for homocystinuria — was unremarkable.

This case suggests that a blow to the chest may precipitate infarction by an occlusive thrombus.

Anne E. Dixon, B.M., B.Ch.
Steven Shulman, M.D.
Johns Hopkins Hospital, Baltimore, MD 21287

1 References

1
Maron BJ, Poliac LC, Kaplan JA, Mueller FO. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med 1995;333:337-342
Full Text | Web of Science | Medline

To the Editor:

The interesting study by Maron et al. of sudden death resulting from a blunt impact to the chest draws attention to a particular form of mechanically induced sudden death during sports activities. However, the vast majority of these victims were able briefly to perform some kind of activity before collapsing, which suggests that death was preceded by a short period of ventricular tachycardia.

Leor et al.1 described two brothers, one with ventricular tachycardia documented after chest impact from a soccer ball. In the other, the same arrhythmia was highly probable. These events led to the discovery of a typical form of arrhythmogenic right ventricular dysplasia (ARVD), in which ventricular tachycardia induced by chest impact was the first manifestation of the disease.

The prevalence of ARVD as a cause of sudden death in people under 35 years of age ranges from 24 percent in the Veneto region of northern Italy2 to less than 1 percent in Maryland.3 In our experience, the diagnosis of ARVD is rarely evident on gross pathological examination, and systematic histologic analysis of the right ventricle is necessary to make the diagnosis. Isolated fat infiltration can be a normal variant, and the distinctive marker of ARVD is surviving strands of cardiac myocytes embedded in fibrous tissue within fat.4 If there is fibrous tissue in the right ventricular free wall, it may be due to an ischemic scar, the early stage of a generalized cardiomyopathy, or healed myocarditis, but not dysplasia.

Guy Fontaine, M.D., Ph.D.
Fabrice Fontaliran, M.D.
Hôpital Jean Rostand, 94200 Ivry, France

4 References

1
Leor J, Glikson M, Vered Z, Kaplinsky F, Motro M. Ventricular tachycardia after soccer ball blow to the chest: first manifestation of arrhythmogenic right ventricular dysplasia in two brothers. Am J Med 1990;89:687-688
CrossRef | Web of Science | Medline

2
Thiene G, Nava A, Corrado D, Rossi L, Pennelli N. Right ventricular cardiomyopathy and sudden death in young people. N Engl J Med 1988;318:129-133
Full Text | Web of Science | Medline

3
Goodin JC, Farb A, Smialek JE, Field F, Virmani R. Right ventricular dysplasia associated with sudden death in young adults. Mod Pathol 1991;4:702-706
Web of Science | Medline

4
Fontaliran F, Fontaine G, Fillette F, Aouate P, Chomette G, Grosgogeat Y. Frontières nosologiques de la dysplasie arythmogene: variations quantitatives du tissu adipeux ventriculaire droit normal. Arch Mal Coeur Vaiss 1991;84:33-38
Medline

To the Editor:

In his editorial (Aug. 10 issue), Dr. Estes1 indirectly raises an issue that I believe has been left untouched in the world of sports and sports medicine: whether a piece of protective equipment in a contact sport can cross the boundary of “body defense” and become a weapon for punishing the opposition. An obvious case in point is the football helmet. Originally designed to protect the heads of players during physical collisions, helmets were made of relatively soft leather and cushioned blows to the head. Today's football helmet can easily be used like the steel-encased tip of a 250-to-300-lb battering ram. A similar case can be made for shoulder pads, which are fashioned from the same space-age plastic that can see the space shuttle safely through a meteor shower. In ice hockey, the helmet has become a protective cage that allows players to swing their sticks freely, like Arthur wielding Excalibur.

Of course, I recognize the need to protect athletes from injuries, but some types of protective equipment can easily become shields for athletes of lesser skill. On the flip side, how many skilled athletes have been lost to the sporting world and added to the world of the chronically decrepit as a result of equipment-engendered injuries?

The solution? Develop soft-shelled protective equipment that truly protects athletes without punishing their opponents. For every career-ending injury in professional sports, I expect there are dozens of career-aborting injuries in the minor leagues. How many could have been avoided? We will probably never know, but each one of those injuries engenders a cost to the athlete's health and well-being (let us not forget that an athlete is a person first) and to health care systems searching high and low for ways to reduce expenditures.

J. Bradley Sinclair, B.A.
133 Treverton Dr., Scarborough, ON M1K 3T1, Canada

1 References

1
Estes NAM III. Sudden death in young athletes. N Engl J Med 1995;333:380-381
Full Text | Web of Science | Medline

Author/Editor Response

Dr. Maron replies:

To the Editor: The letters of Dixon and Shulman and of Fontaine and Fontaliran are helpful in further defining the dangers of sports and the cardiovascular risks associated with participation in sports. Dixon and Shulman document an unusual case of a 19-year-old man in whom chest blows inflicted during a football game were directly responsible for acute myocardial infarction due to the formation of an occlusive thrombus in the left anterior descending coronary artery. Several years ago, we reported a case in which a professional football player (with underlying coronary artery disease) had a ruptured atherosclerotic plaque that apparently resulted from a chest blow.1

Fontaine and Fontaliran raise the issue of ARVD, a known cause of sudden death in young people (including athletes) that is reported to be particularly common in some parts of Italy.2 Indeed, one previously reported case of ARVD was initially identified when the blunt chest impact of a soccer ball appeared to initiate ventricular tachycardia in an 11-year-old boy.3 I would agree with Fontaine and Fontaliran that ARVD (particularly the mild morphologic forms) may be difficult to diagnose, even after careful gross and histologic examination of the right ventricle at autopsy. Therefore, emphasizing the potential role of this disease in athletic-field catastrophes is certainly appropriate.

Barry J. Maron, M.D.
Minneapolis Heart Institute Foundation, Minneapolis, MN 55407

3 References

1
Roberts WC, Maron BJ. Sudden death while playing professional football. Am Heart J 1981;102:1062-1063
CrossRef | Web of Science | Medline

2
Thiene G, Nava A, Corrado D, Rossi L, Pennelli N. Right ventricular cardiomyopathy and sudden death in young people. N Engl J Med 1988;318:129-133
Full Text | Web of Science | Medline

3
Leor J, Glikson M, Vered Z, Kaplinsky F, Motro M. Ventricular tachycardia after soccer ball blow to the chest: first manifestation of arrhythmogenic right ventricular dysplasia in two brothers. Am J Med 1990;89:687-688
CrossRef | Web of Science | Medline

Citing Articles (1)