Correspondence

Sudden Death in Young Athletes

N Engl J Med 2003; 349:2464-2465December 18, 2003

Article

To the Editor:

In his article on sudden death in young athletes (Sept. 11 issue),1 Maron includes a discussion of commotio cordis, in which he illustrates and describes a blow directly over the heart as an initiator of ventricular tachyarrhythmias. Although he discusses the necessity for protective precordial guards, there is no mention of the specific need to avoid direct strikes to the area over the heart as a means of prevention.

Athletes training in the martial arts and other combat-like sports can be trained to “miss” the precordium. This preventive measure is pertinent, as these sports (including karate, kung fu, and Olympic tae kwon do) are practiced worldwide by large numbers of the high-risk adolescent subpopulation.2 We have successfully introduced this cardiac avoidance system to our athletes without any detriment to proficiency.

Hutan Ashrafian, M.B., B.S.
St. Mary's Hospital, London W2 1NY, United Kingdom
ashrafian@email.com

2 References

1. 1

   Maron BJ. Sudden death in young athletes. N Engl J Med 2003;349:1064-1075
   Full Text | Web of Science | Medline

2. 2

   Patel DR, Stier B, Luckstead EF. Major international sport profiles. Pediatr Clin North Am 2002;49:769-792
   CrossRef | Web of Science | Medline

To the Editor:

Maron mentions coronary anomalies but does not discuss Kawasaki's disease, the most common cause of acquired heart disease in the United States. Although regression of coronary-artery aneurysm is recognized, long-term sequelae involving the coronary arteries can develop into young adulthood.1 Iemura et al.2 have shown evidence of persistent abnormal vascular-wall morphology and vascular dysfunction, including intimal-wall thickening, at the sites of regressed coronary aneurysms, which has led to early myocardial infarction and arrhythmia in young adults. Iemura et al. suggest long-term follow-up into adulthood, together with the avoidance of risk factors for atherosclerosis.

Transthoracic echocardiography is usually sufficient to examine coronary arteries in childhood; however, the procedure becomes difficult as children grow. Coronary magnetic resonance angiography has been shown to be very useful in adolescents and young adults.3 Once abnormal arteries have been visualized in young adults by screening, treatment is possible by means of coronary-artery bypass grafting.4

Andrew Gogbashian, M.B., B.S.
Hammersmith Hospital, London W12 0HS, United Kingdom
andrew@cardiacforum.com

4 References

1. 1

   Burns JC, Shike H, Gordon JB, Malhotra A, Schoenwetter M, Kawasaki T. Sequelae of Kawasaki disease in adolescents and young adults. J Am Coll Cardiol 1996;28:253-257
   CrossRef | Web of Science | Medline

2. 2

   Iemura M, Ishii M, Sugimura T, Akagi T, Kato H. Long term consequences of regressed coronary aneurysms after Kawasaki disease: vascular wall morphology and function. Heart 2000;83:307-311
   CrossRef | Web of Science | Medline

3. 3

   Greil GF, Stuber M, Botnar R, et al. Coronary magnetic resonance angiography in adolescents and young adults with Kawasaki disease. Circulation 2002;105:908-911
   CrossRef | Web of Science | Medline

4. 4

   Hayashida N, Tayama E, Teshima H, Kawara T, Aoyagi S. Coronary artery bypass grafting in an adult case with Kawasaki disease. Ann Thorac Cardiovasc Surg 2002;8:47-50
   Medline

Author/Editor Response

I agree with Dr. Ashrafian's pertinent views regarding the occurrence of chest blow–induced cardiac arrest (i.e., commotio cordis). Certainly, a general principle drawn from studies of commotio cordis by my colleagues and me1,2 is that striking the precordium should be avoided under any circumstances — regardless of intent or force. In this regard, Dr. Ashrafian is to be congratulated on successfully introducing potentially lifesaving “precordial avoidance” into sports such as karate, kung fu, and Olympic tae kwon do. Unfortunately, we have not been nearly as successful in making this same point to the organizations governing such sports in the United States.

I appreciate the comments of Dr. Gogbashian regarding the potential link between coronary-artery anomalies (associated with Kawasaki's disease) and sudden death in young athletes. Indeed, Kawasaki's disease may be an occasional cause of sudden death during physical activity. I did not mention it in my review, however, since our national registry has not yet recognized such a case during competitive sports.3

Barry J. Maron, M.D.
Minneapolis Heart Institute Foundation, Minneapolis, MN 55407
hcm.maron@mhif.org

3 References

1. 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

2. 2

   Maron BJ, Gohman TE, Kyle SB, Estes NAM III, Link MS. Clinical profile and spectrum of commotio cordis. JAMA 2002;287:1142-1146
   CrossRef | Web of Science | Medline

3. 3

   Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young competitive athletes: clinical, demographic, and pathological profiles. JAMA 1996;276:199-204
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   P. Lamprecht. (2009) Neues zur Pathogenese primär systemischer Immunvaskulitiden. Der Internist 50:3, 291-297
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