Sudden Cardiac Arrest on the Field: Now What?

Podcast Transcript

Announcer:

Welcome to Cleveland Clinic Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic.

Michael Emery, MD:

Hi. I'm Dr. Michael Emery. I'm the Co-Director of the Sports Cardiology Center at the Cleveland Clinic.

Tamanna Singh, MD:

Hi. I'm Dr. Tamanna Singh. I'm also a Co-Director of our Sports Cardiology Center.

Michael Emery, MD:

We'd like to spend a few minutes talking with you about sudden cardiac arrest and sudden cardiac death, particularly in athletes. So Dr. Singh, remind us as we get started, the difference between a cardiac arrest and a heart attack.

Tamanna Singh, MD:

Sure. So cardiac arrest specifically speaks to the electrical abnormalities that we can see that can precipitate cardiac death, so specifically ventricular rhythms like ventricular tachycardia, ventricular fibrillation. Whereas a heart attack or an MI is specifically going to be correlating to abnormalities and perfusion of a specific part of the heart muscle that could then subsequently lead to an abnormal ventricular rhythm and possibly cardiac arrest and death.

Michael Emery, MD:

So when we're talking about sudden cardiac arrest in athletes, we see a lot of athletes go down on the field for various reasons. What should a trainer or a medical professional that's covering a game start to think about when you see an athlete go down versus a hit versus sudden cardiac arrest?

Tamanna Singh, MD:

Yeah, so I mean the immediate difference you're going to see is that person's not going to get up or they might get up and then kind of falter here and there depending upon what's going on, and then go down and just not respond. So the response is going to be very similar to what you will do in a hospital if you see someone has gone down, you know will be calling for help. Fortunately, in a lot of these competitive leagues and even our recreational teams, there's an emergency action plan that allows for people to know what the steps are going to be to provide adequate and timely resuscitation of the athlete. So we immediately want to start CPR. We want to start high quality chest compressions, help with breathing if they require intubation. If the patient remains unconscious, get an external defibrillator if you're concerned that it could be a cardiac arrest. Apply the pads, turn the device on, and if it is a shockable rhythm, we could save that athlete's life.

Michael Emery, MD:

And I think one of the important lessons is if an athlete goes down on the field, you should assume it's cardiac arrest until proven then otherwise. It may be quick for you to decide that it's not cardiac arrest, but if it is that sort of timeframe or delay that may be there if you don't, could be detrimental. Because prompt defibrillation in the setting of cardiac arrest from ventricular fibrillation is what saved lives with a dramatic decrease in survivability for every minute delay that you don't restore spontaneous circulation. Moving past the sort of emergency action plan and how important that is to have a rehearsed well-organized emergency action plan, what are our next steps after hospitalization if you survive the sudden cardiac arrest or even if you don't, try to elucidate an etiology?

Tamanna Singh, MD:

So we want to think about the basic causes for cardiac arrest and cardiac deaths. So when individuals do come into the hospital, they're going to be going through aggressive cardiac testing, which will include imaging like echocardiography, usually MRI or CT, as well as cardiac catheterization, to elicit whether or not the coronary arteries were involved in the arrest at all. And the etiologies are also going to be differentiated upon the age of the athlete. When athletes are younger, typically less than 35, we're looking at probable genetic or congenital abnormalities, so things like coronary anomalies or some sort of cardiomyopathy. Hypertrophic cardiomyopathy is something I think a lot of providers outside of cardiology are aware of. There's other cardiomyopathies as well, arrhythmogenic cardiomyopathy, idiopathic dilated cardiomyopathy. So what I'm getting at is we want to see if it's a heart muscle that caused a problem, if it was something a part of the electrical circuitry causing a problem, so perhaps a channelopathy, or if it's something that's correlating to the coronary artery, so coronary anomalies in younger individuals. And then we typically think of coronary artery disease in our masters athletes or those above 35 to 40 years old. And once we figure out what the actual cause is, and I think Dr. Emery, you are great at explaining we never always know what the causes of every possible sudden cardiac arrest and death, and we can talk about that a little further. That's going to delineate what our treatment strategy is going to entail, whether it's going to be medications, sport restriction, the need for defibrillator, an implanted defibrillator, to help prevent any other future arrests and whatnot.

Michael Emery, MD:

I think it's important to also realize and acknowledge that despite everything we can do, we don't always figure out the cause of a sudden cardiac arrest. Despite all of our imaging techniques and genetic techniques and so on, we can't always figure it out. And that's been borne out in the literature as of late as well. So that leads us then to the question we often get is like, well, should we be screening more aggressively then? Is that going to prevent all these sudden cardiac deaths? What are your thoughts on that, Dr. Singh?

Tamanna Singh, MD:

I think you brought up an excellent point. So screening, and I think what I will start with is EKG screening just because that's something that a lot of us are well aware of from a recreational professional standpoint, does not necessarily catch all of the causes of cardiac arrest and death. What I'm speaking to are things like coronary anomalies. You can't see coronary anatomy on an EKG. And sometimes even cardiomyopathies, we may not see some suggestion of a structural issue on an EKG. So from the data that we have gathered, there's quite controversy about whether EKG screening is more beneficial with respects to identifying at-risk athletes versus does it lead to more diagnostic testing that may not be necessary. I think the most important thing outside of screening is making sure that we've delineated what an athlete's family history is, whether or not they've had symptoms even before any such thing may occur, and just identifying what their risk is with that particular context more so than just a piece of paper.

Michael Emery, MD:

Yes, screening should always start with a history and physical exam using the AHA 14 points or the fifth PPE which is now out, which are very structured with regards to the cardiac evaluation. Adding an ECG or other imaging ought to be a very well thought out discussion amongst healthcare providers that are taking care of an athletic population, because it is still controversial and we will acknowledge that. But regardless of the controversy and screening, I'm going to bring it back to where there is zero controversy and that's an emergency action plan because we know we can't detect everything. We always want to be ready for what if. And emergency action plans clearly save lives and we don't want to leave that out.

Tamanna Singh, MD:

No, excellent point. Dr. Emery. I think one thing that you can do for yourself or your family and your friends is really stress upon the importance of getting comfortable with recognizing individuals who may be arresting and understanding what to do in those situations. I think as medical providers, we're really privileged and have the experience and constantly undergo a lot of educational sessions retraining us to learn how to do effective CPR. But there's a lot of tools out there. We as providers, I think I personally try to stress that athletes learn how to do CPR, coaches, parents, friends, we have a lot of tools, whether they be online, whether they be in person. Even at our airport there's stations to learn how to do high quality CPR. And I think one of the other things, Dr. Emery always brings this up, is really get comfortable with knowing how to use an external defibrillator. Right?

Michael Emery, MD:

Yeah. And it's more likely that a person who's trained in CPR, if he's familiar with CPR, is going to do it on a bystander than they are an athlete. But still, having those emergency action plans for you, for your family, for your friends are so important. Let's talk about now, we've had an athlete arrest. They've survived. We've determined or not determined an etiology, but now there's a discussion about what to do next. Can they go back to play after an arrest? What are your thoughts on that?

Tamanna Singh, MD:

It really depends. It depends upon the cause, depends upon the player's goals, and it depends upon safety. And I think that's where the importance of shared decision making among the provider, the patient, perhaps the patient athlete's parents if that individual is a minor, any stakeholders who are also involved within that sport field. It's really a comprehensive decision about safety, balancing risk, and then obviously what the goals are.

Michael Emery, MD:

Those are very personal discussions. They really are very long and personal discussions as they should be because this is a big decision and discussion between not only the athlete but the family and potentially the school and everyone else involved. So those aren't blanket statements that we can ever make. They're very personalized discussions that require expertise and knowledge in both the sport and the disease states that may have affected that young athlete. So as a Sports Cardiology Center here at the Cleveland Clinic, we're happy to discuss these kinds of cases with you in the future. Dr. Singh, any last thoughts or comments?

Tamanna Singh, MD:

You know, I think just reach out to us if you ever have any questions about athletes, if you have questions about emergency action plans, if you're involved with the sports within your community, if you have any questions about tools that you can disperse either to your patients or to your support systems about learning effective CPR and getting comfortable with using an external defibrillator. We're here to help you out. And then I think final point is always remember that these things do affect us physically, but they can also affect us mentally. So, if you witness cardiac arrest yourself or you know of people who have witnessed them or experienced them, it's really important to talk about them, kind of get through your feelings about what happened, work through those emotions and process just to make sure that you can kind of regain some psychological wellbeing after, because these things impact us, I think, from patient to provider.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us heart@ccf.org. Like what you heard? Subscribe wherever you get your podcasts or listen clevelandclinic.org/cardiacconsultpodcast.