Revisiting Commotio Cordis: Novel Insight Into Clinical Variability, Diagnosis, Epidemiology, and Prevention

Commotio cordis is a potentially life-threatening cardiac event caused by impacts to the chest during cardiac repolarization that result in arrhythmia. These impacts range from baseballs and soccer balls to a closed fist or vehicular accident. The arrhythmic outcome is a result of mechanoelectro coupling, in which a mechanical stretch of cardiac tissue results in electrical instability of the heart. There is a wide range of clinical presentation in the arrhythmias documented in commotio cordis cases, furthering our understanding of this complex mechanism that presents unique diagnostic and treatment challenges. A definition of commotio cordis is not consistent in the literature, specifically regarding the existence of structural damage to the rib cage or sternum, which remains a controversial diagnostic criterion and one that is argued against in this review. This clinical review has made significant steps toward building a global repository by including 100 new case reports and synthesizing all epidemiological data from 434 published case reports, which include 302 cases in sports and 132 cases in nonsporting events, including violence, motor vehicle accidents, and daily activities. Male dominance across these cases reports is clearly established, as men make up 94% of cases in sports and 93% of nonsporting events. Treatment using cardiopulmonary resuscitation and automated external defibrillators has increased survival rate >50% in recent years. Meanwhile, preventative measures have focused on improved chest protection in sports, simulation studies in human models, and the effectiveness of safety baseballs and safety regulations such as National Operating Committee on Standards for Athletic Equipment ND-200 to mitigate commotio cordis in sports for all ages.