Cardiac Collapse & Death in Athletes

On July 24th, 2023, Bronny James, the son of future Hall of Fame professional basketball player Lebron James, collapsed during the USC Trojans basketball practice. It is unclear to me from researching the event if CPR was performed or whether he required “defibrillation” from an AED or Automated Electrical Defibrillator to be resuscitated. Regardless, he was hospitalized in the ICU and eventually discharged in stable condition. He is doing well in the weeks since the event and his Father even posted him playing the piano and going out to dine with the family soon after his “cardiac arrest”.  He will now undergo an extensive evaluation prior to being “cleared” to participate in Division 1 collegiate basketball again. Assuming he does not have a condition that would medically prohibit him from playing in the future.

His collapse and near-death experience from a possible cardiovascular cause is not the first to occur during my 30-year career as a physician and 22-year career as a cardiologist and it brings with it the opportunity to discuss the medical causes and reasons a young, supremely conditioned, and competitive athlete would collapse and either:

1. Spontaneously recover. 
2. Be resuscitated and survive. 
3. Be resuscitated and not survive. 

As a father of a 15-year-old High School football player myself, I want to know what I need to be concerned about, how to have my child properly evaluated before participation and what to do if my child experiences any symptoms that may be related to the heart or cardiovascular system. I may not be the only one with these pressing questions. 

There are a lot of reasons someone can collapse and die, athlete or couch-potato. In general, it falls into 4 broad categories: 

1. Structural abnormality of the heart 
2. Electrical abnormality of the heart 
3. Vascular abnormality of the heart. 
4. Blunt force trauma to the chest and subsequently the heart. 

To illustrate these four categories, I will use four examples of highly competitive athletes that either collapsed and survived or did not survive their fatal event since 1988. 

1988 – A Problem with the Plumbing 
On November 5th, 1988, “Pistol” Pete Maravich, a retired NBA Hall of Fame basketball player collapsed and died during a pickup basketball game in Pasadena, CA. The cause of death was an anomalous coronary artery. He had played at the highest of levels for many years without any sign of this condition or concerning symptoms of this life-threatening condition. 

An anomalous coronary artery is one in which its origin is aberrant or anomalous. It leads to the abnormal dilation of the coronary blood vessels. The severely dilated coronary arteries can develop blood clots which can suddenly block blood flow. This can cause a heart attack and sudden death, as was the most likely cause in the case of “Pistol” Pete. Individuals with anomalous coronary arteries often have no symptoms and can compete at very high levels athletically until they suffer from Sudden Cardiac Death (SCD). They can also have symptoms of angina or chest pain, but each circumstance is unique. More importantly, this is a very difficult condition to diagnose unless the patient has symptoms or survives their SCD event to be evaluated and diagnosed. 

Other causes of arterial disease that can lead to cardiac arrest are coronary spasm, coronary thrombosis, coronary dissection, aortic aneurysm rupture or aortic dissection (John Ritter, comedian of Three’s Company fame and Lucille Ball). 

1990 – March Madness 
On March 4th, 1990, Hank Gathers, an All-American, Collegiate Division 1 basketball player at Loyola Marymount University, collapsed and died during the first half of the West Coast Conference Championship Tournament against the Portland Pilots. His cause of death was an electrical abnormality; Exercise Induced Ventricular Tachycardia. What is unfortunate about Hank Gather’s death on the court is that he knew he had an electrical problem with his heart. On December 9th 1989, just a few months before his death, Hank collapsed during a game against UC Santa Barbara. He was subsequently diagnosed with the exercise induced VT. His heart was mechanically sound and strong but the electrical pathways that make the heartbeat were abnormal and could, under exercise conditions, change abruptly to VT, which if not corrected with a defibrillator, can lead to ventricular fibrillation (VF) and to death in minutes. At the time his exercise-induced VT was diagnosed, he was treated with an appropriate medication, a beta blocker, and returned to competition. Apparently, the medication made his performance on the court suffer and the dose was reduced.  In addition, without telling his doctors, he stopped taking the medication on game days. Whether the reduction in his dose of medication ultimately led to the VT that took Hank Gathers life will never be known. 

Ventricular tachycardia is considered an arrhythmia. It has many causes, not just exercise induced, and in many cases of cardiovascular disease, all roads ultimately lead to an episode of VT and then ventricular fibrillation (VF), which is true “cardiac arrest”. The pre-collapse diagnosis of VT in anyone and especially a competitive athlete is very difficult and is usually established after the person has survived the event. In some cases, it may be suspected based on symptoms of a near collapse and then diagnosed with appropriate cardiac monitoring tests. 

Other causes of electrical or arrhythmias that can cause cardiac arrest are Wolf-Parkinsons-White syndrome, Long QT syndrome, Brugada syndrome and right ventricular arrhythmogenic dysplasia. 

1993 – Common Things are Common 
On July 27th, 1993, Reggie Lewis, a 27-year-old up and coming NBA All-Star player with the Boston Celtics collapsed during an off-season practice and could not be resuscitated. He died on the court. His autopsy revealed he had Hypertrophic Cardiomyopathy or HCM. Hypertrophic Cardiomyopathy is the most common cardiac condition that athletes die from suddenly. In HCM, there is an abnormal thickening of the walls of the heart. The abnormal structure of the muscle can lead to abnormally elevated pressures in the heart chambers as well as to unstable cardiac arrhythmias like VT and VF (remember all roads lead to VT and VF). In the case of Reggie Lewis there was some forewarning of his underlying heart disease. In April of 1993, he collapsed to the court during a playoff game against the Charlotte Hornets. He remained down for several moments but was able to regain his feet. He appeared confused and disoriented and after a brief return was removed from the game. He underwent an extensive evaluation by a dozen or more world renown heart specialists at New England Baptist Hospital. He was diagnosed with focal cardiomyopathy that was not specifically called HCM. He was told he could never play again. Unsatisfied, Reggie got a second opinion and was given an alternate diagnosis of “neurocardiogenic syncope”, which is a benign form of fainting and carries no risk of SCD. He resumed practice and preparation for the 1994 season but collapsed and died as described. His autopsy revealed that HCM was present. 

Hypertrophic cardiomyopathy or HCM is by far the most common reason an athlete will collapse and possibly die during competition. It is a very complex and complicated cardiac disease. It can be best described as an abnormal growth and thickening of the muscular walls of the heart. The increased thickness of the walls causes elevated pressures in the chambers which can lead to symptoms of shortness of breath and heart failure as well as low blood pressure and fainting. The abnormal structure of the thickened muscle causes arrhythmias like VT and VF, which are the primary cause of collapse and death in this condition. Fortunately, this is a disease that can be diagnosed during pre-participation physical exams. Not every athlete with this condition will be diagnosed though and it takes an astute clinician to be watchful of the exam and ECG findings that help discover this deadly disease. 

Other structural cardiac abnormalities that can lead to collapse and death are other types of cardiomyopathies, valvular conditions like aortic stenosis or bicuspid aortic valve disease, congenital defects that were not diagnosed earlier in childhood. 

2023 – Monday Night Football Collision 
On Monday night January 2, 2023, Damar Hamlin, a cornerback for the Buffalo Bills Professional football team tackled wide receiver Tee Higgins of the Cincinnati Bengals. During the tackle, it appeared that Damar was struck in the center of his chest by Higgin’s helmet. Immediately after the tackle, Damar stood up and then fell in a heap to the field. First responders rushed to his side and started performing CPR. They used an AED or cardiac defibrillator to restore a normal heart rhythm and resuscitated him from death. He was hospitalized and recovered and has had a complete cardiovascular evaluation. All of which was normal. The cause of his on-field cardiac arrest was Commotio Cordis, which I will explain. 

Commotio is Latin for commotion and Cordis is Latin for heart. Commotio Cordis is used to describe an event in which the chest wall is struck by an object with enough impact and at just the right time to cause an unstable arrhythmia to develop like VT or VF and cardiac arrest to ensue. There is nothing structurally or electrically wrong with the athlete’s heart, as is the case for Damar Hamlin. It is just a matter of being struck in the chest at exactly the right moment during the cardiac electrical cycle to cause the fatal arrhythmia. Exceedingly rare and unusual but worth the discussion here given the recent case during a Nationally televised event seen by millions of people live. 

How Do I Protect My Athlete from Sudden Cardiac Death? 
For all of us parents out there with children that have played or are playing sports, how do we prevent or protect our children from such a horrible fate?  

First off, pay attention to any symptoms one might have. Anytime someone collapses without a warning or reason it is serious and needs to be evaluated. Symptoms of chest pain, pressure, difficulty breathing or an inability to keep up with athletes when competing or training can be a subtle clue to a serious cardiac problem. Symptoms of a rapid, racing, or irregular heartbeat need to be investigated, especially if associated with a loss of consciousness or near loss. 

Second is an athletic pre-participation physical. That is when a medical provider might discover cardiac murmurs or other physical findings that might be the result of an undiagnosed heart condition. It is also the athletes and parents’ opportunity to discuss any concerning symptoms they might have. 

Third is to consider a more detailed cardiac evaluation. An electrocardiogram or EKG is a relatively low-cost screening tool for heart disease. It can potentially identify cardiomyopathy or heart rhythm disturbances. An echocardiogram or ultrasound imaging of the heart is often ordered based on symptoms or when a murmur is heard on exam. It is the standard of diagnoses for HCM and other cardiomyopathies as well as heart valve abnormalities that can lead to collapse and death, which I did not discuss in detail here. A cardiac rhythm monitoring test can also be done in athletes with symptoms of an irregular heartbeat or if they have fainted and recovered. The heart rhythm can be recorded for up to 14 days and sometimes up to a year with an implanted monitoring device. 

Collapse and Sudden Death Is Not Common 
When the 18-year-old son of arguably one of the greatest basketball players of the modern era collapses and almost dies, it is big news. Fortunately, the risk of any of our children having a serious cardiac disease that will cause them to collapse and die during competition is unlikely. That does not mean we should not do our best to ensure our young athletes are safe: 

• Listen to symptoms. 

• A loss of consciousness in any person is serious and should be evaluated right away. 
• Have an experienced medical professional perform an athletic pre-participation evaluation. 
• Get an ECG as part of the pre-participation evaluation if there is any history of sudden cardiac death in the family, unexplained loss of consciousness or any potentially cardiac related symptoms. 
• Consider an echocardiogram if there are any concerns that structural heart disease is present. 
• Consider a cardiac rhythm monitoring test for symptoms of an irregular heartbeat or if fainting has occurred previously. 

Athletics are truly institutionalized in our country and the world. Athletic competition is healthy and participation in team sports teaches us invaluable lessons about working with others, together, towards a common purpose and goal. There are also many unknowns in life, certainly more unknowns than things we truly know and understand. The fear that my child might have a serious condition is one of those unknowns. But we cannot let the fear of those unknowns keep us from moving forward. Damar Hamlin says it best as he will be resuming full football activities at the Buffalo Bills NFL camp this month after surviving a near death experience:

“I just want to show people that fear is a choice. You can keep going at something without having the answers and without knowing what’s at the end of the tunnel,” he said. “You might feel anxious – you might feel any type of way – but you just keep putting that right foot in front of the left one and you keep going. I want to stand for that.”

1. Spontaneously recover.
2. Be resuscitated and survive.
3. Be resuscitated and not survive.

As a father of a 15-year-old high school football player, I want to know what I need to be concerned about, how to have my child properly evaluated before participation and what to do if my child experiences any symptoms that may be related to the heart or cardiovascular system. I may not be the only one with these pressing questions.

There are a lot of reasons someone can collapse and die, athlete or couch-potato. In general, it falls into 4 broad categories:

1. Structural abnormality of the heart.
2. Electrical abnormality of the heart.
3. Vascular abnormality of the heart.
4. Blunt force trauma to the chest and subsequently the heart.

To illustrate these four categories, I will use four examples of highly competitive athletes that either collapsed and survived or did not survive their fatal event since 1988.

1988 – A Problem with the Plumbing
On November 5th, 1988, “Pistol” Pete Maravich, a retired NBA Hall of Fame basketball player collapsed and died during a pickup basketball game in Pasadena, CA. The cause of death was an anomalous coronary artery. He had played at the highest of levels for many years without any sign of this condition or concerning symptoms of this life-threatening condition.

An anomalous coronary artery is one in which its origin is aberrant or anomalous. It leads to the abnormal dilation of the coronary blood vessels. The severely dilated coronary arteries can develop blood clots which can suddenly block blood flow. This can cause a heart attack and sudden death, as was the most likely cause in the case of “Pistol” Pete. Individuals with anomalous coronary arteries often have no symptoms and can compete at very high levels athletically until they suffer from Sudden Cardiac Death (SCD). They can also have symptoms of angina or chest pain, but each circumstance is unique. More importantly, this is a very difficult condition to diagnose unless the patient has symptoms or survives their SCD event to be evaluated and diagnosed.

1990 – March Madness
On March 4th, 1990, Hank Gathers, an All-American, Collegiate Division 1 basketball player at Loyola Marymount University, collapsed and died during the first half of the West Coast Conference Championship Tournament against the Portland Pilots. His cause of death was an electrical abnormality; Exercise Induced Ventricular Tachycardia. What is unfortunate about Hank Gather’s death on the court is that he knew he had an electrical problem with his heart. On December 9th, 1989, just a few months before his death, Hank collapsed during a game against UC Santa Barbara. He was subsequently diagnosed with the exercise induced VT. His heart was mechanically sound and strong but the electrical pathways that make the heartbeat were abnormal and could, under exercise conditions, change abruptly to VT, which if not corrected with a defibrillator, can lead to ventricular fibrillation (VF) and to death in minutes. At the time his exercise-induced VT was diagnosed, he was treated with an appropriate medication, a beta blocker, and returned to competition. Apparently, the medication made his performance on the court suffer and the dose was reduced.  In addition, without telling his doctors, he stopped taking the medication on game days. Whether the reduction in his dose of medication ultimately led to the VT that took Hank Gathers life will never be known.

Ventricular tachycardia is considered an arrhythmia. It has many causes, not just exercise induced, and in many cases of cardiovascular disease, all roads ultimately lead to an episode of VT and then ventricular fibrillation (VF), which is true “cardiac arrest”. The pre-collapse diagnosis of VT in anyone and especially a competitive athlete is very difficult and is usually established after the person has survived the event. In some cases, it may be suspected based on symptoms of a near collapse and then diagnosed with appropriate cardiac monitoring tests.

1993 – Common Things are Common
On July 27th, 1993, Reggie Lewis, a 27-year-old up and coming NBA All-Star player with the Boston Celtics collapsed during an off-season practice and could not be resuscitated. He died on the court. His autopsy revealed he had Hypertrophic Cardiomyopathy or HCM. Hypertrophic Cardiomyopathy is the most common cardiac condition that athletes die from suddenly. In HCM, there is an abnormal thickening of the walls of the heart. The abnormal structure of the muscle can lead to abnormally elevated pressures in the heart chambers as well as to unstable cardiac arrhythmias like VT and VF (remember all roads lead to VT and VF). In the case of Reggie Lewis there was some forewarning of his underlying heart disease. In April of 1993, he collapsed to the court during a playoff game against the Charlotte Hornets. He remained down for several moments but was able to regain his feet. He appeared confused and disoriented and after a brief return was removed from the game. He underwent an extensive evaluation by a dozen or more world renown heart specialists at New England Baptist Hospital. He was diagnosed with focal cardiomyopathy that was not specifically called HCM. He was told he could never play again. Unsatisfied, Reggie got a second opinion and was given an alternate diagnosis of “neurocardiogenic syncope”, which is a benign form of fainting and carries no risk of SCD. He resumed practice and preparation for the 1994 season but collapsed and died as described. His autopsy revealed that HCM was present.

Hypertrophic cardiomyopathy or HCM is by far the most common reason an athlete will collapse and possibly die during competition. It is a very complex and complicated cardiac disease. It can be best described as an abnormal growth and thickening of the muscular walls of the heart. The increased thickness of the walls causes elevated pressures in the chambers which can lead to symptoms of shortness of breath and heart failure as well as low blood pressure and fainting. The abnormal structure of the thickened muscle causes arrhythmias like VT and VF, which are the primary cause of collapse and death in this condition. Fortunately, this is a disease that can be diagnosed during pre-participation physical exams. Not every athlete with this condition will be diagnosed though and it takes an astute clinician to be watchful of the exam and ECG findings that help discover this deadly disease.

2023 – Monday Night Football Collision
On Monday night January 2, 2023, Damar Hamlin, a cornerback for the Buffalo Bills Professional football team tackled wide receiver Tee Higgins of the Cincinnati Bengals. Immediately after the tackle, he stood up and then fell in a heap to the field. First responders rushed to the field and started performing CPR and used an AED or cardiac defibrillator to restore a normal heart rhythm and resuscitated him from death. He was hospitalized and recovered and has had a complete cardiovascular evaluation. All of which was normal. The cause of his on-field cardiac arrest was Commotio Cordis, which I will explain.

Commotio is Latin for commotion and Cordis is Latin for heart. Commotio Cordis is used to describe an event in which the chest wall is struck by an object with enough impact and at just the right time to cause an unstable arrhythmia to develop like VT or VF and cardiac arrest to ensue. There is nothing structurally or electrically wrong with the athlete’s heart, as is the case for Damar Hamlin. It is just a matter of being struck in the chest at exactly the right moment to cause the fatal arrhythmia. Exceedingly rare and unusual but worth the discussion here given the recent case during a Nationally televised event seen by millions of people live.

How Do I Protect My Athlete from Sudden Cardiac Death?
For all of us parents out there with children that have played or are playing sports, how do we prevent or protect our children from such a horrible fate?

First off, pay attention to any symptoms one might have. Anytime someone collapses without a warning or reason it is serious and needs to be evaluated. Symptoms of chest pain, pressure, difficulty breathing or an inability to keep up with athletes when competing or training can be a subtle clue to a serious cardiac problem. Symptoms of a rapid, racing, or irregular heartbeat need to be investigated, especially if associated with a loss of consciousness or near loss.

Second is an athletic pre-participation physical. That is when a medical provider might discover cardiac murmurs or other physical findings that might be the result of an undiagnosed heart condition. It is also the athletes and parents’ opportunity to discuss any concerning symptoms they might have.

Third is to consider a more detailed cardiac evaluation. An electrocardiogram is a relatively low-cost screening tool for heart disease. It can potentially identify cardiomyopathy or heart rhythm disturbances. An echocardiogram or ultrasound imaging of the heart is often ordered based on symptoms or when a murmur is heard on exam. It is the standard of diagnoses for HCM and other cardiomyopathies as well as heart valve abnormalities that can lead to collapse and death, which I did not discuss here. A cardiac rhythm monitoring test can also be done in athletes with symptoms of an irregular heartbeat or if they have fainted and recovered. The heart rhythm can be recorded for up to 14 days and sometimes up to a year with an implanted monitoring device.

Collapse and Sudden Death Is Not Common
When the 18-year-old son of arguably one of the greatest basketball players of the modern era collapses and almost dies, it is big news. Fortunately, the risk of our children having a serious cardiac disease that will cause them to collapse and die during competition is unlikely. That does not mean we should not do our best to ensure our young athletes are safe:

• Listen to symptoms.
• A loss of consciousness in any person is serious and should be evaluated right away.
• Have an experienced medical professional perform an athletic pre-participation evaluation.
• Get an ECG as part of the pre-participation evaluation if there is any history of sudden cardiac death in the family, unexplained loss of consciousness or any potentially cardiac related symptoms.
• Consider an echocardiogram if there are any concerns that structural heart disease is present.
• Consider a cardiac rhythm monitoring test for symptoms of an irregular heartbeat or if fainting has occurred previously.

Athletics are truly institutionalized in our country and the world. Athletic competition is healthy and participation in team sports teaches us invaluable lessons about working with others, together, towards a common purpose and goal. There are also many unknowns in life, certainly more unknowns than things we truly know and understand. The fear that my child might have a serious condition is one of those unknowns. But we cannot let the fear of those unknowns keep us from moving forward. Damar Hamlin says it best as he will be resuming full football activities at the Buffalo Bills NFL camp this month after surviving a near death experience:

“I just want to show people that fear is a choice. You can keep going at something without having the answers and without knowing what’s at the end of the tunnel,” he said. “You might feel anxious – you might feel any type of way – but you just keep putting that right foot in front of the left one and you keep going. I want to stand for that.”