He’s on the mend now, but on July 25, Bronny James, 18-year-old son of NBA legend LeBron James, suffered cardiac arrest during basketball practice at the University of Southern California (USC).
Many sports fans were reminded of a similar incident earlier this year. Buffalo Bills safety Damar Hamlin, just 24 at the time, experienced a cardiac event during the Bills’ game against the Cincinnati Bengals.
People often use “sudden cardiac arrest” and “heart attack” interchangeably, but they’re not the same.
The American Heart Association explains: A heart attack is a circulation problem because of a blockage in the arteries that feed the heart muscle; sudden cardiac arrest is an electrical problem that causes the heart to go into an abnormal rhythm and stop beating effectively.
Question about your heart? Start with a visit to your doctor.
Bronny James’ sudden cardiac arrest is another reminder that the general public – and even the media – use “sudden cardiac arrest” and “heart attack” interchangeably. But they’re not the same thing, are they?
They are not. But they’re certainly closely related. Across the country, there are about 350,000 sudden cardiac arrests in older adults every year. They were in a normal rhythm, and then they went into an abnormal rhythm that ultimately led to their collapse.
When someone has a heart attack, there is not enough blood flow to the heart muscle to meet the demand. This usually causes chest pain and is a medical emergency that needs immediate attention. Not all heart attacks lead to cardiac arrest, but they can if the damage to the heart muscle is severe.
To say it a different way, you can have sudden cardiac arrest from a cause other than a heart attack even if your coronary arteries that feed the heart muscle are completely normal.
Sudden cardiac arrest in the young, athletic population we're talking about it is very rare. When it happens, it makes headlines. The causes of sudden cardiac arrest in young, healthy people are almost always very, very different than they are in our parents and grandparents. And that leads to some confusion. It is highly unlikely that an 18-year-old basketball player is going to have a heart attack from blockage of the coronary arteries that feed the heart muscle.
The sudden cardiac arrest in a young athlete is likely related to some other cause. It could be related to a thick heart. Hypertrophic cardiomyopathy, where the walls of the left ventricle thicken, can be hereditary. Sometimes, the heart can be dilated – meaning, very enlarged – a condition that can be caused by a virus. This is called dilated cardiomyopathy.
There are also coronary anomalies, like coronary arteries that don't run to the normal place they're supposed to. And that – in a very small percentage of patients – can lead to sudden cardiac arrest. And then there are other potentially inherited rhythm issues that can lead to a sudden change to an abnormal heart rhythm. Electrophysiologist rhythm specialists can recognize symptoms in patients who are at risk and intervene before something tragic happens.
How are these events – heart attacks and sudden cardiac arrest – treated in the short term?
How we respond really matters, right? In the immediate aftermath, you hope there's someone who knows CPR at every event where one of these things might happen.
When we teach CPR, we talk about mortality being 10% per minute (after a cardiac episode). If I collapsed right now, and it took 10 minutes for somebody to take care of me, my chances of a good outcome are very low. We need knowledge of how to do CPR to be widespread in our communities. Certainly, coaches and trainers need to know it. That’s No. 1.
No. 2 is that when you go into an abnormal rhythm, you need to get back into that good rhythm. And while CPR is great at providing circulation, a lot of times what the person needs is an electrical shock. When you see defibrillators in airports, shopping malls and other public spaces, that's what they’re designed to do. CPR is great, but let's get an AED – an automated external defibrillator – to the patient as quickly as we can.
We know from years of research that CPR can be done with just chest compressions. This means that if you are at the ball field or the mall and you see someone collapse and stop breathing or responding, you can start chest compressions and ask someone nearby to get an AED. The AED will let you know if an electrical shock is needed and direct you on how to proceed. CPR classes teach both chest compressions and how to use the AED. Quick thinking – and acting – on your part could help save a life.
We don’t know yet all the details that surrounded Bronny James’ incident. But we know from Damar Hamlin’s incident that early defibrillation, in addition to the resuscitation he got on the field, helped save his life.
This incident may create fear among young athletes or, certainly, their parents. How can we ensure that something like this won't happen to them? Or is that even possible?
Obviously, some of these incidents are not preventable. Sometimes, the first symptom is the only symptom and the last symptom.
If you want to decrease the incidence of sudden cardiac death, most of that – probably 80% – is going to come from knowledge of family history and the athlete’s history. That’s hugely important. A much smaller percent will come from physical exams, and an even smaller percent will come from additional tests. We tend to get hung up on electrocardiograms or echocardiograms, and those are hugely valuable to cardiologists. But what’s really going to make a dent in the incidence of sudden death is history, history, history.
Many times, there's either a family history of something nobody has really picked up on or discussed, or there's a history of symptoms in the young athlete, who was reluctant to come forward with it. So, a focus on personal and family history is critical.
I'm a big proponent of a good, detailed sports physical, but it is no substitute for an annual physical. Our primary care providers really know their patients and their families – in many cases, for years or even decades. They can be the first line of defense. Make sure you see them for your annual exam.
Do you think there's been an increase in young athletes having cardiac arrest?
I don't think there's any increase in incidents. I think there may be increased reporting. We have sudden cardiac death registries around the country. We’re much better today at capturing those things.
One of the most common causes of sudden death in athletes is hypertrophic cardiomyopathy, and there’s now a genetic test for that in which about 70% or 80% of the time, we can identify a mutation. "And it's inherited autosomal dominant, which means that, if one of your parents has the mutation, you have a 50/50 chance of inheriting it from that parent."
We’re now able to screen entire families and potentially save a life that we may not have been able to before. And that's true with a lot of inherited conditions. We’re not only able to intervene with the patient, but we can intervene with siblings and other family members – or at least screen them so we know what the risks are.
There are always going to be some things we’re not able to screen for. A coronary anomaly, for instance, is not inherited. It's a one-in-a-bazillion thing, and when it happens, it's horrible. But it’s also very rare; hypertrophic cardiomyopathy occurs in one in 500 people. We want to find that one. And, if they do have an event, let me reiterate how important it is to resuscitate them as soon as possible through CPR or with an AED.
You mentioned some student athletes not wanting to tell anyone about worrisome symptoms they're experiencing. What are some of those symptoms parents can look for?
First, if any athlete passes out during or after exercise, that’s a red flag for the family, for coaches, for team members. I’m not talking about people who stand up too quickly or pass out when getting blood drawn. That's a very different sort of passing out. The young athlete on the field or on the court who suddenly drops – that’s scary. And that always demands an extensive workup.
Other things to notice are chest pain during or after exercise, palpitations or feeling like your heart is racing, an abnormal heartbeat during or after exercise, significant changes like shortness of breath in your exercise capacity. While chest pain can be very scary for the athlete or the family, the workup often shows a strong, healthy heart. And doctors are able to clear those athletes to return to playing. The reassurance that everything is normal always comes as a big relief.
Are you aware of any local cases like Bronny James’?
Absolutely. It certainly does happen, and it’s devastating when it does.
You see different numbers, but we might see a death in one out of every 100,000 to 200,000 young athletes. If you have 100,000 kids every year participating in competitive sports, we might see one sudden death among them a year. If you look back over the last five to 10 years – and certainly the 14 years I've been in Mecklenburg County – that’s been borne out.
Bronny is doing better, and that's great news. But after an incident like his, the onus is on us as physicians to ask: What happened? How did it happen? Why did it happen? How do we prevent it from happening again?
Anything you’d like to add?
I’ll just reiterate that we need education and training so that when bad things happen, people are prepared to intervene quickly. We want people to be trained in CPR/AED and feel confident they can jump in and save a life.