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A Stricter Approach for Commotio Cordis in Lethal Cases

      Cooper and colleagues recently proposed an interesting article that depicted the most important characteristics of the commotio cordis (CC) phenomenon as cause of sudden death in United Kingdom (UK) sports.
      • Cooper S
      • Woodford NW
      • Maron BJ
      • Harris KM
      • Sheppard MN
      A lethal blow to the chest as an underdiagnosed cause of sudden death in United Kingdom sports (Football, Cricket, Rugby).
      Nevertheless, as it happened for other articles that dealt with CC lethal cases,
      • Lupariello F
      • Di Vella G
      The role of the autopsy in the diagnosis of commotio cordis lethal cases: review of the literature.
      in the aforementioned article the authors risk nullifying their precious work. Indeed, one of the most important things that they should have clearly reported in the article is the specific definition of CC that they used to identify CC lethal cases in their database. This method may allow to avoid uncorrected reports and to make stricter the approach to the CC topic.
      • Lupariello F
      • Di Vella G
      The role of the autopsy in the diagnosis of commotio cordis lethal cases: review of the literature.
      In order to clarify the latter statement, it is useful to focalize the analysis on the case of the aforementioned article in which the authors described the presence of a broken rib. The inclusion of this case in the article is not obvious. Indeed, in the literature there are 2 different definition of CC. The first was proposed by Maron and colleagues in 1999: CC is characterized by an “instantaneous cardiac arrest that is produced by non-penetrating chest blows in the absence of heart disease or identifiable morphologic injury to the chest wall or heart”.
      • Maron BJ
      • Link MS
      • Wang PJ
      • Mark Estes NA
      Clinical profile of commotio cordis: an under appreciated cause of sudden death in the young during sports and other activities.
      • Lupariello F
      • Curti SM
      • Di vella G
      Diagnostic criteria for commotio cordis caused by violent attack: review of the literature.
      The second definition was proposed by Nesbit and colleagues in 2001; they defined CC “as a mechanical stimulation of the heart by non-penetrating, impulse-like impact to the precordium that, through intrinsic cardiac mechanisms, gives rise to disturbances of cardiac rhythm of varying type, duration, and severity, including sudden cardiac death, in the absence of structural damage that would explain any observed effects”.
      • Nesbitt AD
      • Cooper PJ
      • Kohl P
      Rediscovering commotio cordis.
      According to Maron and colleagues the presence of rib fractures should exclude the CC diagnosis; on the contrary Nesbit and colleagues did not necessarily exclude CC in such cases.
      • Maron BJ
      • Link MS
      • Wang PJ
      • Mark Estes NA
      Clinical profile of commotio cordis: an under appreciated cause of sudden death in the young during sports and other activities.
      • Nesbitt AD
      • Cooper PJ
      • Kohl P
      Rediscovering commotio cordis.
      That said, even if Cooper and colleagues did not report the CC definition that they used, a careful analysis of their article allows to hypnotize that they founded their evaluations on Maron's studies.
      • Cooper S
      • Woodford NW
      • Maron BJ
      • Harris KM
      • Sheppard MN
      A lethal blow to the chest as an underdiagnosed cause of sudden death in United Kingdom sports (Football, Cricket, Rugby).
      Therefore, they should have excluded from their study the case in which the rib fracture was described or they should have proposed the CC diagnosis only as possible, not as definitive.
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