By Denise Williams | News & Views
The Buffalo Bills kept their hopes for a 2025 Super Bowl appearance alive all the way up until the last round of the playoffs, when a crushing defeat to the Kansas City Chiefs eliminated the squad as a contender. Two years earlier, their hopes were on keeping Damar Hamlin — jersey #3 — alive.
Millions of viewers were watching Monday Night Football when the Bills safety took a hit on January 2, 2023. The collision with a Cincinnati Bengal didn’t appear to be particularly violent but was forceful enough to put both players on the ground. A few seconds after they hopped back to their feet, one — Hamlin — suddenly collapsed backward onto the turf and, to the horror of onlookers, stopped moving. In fact, by the time NFL officials made the call to suspend the game a short while later, he had in fact stopped living.
The sequence of events — a blow to the left chest, over the heart; 5-7 seconds of consciousness; then sudden cardiac death despite a lack of cardiac abnormality — had all the hallmarks of a textbook case of commotio cordis, according to Mark Link, MD, a professor with the University of Texas Southwestern Medical Center and a member of its cardiology division.
What Is Commotio Cordis?
Dr. Link has spent the better part of 25 years investigating the condition which, despite being reported in the literature as far back as the 17th century, had largely remained a mystery. His interest was piqued following the publication of a pivotal report on commotio cordis that ran in the prestigious New England Journal of Medicine in 19951, kindling fresh interest in the cardiac phenomenon.
That paper described 25 cases, typically involving adolescents between the ages of 11 and 18 years of age who sustained what was almost always a fatal blow to the chest — usually in the setting of a sports activity. What Maron et al. couldn’t confirm, since EKGs weren’t performed in any of the case studies, was why commotio cordis happens. Dr. Link struck out on a journey to learn more.
What he and other researchers have since discovered is that the mechanism of death in commotio cordis is ventricular fibrillation. The arrythmia occurs after being struck in the chest at the precise moment during the heart’s electrical rhythm when the lower chambers, or ventricles, are pumping chemicals back to the cells in order to enable the next heartbeat. This strike during the vulnerable period causes ventricular fibrillation, or quivering of the heart. The heart’s ability to pump blood is subsequently compromised, and the affected individual collapses. It’s a perfect storm of the right time, the right velocity of impact, and the right direction of impact, according to Dr. Link, whose lab used an experimental model to examine the different variables that are at play. Approximately 60% of cases unfold during athletic activities, the evidence suggests, with the other 40% stemming from fistfights and other non-sports-related catalysts.
Implications for Cardiac Rehab
Modern evidence also reveals that survival after commotio cordis is possible — and, indeed, likely — with fast and effective resuscitation. The incidence rate is just 10-20 cases per year; and while it is most certainly a rare occurrence, Dr. Link believes the count is probably an underestimation. It likely happens more often than that, he suggests, but isn’t reported because the survival rate is improving. “A resuscitated baseball player who gets struck in the chest isn’t likely to make the news,” he reasons. Of course, he adds, survivors of cardiac arrest — under any circumstances — always run the risk of damage to the brain; however, lasting impact to the heart appears to be less concerning. “There’s no thought that you’re at increased risk of sudden cardiac death in the future,” he notes.
Dr. Link calculates that 60%-70% of people suffering commotio cordis today are brought back to life, their hearts no worse for the wear. Given this reality, along with the insurance hurdles potentially blocking cardiac rehab for a young person who hasn’t suffered an actual heart attack, it’s likely that many CR programs may never handle a commotio cordis case. For those that do have an opportunity to service such a patient, the focus will be two-fold: overseeing a safe and gradual return to physical activity and caring for the fragile mental state that invariably follows a brush with death.
“It’s a big deal, actually,” Dr. Link declares. “The trauma of having a sudden cardiac death experience is immense. You’re going to be afraid to do anything. Cardiac rehab plays a big role in that regard, in that patients are monitored while they’re increasing their activity.” Cardiac rehab plays an equally significant role for other cardiac arrest survivors in whom the psychological trauma of the event is immense.
Megan Hays, PhD, ABPP, FAAVCPR, a clinical psychologist and associate professor specializing in cardiac rehabilitation at the University of Alabama at Birmingham (UAB) Health System, emphasizes the psychological toll such an event can have on survivors. “A sudden cardiac event isn’t just a physical crisis — it’s a deeply emotional one. Many survivors struggle with post-traumatic stress, anxiety, and a fear of exertion,” she explains. “A structured rehab program provides not only medical supervision but also the psychological exposure and reassurance needed to help patients regain confidence in their own bodies.”
Dr. Hays also highlights the importance of peer support during recovery. “I’ve seen firsthand how connecting with others who have survived cardiac events can be transformative," she says. "Knowing you’re not alone in your fears and challenges is a crucial step in the healing process.”
Promoting CPR
While cardiac rehab stands ready to help this small patient population, that’s possible only if the individual who suffered commotio cordis survives. That’s increasingly
the case, as illustrated by Damar Hamlin’s remarkable recovery and return to football the same year as his near-tragedy on the field. He and other survivors are here today because life-saving measures — CPR and defibrillation — were employed immediately.
“That’s the biggest takeaway I get from this and other cases: CPR should be known by everybody,” Dr. Link emphasizes, pointing out that hands-only is an established and effective alternative for those who are squeamish about mouth-to-mouth. It’s as simple as taking an online course, he adds.
Dr. Hays reinforces this point, noting that the psychological barriers to responding in an emergency are often as significant as the physical ones. “People hesitate to act because they fear doing something wrong. But in cases like commotio cordis, immediate action is the difference between life and death. Training and education reduce that hesitation, making bystanders more confident and willing to step in,” she says.
Greater community access to automated external defibrillators (AEDs), which Hamlin has made his personal mission, is also critical, according to Dr. Link, but useless in the absence of CPR. Both, he insists, should be universally available, adding that Hamlin has been instrumental in promoting that narrative.
Teaming up with Sen. Chuck Schumer (D-NY), Hamlin lobbied heavily for the HEARTS Act. The legislation — which supports CPR and AED training for staff, students, and volunteers in American schools — was passed into law by President Biden in December 2024.
Dr. Link appreciates the attention that Hamlin’s case and his advocacy efforts have directed toward commotio cordis, CPR, and AEDs. “I think he's done a wonderful job for resuscitation efforts in the United States, probably more than any other thing that's happened,” he concludes.
Dr. Hays agrees. “Damar Hamlin’s story is a powerful reminder that survival is possible with immediate intervention,” she remarks. “His advocacy ensures that more people will be prepared to respond, saving lives in ways we may never even hear about.”
References
1Maron, BJ, Poliac, LC, Kaplan, JA, Mueller, FO. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med 1995;333:337-342