Looking to Provide Athletes the Best Heart Protection Possible
Commotio cordis is a sudden cardiac arrhythmia caused by a direct blow to the chest. It typically results from a low-velocity impact to the chest from a thrown or batted ball, puck, or other object, typically traveling between 20 and 50 mph. The risk increases the closer the impact is to the center of the heart. Death results when an abnormal rhythm, ventricular fibrillation, develops. However, blood circulation to the heart may also be affected.
For commotio cordis to occur, the impact has to be precisely timed to strike the heart during a 15–30 millisecond phase of the electrical cycle. It can cause sudden death in young baseball, softball, and hockey players, as well as other athletes.
Commotio Cordis by the Numbers
- The sport with the highest incidence of commotio cordis is baseball, followed by softball, hockey, football, soccer and lacrosse.
- An overwhelming 95 percent of cases affect males.
- The most frequently affected age group is 10 to 18 years.
- Since 1995, the U.S. Commotio Cordis Registry has received reports of over 250+ cases. Many more unreported cases are suspected of having occurred.
- Recent registry data show survival rates have improved dramatically — now approximately 40–60% — due to faster recognition, CPR, and AED use.
Survival Outcome
While instances of commotio cordis are rare, historically, survival was below 10%. However, modern data show survival has improved substantially when CPR and defibrillation occur rapidly.
Responding with CPR efforts within 3 minutes or less is critical. Studies indicate that survival odds are greatly enhanced if an automated external defibrillator (AED) shock can be delivered promptly. Early CPR and rapid AED use now represent the strongest predictors of survival.
Most ballparks still lack accessible AEDs, and those that do must have well-practiced Emergency Action Plans (EAPs) that include staff trained to retrieve and use the device immediately. The NFHS now recom
mends venue-specific EAPs reviewed annually, with AEDs reachable within 3 minutes of every playing area. Otherwise, all preparation is for naught.
Also, the high-profile lawsuit in New Jersey involving a pitcher struck by a batted ball from an alleged “hot bat” involved commotio cordis and permanent disability. The metal bat manufacturer and others were sued. It is interesting to note that commotio cordis usually occurs only when a projectile travels at a relatively moderate speed — usually between 20 and 50 mph — making this case unique.
Protecting Against Commotio Cordis
Researchers have been looking for solutions, typically in the form of chest protectors. But statistics show that somewhere between 20 and 30 percent of commotio cordis victims collapsed while wearing chest protection of some sort. Obviously, this means that the protection athletes were given wasn’t good enough.
Educating coaches, players, and parents about the importance of technique and situational awareness is critical. For example, baseball and softball players should be taught to step aside or turn and deflect balls using their shoulders, not their chest walls.
Commotio cordis is not related to an underlying heart condition; therefore, susceptibility cannot be predetermined by medical screening.
Spectators, players, and staff need to be able to recognize the signs of commotio cordis and take immediate action if a player is struck in the chest and collapses — call 911, begin CPR, and use an AED without delay.
New NOCSAE Standards in Protection
In July 2018, the National Operating Committee on Standards for Athletic Equipment (NOCSAE) set the world’s first performance standard for chest protection from commotio cordis (NOCSAE ND200). NOCSAE developed separate versions for baseball and lacrosse. Governing bodies of the various sports decide whether to require compliance and when to enforce it.
The ND200 standard has since been updated (most recently ND200-22, effective February 2023), reaffirming its performance levels while clarifying test procedures.
The Science Behind the New Standards
Together with the Louis J. Acompora Memorial Foundation, NOCSAE funded more than $1.1 million in research that pinpointed the cause of commotio cordis, including the critical moment of occurrence. To test impacts to the chest and heart, research engineers developed a mechanical surrogate torso that mimics the human response. All this led to NOCSAE creating the first commotio cordis-specific chest protection standard.
NOCSAE’s goal is to significantly reduce — though not eliminate — the risk of death from commotio cordis for athletes using equipment certified to this standard.
Chest Protector Certifications By SEI
The Safety Equipment Institute (SEI) issues certifications for chest protectors that meet NOCSAE’s ND200 standard. The NOCSAE criteria support a test method that produces reliable measurements to evaluate various types of chest protectors.
Manufacturers participating in SEI’s certification program must have their facilities audited annually for quality assurance. All SEI- and NOCSAE-certified products are retested and recertified each year. SEI remains the world’s premier certification body for protective sports equipment.
Consumers and coaches can verify model compliance at SEI’s public directory, by searching “ND200” and the relevant sport (baseball or lacrosse).
High School Rule Change in Baseball For Catchers
The NOCSAE standard resulted in multiple rule changes:
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Baseball (NFHS): Rule 1-5-3, effective January 1, 2020, requires all high school catchers to wear NOCSAE ND200-compliant chest protectors.
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Lacrosse: Goalies (boys’ and girls’) have been required to wear ND200-certified chest protectors since January 1, 2021, and boys’ field players must wear ND200-certified heart-protective shoulder pads since January 1, 2022, under USA Lacrosse, NFHS, and NCAA rules.
These changes provide assurance that athletes are using equipment tested to the latest standards for heart protection.
No Guarantees of Protection and Ongoing Debate
It’s important to note that neither NOCSAE nor SEI offers any guarantees of protection from the certified chest protectors. They clearly state that no thoracic or chest protector can prevent all cardiac injuries, and that catastrophic injury or death may still occur.
Opponents of the standard argue that manufacturers cannot claim prevention, and question whether the additional expense of compliance is justified given the rarity of the condition. Others express concern about potential side effects such as added bulk or heat stress.
However, most medical and sports-safety experts emphasize that ND200-certified gear, combined with early CPR/AED access and proper technique, offers the best currently available multilayer defense against commotio cordis.
If you found this blog on commotio cordis to be beneficial, please check out our other sports risk management content and other risk management blog posts.
