Scott Webb (Host): Sudden cardiac arrest is the leading cause of death in young people. According to the American Heart Association, there are more than 365,000 out of hospital cardiac arrest incidents. Joining us today to discuss the importance of sudden cardiac arrests and understand the causes, prevention, and management among at risk populations, is Dr. Jared Salvo. He's a Cardiac Electrophysiologist on behalf of Dignity Health.

 This is Hello Healthy from Dignity Health. I'm Scott Webb.

 Doctor, it's nice to have you here today. We're going to talk about sudden cardiac arrest and what that means exactly and how that works and who it happens to. And I've got a bunch of questions for you. So let's just start there. What is sudden cardiac arrest? And maybe you can explain how it occurs.

Jared Salvo, DO: Sudden cardiac arrest is one of the most catastrophic things that can happen to someone. It's basically electrical death of the heart. And you'll sometimes hear people call it a heart attack, but it's really not a heart attack. It's not a blood clot. It's not a blocked artery. It's electrical death of the heart. And the heart is a electrically active organ, and all of the cells beat in synchrony, and they have to follow the hierarchy of order to beat in a synchronous fashion. And sudden cardiac arrest is when that order becomes chaos and disorder particularly in the bottom chambers of the heart, the ventricles. And it's really not compatible with life. So when I say catastrophic, it really means that the person is unlikely to survive if it happens outside of a hospital or a medical setting.

Host: Yeah. And I've talked to other heart docs. We've talked about plumbing issues with the heart, you know, and so today we're talking more about the electrical issues. Are there some main causes or some reasons why this happens to folks?

Jared Salvo, DO: You mentioned plumbing. Now plumbing can intersect with this. Now if you have plumbing problems, if you've had a heart attack or blocked arteries, it can lead to scar tissue buildup in the muscle of the heart, and that scar tissue is what is very irritable in some folks and causes this electrical short circuit. The interface of healthy muscle and scar tissue is, in particular, a danger zone. The other thing that can happen is if you develop what's called a cardiomyopathy, where the heart is weak, it loses its squeezing function, and it dilates and becomes what people in the community call it an enlarged heart and that puts undue strain and stress and stretches the electrical fibers and can cause that as well. And then, one thing I would add

Host: Yeah.

Jared Salvo, DO: Athletes probably have a higher incidence of this than the average folks. And the reason is because they're asking their hearts to do things on a day in, day out basis that most of us aren't asking our hearts to do on the athletic field.

Host: Yeah. Yeah. I was going to ask you about that. There've been some alarming cases of young athletes, especially high school athletes, college athletes, having sudden cardiac arrest and just wondering, maybe we can roll up our sleeves a little bit and delve a little bit more into that. Like, why does that happen to young athletes? Because they're so young and athletic and vibrant and amazing. So how does that happen to them? And why are they particularly vulnerable?

Jared Salvo, DO: There's two reasons, really. There's the unfortunate, which is just unlucky. And I, that would bring to mind the Damar Hamlin catastrophe year and a half ago on Monday Night Football. He had what's called commotio cordis, and that's the medical term for an untimely hit to the chest, during the cardiac cycle, which sent the heart spiraling into this ventricular fibrillation, and that could happen to anyone. And so on the athletic field, believe it or not, the number one sport where that happens is hockey, and that happens to be if a hockey puck gets slammed into your chest at the inappropriate time.

Lacrosse and baseball are also on that list. And so that's just unlucky, but that's why we need to have defibrillators in places like sporting events to promptly resuscitate people. On the other hand, you could also have someone who has an undiagnosed or maybe diagnosed condition where their heart is enlarged and maybe they shouldn't be on the field.

The controversial one that comes to mind for me a little bit before my time in medicine, but the Hank Gathers story, which I'm sure many people probably still remember, he was the Loyola Marymount basketball player.

Host: I was just thinking about that as you were beginning that I was like he's gonna mention Hank Gathers because I remember that so vividly.

Jared Salvo, DO: Yeah, and so Hank actually as far as I know, from what I know about the story he did have a pre existing condition, but we didn't fully understand it. I think that was about 1989. We had some idea and defibrillators were really new at that time bulky but that's the sort of thing we're talking about where someone can have a pre existing condition and have a catastrophe on the athletic field.

Host: Yeah, as you say, Damar Hamlin, Hank Gathers, some notable cases, wondering about sports supplements and what role they play in sudden cardiac arrest for young athletes.

Jared Salvo, DO: There has been a limited amount of data on, for example, pre workouts and energy drinks. These are strong stimulants and they usually contain a fair amount of caffeine and I'd like the uh, folks out there to know that green tea and green coffee extract are basically just other wordings for high density intense doses of caffeine.

But there's other things like taurine and some of the other things that they put in energy drinks that really stimulate the heart. And they're pretty toxic. I'm not going to say they're on the level of, say, abusing cocaine, which also stimulates the heart intensely. But if you use these energy drinks and then go out on the athletic field and ask your heart to play four quarters of basketball, you could get yourself into trouble because the heart's just pedal to the metal the entire time.

Host: Yeah. Yeah. My daughter is a junior in high school and she's a pretty good basketball player and she often plays all game, every game, just because of the makeup of her team. And you know, she'd gotten in the habit of taking a Red Bull or something like that. And that became part of her pregame routine, we'll call it.

And I encouraged her to not slam those types of drinks, you know, to sip it maybe the hour leading up to a game, something like that. But I said, I know you're this finely tuned, amazing young athlete, but these drinks probably aren't good for you. And it's definitely not good to slam one of these right before you run out in the basketball court, right?

Jared Salvo, DO: Yeah, I would agree with that statement. And the energy drink, we could have a whole conversation on the energy drink market. And there's no oversight on those things.

Host: Just wondering about warning signs and symptoms. You know, I remember, Doctor, back in my day when we would have these like triple sessions of football in the summer and everyone was sort of crying and vomiting. It was just horrendous what they put us through. And I hear these stories, especially of like, you know, young football players just being pushed to the point of exhaustion.

So what are some of the warning signs and symptoms that coaches, parents, teammates can be on the lookout for?

Jared Salvo, DO: Before I get into the warning signs, let's talk a little bit about screening. And we all go through not everybody, but you're supposed to go through sports a physical, right? I mean, I was a high schooler in the late eighties, early nineties, and the sports physicals back then were extremely rudimentary and and they probably didn't check for very much of consequence.

They were just make sure you were breathing and had a pulse. But the Japanese and the Italians have been very savvy on screening for these things for years. And most notably, that was they were able to get screening EKGs on their incoming high school athletes. An EKG can really pick up a lot of this, not all of it, but a significant amount, and if there was a screening EKG abnormality, then that would lead to further testing, and most of the time, it would be nothing, but occasionally, you would pick up that one person who didn't know that they had a condition, and so now in America, it is becoming more adopted and more accepted now. It's just funny that we're basically decades behind the Japanese and Italians in that matter.

But when your questioned about symptoms; one of the big ones is going to be unexplained fainting. Most fainting, the vast majority of it is benign. People pass out at the sight of blood and that sort of thing. But, post exertional passing out after you've had a workout or you're running wind sprints and then faint; that needs to be investigated to make sure that it is just one of these benign, you know, your blood pressure dropped because of stress versus something that is sinister underlying.

And so I would say fainting is probably one of the big ones. Racing heart can be another one, where you exert yourself and then your pulse rate stays very high for a long period of time. So those two are probably some of the bigger ones in the athlete. Now in the average person for sudden cardiac arrest, you may have other things, so if you, for example, have a dilated heart like we talked about, an enlarged heart, you may start finding yourself short of breath with just minor daily activities that you could do in the past, and that may be a sign that you need to have your heart checked to see if you do indeed have a structural problem.

Host: I've often wondered why they don't do EKGs, you know, because the thing about heart issues, I don't need to tell you, of course, you're an expert, but you know, a lot of these things are sort of silent killers.

People who have heart problems, undiagnosed heart problems, don't necessarily look like they have undiagnosed heart problems. So to look at some 17 year old kid, like my daughter, who's this, you know, amazing athlete and just assume that, well, she's probably fine. Right. I hope you're right. I hope that the way things are trending, that we do more and better screening for young athletes.

Jared Salvo, DO: I would agree with that. So, I have a freshman in high school who's on the basketball team. And so he had to go through his pediatrician to get a clearance, a physical clearance, right? And when, I'm assuming you and myself we would never have to go to see our physician to get a clearance.

They lined us up at the school office and we went through the line. So hopefully those types of things will improve that, but I would also say parents can advocate that their children have a screening EKG during that sports physical, and the pediatrician will hopefully see the importance of that.

The other thing that I would tell you that's exquisitely important is family history. Let's say that there's an unexplained cousin or an aunt who passed away in their sleep or someone that died unfortunately on the athletic field of competition. 1st and 2nd degree relatives really need to take a 2nd look to make sure that there wasn't a genetic cause.

And if there is suspicion, then it's checked. And we actually have genetic testing now. It's not the perfect science because there's so much that we don't know about genetic mutations, but it can be helpful if you can identify certain gene anomalies and screen for them. And once you identify what that one gene is, then it's actually very simple to screen for that one gene in relatives.

And most of these are what we call autosomal dominant genes, meaning that if you have it, there's a strong possibility that you could develop the problem. And we can just find that one gene once we identify it.

Host: Yeah. As you say, things that are within our control, behavior, lifestyle, eating, exercise, those kinds of things. But obviously family history, genetics is not something that we can outrun and maybe a little bit along those lines, when we think about the common heart conditions that lead to sudden cardiac arrest for young athletes. What are we talking about?

Jared Salvo, DO: Some of the more common things are the enlarged heart, and those can be genetic but really viral cardiomyopathy is something that is really common especially coming out of the pandemic. So, the common cold virus, believe it or not, can attack the heart, and it can weaken the heart. And the person may not know it right away. It may be years later when the weakened heart muscle finally settles in and the patient starts getting short of breath and they go to their doctor and the workup reveals that they have a weak, dilated heart. So viral cardiomyopathy is really common. And one of the more sinister reasons and probably more relevant in recent times of why we would see sudden cardiac arrest.

The other thing, unfortunately, and I hate to bring this up, but the use of illicit drugs and alcohol. In some people, not everybody; alcohol can literally be toxic to the heart. And so the use of alcohol can weaken the heart muscle, cause the heart to dilate and put them at risk of sudden cardiac arrest.

There are some people who can be you know, really strong alcoholics drinking every day and their hearts do just fine. Other folks, not that way. Sometimes a family history of alcoholic cardiomyopathy will give you some understanding if maybe there's a predisposition there. But the one that comes to mind that's probably the most toxic is the use of illicit drugs like methamphetamine.

I tell my patients; you would literally be the equivalent of taking in the most toxic substance that you could think of. And I bring to light example of antifreeze. No one would even in their right mind, take that. But those types of drugs can really weaken the heart and cause sudden cardiac arrest.

Host: Yeah, for sure. You know, you talked about how technology has come a long way, especially like, you know, on the sidelines and courts and things like that. So I wanted to ask you about CPR and AED and how we can sort of optimize that use in sports settings.

Jared Salvo, DO: I came to town here about 18 years ago when I was out of training. And at the time, AEDs were not readily available anywhere. And we advocated and went before our local high school board to, to try and get AEDs as a common standard on our campuses. And there was a lot of pushback in the beginning, the concern being for liability of misuse of the device.

But then I think people started realizing that the liability and the catastrophe of not having it, even if it meant that maybe the device didn't work or they didn't put it on properly; having a fighting chance with an AED, far outweighed that risk. And if we look at a state like Texas, for example, they had the standard of AEDs in elementary schools and high schools long before many other states did.

So here in California, we eventually adopted it, and now it's the standard, and here in our town I hate to bring this up, but the tipping point was a catastrophe that happened at our local high school, where a student died of sudden cardiac arrest in the gymnasium. Fast forward when the school board finally put in AEDs; the first save was at that very same school, and I was involved in both of those cases, and to come full circle like that, to see someone survive because of a tragedy was very meaningful. But I would tell you that even if we don't have AEDs, CPR is absolutely critical, and if you look at the Monday Night Football incident, CPR was initiated almost immediately when they recognized the problem.

And within moments after that, within minutes, they had the AED, which was waiting at the, in the tunnel, basically, of the stadium. We don't have the luxury of having a crew like that around, so we're oftentimes, as a community, beholden to the bystander, and I would just hope that everyone can get CPR trained, because you never know when you may be called into action.

Host: Right. Right. They absolutely, when they recognized what Damar Hamlin was experiencing, they absolutely saved his life, as you say. We got to see it live on television, you know, starting CPR immediately before they could get the AED to him is what saved his life. And you mentioned there the role of bystanders.

I wanted to ask you about that. Coaches, parents, other bystanders who maybe know CPR, like what's our role in some sort of SCA event? Like, should we just raise our hand? Should we just run down there and make sure, you know, and help out if we can?

Jared Salvo, DO: Yeah, this is not the time to be timid. This is the time to be called into action and the worst case scenario, you go down there and they say, go get help. Okay, fine. You fulfilled that role. But what if you go down there and you're the only one who knows how to do CPR? You will absolutely be called into action.

The other thing is if, if it takes a while to get emergency responders there, the CPR change out, meaning it becomes very tiring very quickly. It's a physically intense if you do it correctly, it's a physically intense activity. And so having someone to tag team you out, give you a break is very important.

And so yeah, it is not a time to be timid. It's a time to, to act. And I think the more people that know it, the better off we are. And we've seen CPR evolve. We really have it. We used to have breaths given in between, and now it's hands only, because we recognize that the breathing is probably, not as important as keeping the heart circulating.

And one thing I want to mention is the importance of time. Time is muscle. So every moment that goes by that the heart is not receiving circulation, is time that the muscle was potentially dying. The brain, the kidneys, the liver, they become very sensitive to lack of blood flow. So you have roughly three to four minutes to get an AED onto somebody before you start running into big problems of long term organ damage.

So unfortunately, and I hate to give this statistic, but the likelihood of surviving an out of hospital cardiac arrest in the community is less than 10 percent right now.

Host: Yeah, as you say when it comes to stroke, time is brain. When we're talking about the heart, time is heart, of course. As you say, most importantly, it's not a time to be timid. I just want to sort of conclude here today and ask you about, you know, if folks have more questions about sudden cardiac arrest and maybe they do despite, you know, this great conversation we've had today. Where would you direct them? Where can they go?

Jared Salvo, DO: There's a lot of resources out there. The American Heart Association is probably the go to because they're basically the standard of CPR training. And I might add before we wrap up here that CPR training is now a requirement for high school graduation in Kern County. That's been a big advancement and we were involved with that and the local American Heart Association helped with that.

Other things, Heart Rhythm Society, which is the governing body that oversees electrical cardiologists and the American College of Cardiology. And there are lots of resources on all 3 of those for patients to learn about sudden cardiac arrest, AEDs and I would also add, we talked about CPR, but don't forget if you're in a public place where you see someone have a cardiac arrest or there's suspicion, have someone, a bystander, look, go see if there's an AED anywhere nearby.

For example, if you're at the local mall, there should be an AED somewhere there, or an airport, or churches now have them. But if you don't think to go get it, then you're not going to use it. And I would also add they're on most commercial airlines now. So if you have a suspicion while you're in flight, tell the attendant, please get the AED.

Host: Yeah. The chance of survival for these sudden cardiac arrest events for most in the community is not great. But the fact is, more and more people know CPR, and the more we can do that, more places have AEDs, it gives some, at least for me, some room for optimism that we can save more lives, right?

Jared Salvo, DO: I agree. And the big thing is if you have an underlying condition that you don't know about, getting checked out and screened and taken care of, that can make that 10 percent a lot higher number if you've been identified as someone at risk, and that could make a huge difference.

Host: Yeah. I'm with you. Let's get that up from 10%. Let's get that to 50 percent or higher. Appreciate your time, your expertise today. Thank you so much.

Jared Salvo, DO: Thanks for interviewing me.

Host: And for more information, visit dignityhealth.org/bakersfield/heart.

Host: I'm Scott Webb, and if you found this podcast helpful, please share it on your social channels and check out the full podcast library for additional topics of interest.

This is Hello Healthy, a Dignity Health podcast. Thanks for listening.