Drugs and sudden cardiac death

The last 10–15 years have seen the emergence of increasing numbers of “designer” recreational drugs taken for their mood elevating and euphoric effects. They are unlicensed, untested and there is often only scant information on toxic levels. They are associated with sudden death, most likely through cardiac arrhythmias but have a number of other complications including acute kidney injury, rhabdomyolysis, cerebral oedema and serotonin syndrome which may also ultimately lead to death. This article covers the major classes of these drugs that may be encountered and considers some of the pharmacology and pathophysiological effects.     

Cardiogenic shock and sudden cardiac death

The study of 148 cases of sudden cardiac death revealed in 25 (17%) of them morphological signs of cardiogenic shock characterized by severe microcirculatory disorders: uneven blood-filling of the vessels of the microcirculatory bed and increasing number of nonfunctioning capillaries in the myocardium and hypothalamus; signs of juxtamedullar shunting in the kidneys and the development of sludge phenomenon in different parts of their microcirculatory bed combined with high activity of renin in the plasma. The signs of cardiogenic shock in the group of observations of sudden cardiac death were noted predominantly in the presence of myocardial infarction, large foci of ischemia in the heart or multiple scattered foci of cardiomyocyte damage. Cardiogenic shock was found to occur in sharp reduction of the density of adrenergic nerve structures in the myocardium.     

The investigation of sudden cardiac death

Pathologists are faced with an increasing complexity in the cardiac diseases that cause sudden natural death in the absence of coronary artery disease. A significant proportion of such natural sudden deaths are due to familial heart muscle disease (cardiomyopathy). The phenotypic characteristics of both hypertrophic cardiomyopathy and arrythmogenic right ventricular dysplasia are wider than previously thought and the hearts may be very close to normal on naked eye examination. Detailed histology of the myocardium is needed to identify such cases. Up to 200 sudden deaths a year in England occur in young, apparently fit individuals in whom toxicology and detailed examination of the heart for structural abnormalities is negative. Genetic defects in ion channels (long QT interval) are now known to be one cause of this phenomenon. In investigating a case of sudden death without cause, a study of the family -- if they wish it -- may be helpful in arriving at a cause.     

Death-scene investigation in sudden infant death

We conducted death-scene investigations in 26 consecutive cases in which a presumptive diagnosis of sudden infant death syndrome (SIDS) was made and the infants were brought to the emergency room of the Kings County Hospital Center between October 1983 and January 1985. In six cases, we observed strong circumstantial evidence of accidental death. In 18 other cases, we discovered various possible causes of death other than SIDS, including accidental asphyxiation by an object in the crib or bassinet, smothering by overlying while sharing a bed, hyperthermia, and shaken baby syndrome. This study suggests that many sudden deaths of infants have a definable cause that can be revealed by careful investigation of the death scene and that the extremely high rate of SIDS (4.2 per 1000 live births) reported in the population of low socioeconomic status served by Kings County Hospital Center should be questioned.     

Golden opportunity or sudden death threats

King/Drew Medical Center is the only minority academic medical center west of the Mississippi River. As a result of the McCone Commission investigation into the Watts Riots of 1965, it was initially established as the Martin Luther King Hospital. Upon the establishment of Drew University in the mid-70s, the name change was made to recognize the existence of the College of Medicine at Drew University and its affiliated hospital. The medical school and hospital are known as the King/Drew Medical Complex. Referenced are the issues and challenges faced by the institution that have resulted in the current crisis. Restoration and rehabilitation of the academic medical center can be achieved by identifying the uncommon common goals of stakeholders in a collaborative and integrated process.     

Non-atherosclerotic coronary pathology causing sudden death

Coronary atherosclerosis is responsible for >50% of all cases of sudden death and for 90% of sudden coronary death. Four cases encountered in routine autopsy evaluation at our institute in 2004 in which non-atherosclerotic coronary pathology was responsible for sudden cardiac death are reported. The cases of a 31-year-old man with epicardial coronary arteritis, a 57-year-old man with intramyocardial vasculitis, a 45-year-old woman with spontaneous coronary dissection and a 50-year-old man with vascular fibrosis are described. Searching for non-atherosclerotic coronary disease is relevant for both the clinician and the pathologist to prevent coronary causes of sudden death going unrecognised.