Causes of sudden cardiac death in young Australians

OBJECTIVES: To determine the causes of sudden cardiac death in people aged 35 years or younger. DESIGN AND SETTING: A review of all autopsies performed between 1 January 1994 and 31 December 2002 at a major Sydney forensic medicine department serving an area with over 2 million people. MAIN OUTCOME MEASURES: Incidence of various types of cardiac disease causing sudden death in those aged 相似文献   

Sudden death due to ischaemic heart disease in young aboriginal sportsmen in the Northern Territory, 1982-1996.

OBJECTIVE: To estimate the incidence of sport-related sudden cardiac death due to ischaemic heart disease (IHD) in competitive young Aboriginal sportsmen. SETTING: Northern Territory (NT), 1982-1996. DESIGN: Retrospective case series with cases identified from Australian Bureau of Statistics cause-of-death listings and NT coronial autopsy records. MAIN OUTCOME MEASURES: Circumstances and incidence of sport-related sudden cardiac deaths due to IHD; autopsy findings. RESULTS: Between 1982 and 1996, there were eight sudden cardiac deaths due to IHD and related to sporting activity among Aboriginal sportsmen aged 15-37 years in the NT. Six were associated with games of Australian (rules) football. All occurred in the Top End of the NT in the wet season, and all occurred after the first half, or within an hour of, a game. Four of the players had macrosopic myocardial abnormalities (hypertrophy or previous infarcts) on autopsy. The estimated incidence of IHD-related sudden cardiac death among Aboriginal Australian football players in the NT was 19-24 per 100,000 player-years, compared with 0.54 per 100,000 player-years among Australian rules footballers of similar ages in Victoria. CONCLUSIONS: Incidence of sudden cardiac death attributable to underlying IHD was extremely high among young NT Aboriginal Australian footballers. Prevention will best be achieved by funding culturally appropriate long-term strategies to reduce the incidence of IHD. However, in the short-term, community-controlled programs with education of athletes, heat-stress reduction strategies, and cardiovascular screening should reduce the incidence of sudden cardiac death in sport.     

动态心电图表现对猝死患者的预测价值

目的探讨运动心电图表现对猝死患者的预测价值。方法 3600例健康男性进行标准化踏车运动试验。先描记卧位12导联心电图,测量基础血压与心率,然后进行加强双倍二级梯运动测验。运动后测即刻卧位血压与心率,并描记心电图,每导联描记5个P-QRS-T波。结果受试者均为男性,平均随访时间(19±6)年,死亡(全死因)325例(9%),心脏病死亡144例(4%),其中45例为猝死患者,99例为非猝死患者。猝死患者运动试验期间最大平均心率(96±0.8)次/min,非猝死患者或生存者为(97±0.6)次/min。结论运动试验过程中的心率变化模式与无症状健康男性猝死之间存在关联。     

Natural deaths while driving: would screening for risk be ethically justified?

OBJECTIVES: To determine the epidemiology and the underlying pathological conditions of natural deaths among motor vehicle drivers. Sudden death while driving may cause damage to properties, other vehicles or road users. Although the Medical Commission on Accident Prevention recommended restrictions to drivers at risk of sudden death due to their medical conditions, these restrictions are useless if they do not result in greater safety to the public. DESIGN: A retrospective study of natural deaths of motor vehicle drivers. SETTING: Natural deaths of motor vehicle drivers reported to the coroner for Birmingham and Solihull. SUBJECTS: 86 consecutive natural deaths of motor vehicle drivers in a five-year period between 1984 and 1988. RESULTS: Of the 86 fatalities reviewed, 80 (93%) sudden deaths were caused by ischaemic heart disease. Fifty vehicles were involved in collision with 32 properties, 20 other vehicles and six pedestrians. Fifty-one out of 80 cardiac deaths had past cardiac history and three had reported chest pain prior to the sudden death. CONCLUSION: An applied normative ethical assessment based on the basic moral principles of autonomy, justice, beneficence and non-maleficence are discussed. We conclude that medical screening of drivers has little benefit for the drivers or other persons.     

SUDDEN CARDIAC DEATH AMONG AUTOPSIED CASES

Sixty-eight sudden cardiac deaths (10.6%) in 642 autopsied cases of cardiovascular diseases were studied. The incidence was highest in ischemic heart disease (29.6%). Cardiac arrest was the most frequent direct cause of death in ischemic heart disease with or without acute myocardial infarction. Embolism was an important immediate cause of sudden death in theumatic heart disease, pulmonary heart disease and infectious endocarditis.     

The cardiac pathology of sudden, unexplained nocturnal death in Southeast Asian refugees

Sudden death during sleep has occurred among previously healthy Southeast Asian male refugees, but routine autopsies have not determined the cause of death in any of these cases. We report the first systematic attempt to define the cardiac abnormalities associated with this syndrome. Among 18 hearts examined, 14 showed slight to significant cardiomegaly, characteristic of increased cardiac work load. The reasons for the cardiomegaly remain unexplained. Conduction system anomalies were present in all but one heart. These included persistent fetal dispersion of the atrioventricular node and/or bundle of His, present in 14 hearts; accessory conduction fiber connections, found in 13 cases; and congenital heart block, observed in one case. These abnormalities were associated with variations in the structure of the cardiac base, suggesting a common aberrant developmental process. Although the functional significance of these findings has not been established, the conduction system anomalies may be the substrate for sleep-related cardiac arrhythmias and sudden death.     

Ventricular tachyarrhythmia associated with psychological stress. The role of the sympathetic nervous system

Psychological stress has been reported to be a risk factor for sudden cardiac death in individuals both with and without underlying structural heart disease. From a group of 80 patients presenting with life-threatening ventricular tachyarrhythmia, six were identified without underlying structural heart disease. Five of these six patients experienced marked psychological stress. Each of these five patients underwent arrhythmia evaluation, demonstrating recurrent rapid monomorphic ventricular tachycardia related to changes in tone of the sympathetic nervous system. Subsequently, solitary beta-adrenergic blocker therapy was given to each patient. During therapy, four of the five patients had a marked reduction of both arrhythmia and symptoms during a follow-up ranging from 29 to 49 (mean, 38) months.     

75例猝死的临床病理分析

目的探讨猝死的病因、病理基础及防治措施。方法回顾性分析我院75例猝死的临床病理资料。结果 75例猝死中,老年人47例,占62.7％,非老年人28例,占37.3 ％,男女之比约3:1。心原性猝死52例,其中冠心病猝死36例,占69.2％(36/52);非心原性猝死19例,其中以急性出血坏死型胰腺炎所占比例最高42.1％(8/19);4例尸检病理检查未见致死性疾病。冠心病猝死患者主要建立在冠状动脉多支严重病变基础上。结论猝死以老年男性多见,有广泛严重冠状动脉病变的冠心病者猝死发生率高。防治冠心病、改善心肌缺血等综合治疗十分必要。胰源性猝死主要为急性出血坏死型胰腺炎所致,误诊率较高。猝死可发生在无器质性疾病的正常人,应加强心理素质训练。     

29例云南不明原因聚集性猝死的尸检病理学研究

目的：分析云南不明原因聚集性猝死的病理特点,为其病因探索和实施干预提供依据。方法：收集云南省进行这类猝死监测以来临床与病理资料较完整的尸检材料29例,占同期死亡病例的10．2％。年龄8至69岁（平均32岁）,男16例、女13例。核查心脏标本,观察了主要脏器的组织病理改变,对其中5例还做了心脏传导系统检查。心肌炎的病理诊断参照Dallas标准和世界心脏联合会的共识,标准克山病的病理诊断依据国家相关卫生行业标准。结果：心脏主要病理改变有：淋巴细胞性心肌炎11例、中性粒细胞性心肌炎3例、致心律失常性右室心肌病4例、左室肥厚合并流出道异常肌束2例、缺血性心脏病2例、过敏性支气管炎和慢性支气管炎合并肺气肿2例、主要脏器未找到明显致死性病理形态改变5例。29例中均未见克山病和扩张型心肌病的病理形态改变。心肌炎均为局灶性,5例心脏传导组织检查见2例有希氏束或左束支起始段急性出血,1例炎症波及房室结。4对家庭聚集性病例的病理改变不同,4例首发猝死中3例为心肌炎、1例慢性感染,续发猝死中3例与急性心肌缺血有关,1例为致心律失常性右室心肌病。多数病例伴肺水肿,少数伴呼吸道和肺部感染。部分出现淤血性或缺血性肝细胞坏死。结论：云南不明原因聚集性猝死的基本病理改变不同,多数为心肌炎症、心脏发育异常和其他致死性心肺疾患,未见克山病的病理学证据,致心律失常性右室心肌病等基础性心脏病应引起重视,猝死的聚集性可能是多种因素的综合表现。     

热休克蛋白在冠心病猝死病例心肌和血管中的表达及意义

目的:探讨冠心病猝死心肌组织和血管组织HSP70染色改变。为法医学鉴定冠心病猝死提供客观依据。方法:选择8例患冠心病但非冠心病猝死案例(A组)、10例冠心病猝死案例(B组)以及7例非冠心病死亡案例(C组).用免疫组化方法对比检测热休克蛋白70(heat shock protein70 HSP70)的表达。结果:HSP70在患冠心病但非冠心病猝死案例和冠心病猝死案例中呈阳性表达,在心肌组织中冠心病猝死组表达水平明显高于患冠心病但非冠心病猝死组(P0.05),非冠心病猝死组均呈阴性表达。结论:HSP70的阳性表达是心肌和血管缺血缺氧的重要指标,对推断冠心病猝死具有一定的实际应用价值。     

Syncope after effort

A 29-year-old man developed recurrent syncope following exertion. Cardiac investigations revealed no evidence of structural heart disease, but during exercise testing, in the recovery phase, he sustained a bradycardia and then asystole for a prolonged period. Before cardiac massage could be instituted a tonic-clonic fit occurred, and this initiated a return to sinus rhythm. His symptoms were abolished following the implantation of a dual-chamber pacemaker.     

Physical exertion, exercise, and sudden cardiac death in women

Context  Exercise is associated with a lower risk of cardiovascular events but may transiently increase the risk of ventricular arrhythmias. Its short-term and long-term associations with risk of sudden cardiac death among women are unclear. Objectives  To compare the risk of sudden cardiac death in women during moderate to vigorous exertion with the risk of sudden cardiac death during lighter or no exertion; and to assess the long-term association between moderate to vigorous exercise and sudden cardiac death. Design, Setting, and Participants  Prospective, nested case-crossover study of 288 cases of sudden cardiac death within the Nurses' Health Study (1980-2004); and a prospective cohort analysis of 69 693 participants without prior cardiovascular disease followed up from 1986-2004. Main Outcome Measure  Risk of sudden cardiac death associated with moderate to vigorous exertion. Results  The absolute risk of sudden cardiac death associated with moderate to vigorous exertion was exceedingly low at 1 per 36.5 million hours of exertion. In case-crossover analyses, the risk of sudden cardiac death was transiently elevated during moderate to vigorous exertion (relative risk [RR], 2.38; 95% confidence interval [CI], 1.23-4.60; P = .01) compared with the risk during lesser or no exertion. Habitual moderate to vigorous exertion modified this transient risk (P = .005 for interaction) and the risk was no longer significantly elevated among those who exercised 2 or more hours per week. In the cohort analyses, an increasing amount of moderate to vigorous exercise was associated with a lower long-term risk of sudden cardiac death in age-adjusted and multivariable models that excluded biological intermediates (P = .006 for trend). This relationship was attenuated when biological intermediates were included (P = .06 for trend); however, the reduction in risk remained significant among women who exercised 4 or more hours per week (adjusted RR, 0.41; 95% CI, 0.20-0.83; P = .01) compared with women who did not exercise. Conclusions  These prospective data suggest that sudden cardiac death during exertion is an extremely rare event in women. Regular exercise may significantly minimize this small transient risk and may lower the overall long-term risk of sudden cardiac death.      

Sudden cardiac death in young Danes

Sudden Cardiac Death (SCD) in the young (aged 1-35 years), although presumably rare, is always a tragic and devastating event often occurring in apparently healthy persons. Through the last decades, research have been undertaken to estimate the incidence rate and underlying causes of these deaths. However, because autopsy is not always conducted, the true incidence of SCD might be underestimated. The incidence of sudden infant death syndrome (SIDS) has previously been thoroughly investigated, also in Denmark. However, data has not been precise in sudden unexpected death in infancy (SUDI) estimates. SIDS is a diagnosis of exclusion and an ICD-10 diagnosis (R95.9), but to what extent this diagnosis is being accurately applied has not been investigated in Denmark. A genetic screening for mutations in an otherwise unexplained death, might identify a likely cause of (inherited) death. It would be of great clinical interest if DNA derived from the Danish Neonatal Screening Biobank, containing DNA from all Danes born after 1981, could be used in this respect. In this thesis we provide nationwide data on SCD, SUDI and SIDS in Denmark for the period 2000-2006 by reading death certificates, autopsy reports, and registry data. We report the highest possible incidence rate of SCD in the young. We elaborate on regional differences in post-mortem investigations of sudden death cases in Denmark and validate a method for whole-genome amplification of DNA from Guthrie cards to be used in genetic screening for disease causing mutations. We found 7% of all deaths in the young could be attributed to SCD. A total of 25% of sudden unexpected death in the 1-35 years old were not autopsied. The incidence of SCD of 2.8 per 100,000 person-years--when including non-autopsied cases--was higher than previously reported. Unexplained deaths were abundant and accounted for 22% of all sudden unexpected deaths. Sudden deaths occurring during competitive sports, however, were only seen in few cases. We found that regional differences exist in the investigation of sudden unexpected deaths. Fewer deaths were medico-legally investigated by external examinations ("retsl?geligt ligsyn") in some parts of Denmark compared to other parts. The same was the case in autopsy ratios. In infant deaths we found that almost 1 in 2000 live-borns died suddenly and unexpectedly during their first year of life. The R95.9 diagnosis did not reflect the SIDS cases we identified. We were able to get DNA from the Danish Neonatal Screening Biobank on 93 cases of unexplained deaths (including SIDS). Due to the limited amount of DNA available from the dried blood spots, we performed whole-genome amplification on the DNA (wgaDNA). We investigated the use of wgaDNA for genetic screening and it completely resembled genomic DNA (gDNA). Future research will focus on the genetics substrate of sudden unexplained death. In addition, we will investigate the causes of death in the 36-49 years old, as these may also suffer from cardiac disease that can be predisposed in the family.     

急诊抢救205例猝死分析及预防探讨

目的：分析我院急诊科收治猝死病例的临床特点、发生特点和规律。方法：选择1999年6月～2008年12月我院急诊抢救的猝死患者205例,按年龄、性别、时间分布特征、转归及临床特点等进行回顾性临床分析。结果：（1）年龄段分布,年龄〈18岁21例（10.24%）,18～39岁34例（16.58%）,40～59岁68例（33.17%）,60～79岁60例（29.27%）,≥80岁22例（10.7%）;（2）按季度统计,一季度58例（28.29%）,二季度41例（20.00%）,三季度45例（21.95%）,四季度61例（29.76%）。以一、四季度发生猝死病例数最多;（3）猝死患者在入院死亡病例中所占比例有逐年增高的趋势;（4）猝死患者中男129例,女76例,男：女=1.70：1。青壮年所占比例较大（18～59岁102例,占49.76%）;（5）未成年人猝死者多发生在新生儿和婴幼儿期15例（71.43%）,尤以1月～1岁最常见;（6）未成年人猝死患者存在的基础疾患以呼吸系统疾病为多,共10例（47.62%）。成年猝死患者中存在心血管疾病69例（37.50%）占第一位,而其中冠心病28例（40.58%）占主导地位,高血压13例（18.83%）,是一个重要的危险因素,此外慢性肺原性心脏病发生猝死者8例在本组病例中占很高的比例（11.59%）。结论：必须对青壮年男性以及存在冠心病、高血压等高危因素人群加强健康教育,同时重视婴幼儿的猝死问题。医院要加强急诊科队伍的建设和医务人员综合抢救能力的培训,从而提高猝死病例的抢救成功率。     

Sudden death in young Aboriginal adults with rheumatic heart disease

A retrospective review for the period 1983 to 1988 was made of all sudden deaths in young Aboriginal adults from the Darwin and East Arnhem regions who had known rheumatic heart disease. A total of five cases was identified from autopsy reports. The age range was between 16 and 35 years. All were being treated for asymptomatic heart disease (grade I). The sudden, unexpected death in each of these patients resulted in their deaths all being reported to the coroner. In all cases there was no evidence at autopsy of significant coronary artery disease or bacterial endocarditis. All had evidence of rheumatic valvular heart disease affecting either one or both mitral and aortic valves to varying degrees. No other cause of death was found. This report serves to illustrate the fact that rheumatic heart disease is still a significant contributor to morbidity and mortality in Aborigines, and that while the usual picture of progressive deterioration in exercise tolerance may be the norm, sudden death without any apparent preceding symptomatology can occur.     

动态心电图对冠状动脉粥样硬化性心脏病猝死的预测价值

冠状动脉粥样硬化性心脏病(简称冠心病)是心脏性猝死的最常见的基础疾病,对患者风险评价的不足仍然是目前限制临床预防战略的最主要原因。近年来,动态心电图分析仪的一些功能被认为对预测急性心肌梗死后发生猝死有预测价值,且部分动态心电图参数对冠心病患者猝死有预测价值。这在国外通过多项研究已得到证实,我国尚缺乏相关数据,积极开展心脏性猝死的预防研究具有非常重要的社会价值和经济意义。     

国产药物洗脱支架在冠心病弥漫性长病变中的临床应用

目的研究国产雷帕霉素药物洗脱支架(Firebird)在冠心病弥漫性长病变中的疗效及安全性。方法 2008年1月1日至2008年12月22日单纯置入Firebird支架的冠心病弥漫性长病变患者72例。随访患者住院期间和出院后主要不良心脏事件(包括心肌梗死、心源性猝死及靶血管再次血运重建术)、心绞痛发作情况等。结果 72例患者术后随访10~24(16.54±6.68)个月,57例心绞痛症状消失(79.17%,57/72),14例心绞痛复发(19.44%,14/72),1例猝死(1.39%,1/72)。再狭窄2例(2.78%,2/72),随访期间发生猝死1例,无急性心肌梗死发生病例。结论国产Firebird药物涂层支架应用于冠心病弥漫性长病变患者中介入治疗是安全有效的。     

新型冠状病毒肺炎37例死亡原因分析

目的 分析和探讨新型冠状病毒肺炎（COVID-19）患者的死亡原因及其相关危险因素。方法选择住院期间死亡的37例COVID-19患者的主要临床资料进行回顾性分析。结果37例COVID-19死亡病例中男26例,女11例;年龄44～99岁,平均年龄(76.3±19.4)岁,65岁以上者30例（81.1%）,有基础疾病者31例（83.8%）,依次为高血压病、冠心病、糖尿病。86.5%患者有并发症,依次为血糖异常、继发感染、多器官功能衰竭（MODS),多数患者有心、肝、肾、凝血功能异常。死亡原因主要是急性呼吸窘迫综合征（ARDS）、MODS、感染性休克。结论COVID-19患者中高龄、男性、基础疾病多、核酸检测阳性、持续高热者转归不佳,纠正低氧血症,控制基础疾病,稳定血压血糖,保护重要脏器功能,密切关注血钾、血小板和D-二聚体的变化,有利于改善预后、提高治疗效果。     

Plaque rupture and sudden death related to exertion in men with coronary artery disease

Context  Exertion has been reported to acutely increase the risk of sudden coronary death, but the underlying mechanisms are unclear. Objective  To determine the frequency of plaque rupture in sudden deaths related to exertion compared with sudden deaths not related to exertion. Design  Autopsy survey. Coronary arteries were perfusion fixed and segments with more than 50% luminal narrowing were examined histologically. Ruptured plaques were defined as intraplaque hemorrhage with disruption of the fibrous cap and luminal thrombus. Exertion before death was determined by the investigator of the death. Setting  Medical examiner's office. Patients  A total of 141 men with severe coronary artery disease who died suddenly, including 116 whose deaths occurred at rest (mean [SD] age, 51 [11] years) and 25 who died during strenuous activity or emotional stress (age, 49 [9] years). Main Outcome Measures  The frequency and morphology of plaque rupture was compared in men dying at rest vs those dying during exertion. Independent association of risk factors (total cholesterol, high-density lipoprotein cholesterol, glycosylated hemoglobin, cigarette smoking) in addition to acute exertion with plaque rupture were determined. Results  The mean (SD) number of vulnerable plaques in the coronary arteries of men in the exertional-death group was 1.6 (1.5) and in the at-rest group was 0.9 (1.2) (P=.03). The culprit plaque in men dying during exertion was plaque rupture in 17 (68%) of 25 vs 27 (23%) of 116 men dying at rest (P<.001). Hemorrhage into the plaque occurred in 18 (72%) of 25 men in the exertional-death group and 47 (41%) of 116 men in the rest group (P=.007). Histological evidence of acute myocardial infarction was present in 0 of 25 in the exertion group and in 15 (13%) of 116 in the rest group. Men dying during exertion had a significantly higher mean (SD) total cholesterol–high-density lipoprotein cholesterol ratio (8.2 [3.0]) than those dying at rest (6.2 [ 2.7]; P=.002), and the majority (21/25) were not conditioned. In multivariate analysis, both exertion (P=.002) and total cholesterol–high-density lipoprotein cholesterol ratio (P=.002) were associated with acute plaque rupture, independent of age and other cardiac risk factors. Conclusion  In men with severe coronary artery disease, sudden death related to exertion was associated with acute plaque rupture.      

Management of malignant ventricular arrhythmias using antitachycardia devices

Cardioverter defibrillators were implanted in 26 patients at Charleston Area Medical Center for management of cardiac arrest (7 patients), and drug refractory sustained ventricular tachycardia (19 patients). A variety of operative approaches and concomitant surgical procedures were utilized in the implantation of these devices. No operative deaths occurred. A superficial wound infection was the only operative complication. During the follow-up period (9.3 +/- 5 months), 11 of 26 patients (46 percent) had a defibrillator discharge and one death occurred (3 percent), which was due to heart failure. Patients with malignant ventricular arrhythmias may present with sustained monomorphic ventricular tachycardia with associated syncope, pre-syncope or without any associated symptoms. Unfortunately, cardiac arrest may be the initial presentation. The use of antitachycardia devices such as implantable cardioverter defibrillators and antitachycardia pacemakers has allowed physicians to more successfully treat patients with malignant ventricular arrhythmias. In a significant number of patients with these arrhythmias, such devices are now used as first-line therapy.