Contribution of the 24 hour electrocardiogram to the prediction of sudden coronary death.

BACKGROUND--Sudden coronary death is a major public health issue. The identification of patients at high risk should therefore be as efficient as possible. This study compares simple and more elaborate risk stratification procedures. METHODS--Risk functions for the prediction of sudden death were determined in a population of 6693 consecutive patients who had 24 hour electrocardiography for various indications. The functions were based on the clinical and electrocardiographical data on 245 patients who died suddenly during 2 year follow up and 467 patients randomly drawn from the total study population. RESULTS--The model based on history (age, sex, myocardial infarction, congestive heart failure, palpitation, syncope, use of diuretics, and use of nitrates), 12 lead electrocardiography (major intraventricular conduction defect, T wave abnormality, and ST depression > or = 0.05 mV), and standard rhythm analysis of 24 hour electrocardiography (ventricular tachycardia, frequent premature atrial complexes, sinus tachycardia (> 150 min-1), and atrial fibrillation) was almost as efficient in the prediction of sudden death as extended models that also contained information from exercise testing, echocardiography, ventriculography, and computer-aided re-analysis of 24 hour electrocardiography (QT and RR interval variability). CONCLUSIONS--These results indicate that additional information from advanced function tests does little to increase the efficiency of prediction of sudden coronary death over that of tests based on history, the standard 12 lead electrocardiogram, and 24 hour electrocardiography.     

Myocardial lesions in sudden, unexpected coronary death.

In order to test whether sudden coronary death patients had a more "vulnerable" myocardium compared with other patients, morphological lesions of the myocardium and conduction system were examined in a selected autopsy series. Chronic inflammatory microlesions, frequently affecting single muscle fibers, predominated among 47 sudden coronary death cases compared with 34 cases with chronic coronary or noncoronary diseases (P less than 0.001). Nonfibrous lesions of the atrioventricular node and the bundle of His also predominated among the sudden death cases (P less than 0.05). Myocardial infarcts of any age as well as relative heart weight (the ratio: total heart weight/body weight) did not differ in the sudden coronary death and the chronic coronary patients. The chronic inflammatory microlesions and the nonfibrous lesions of the conduction system predominating among the sudden death cases may signify a vulnerable condition of the myocardium in sudden coronary death.     

In-hospital sudden death after coronary care unit discharge.

In a retrospective analysis of in-hospital sudden death among patients with acute myocardial infarction, nine of 48 (18.7%) in-hospital deaths after discharge from the coronary care unit were judged "sudden." This group had a significantly prolonged coronary care unit course, a higher incidence of supraventricular and ventricular arrhythmias, and a noticeable incidence of anterior wall myocardial infarction as compared with those of a matched infarct control group. Seventy-seven percent of the sudden-death group had three or more concomitant high-risk factors as compared with only 3% of a matched control group.     

Factors related to suddenness of death from coronary disease: combined Albany-Framingham studies

One hundred nine sudden deaths in men 45 to 74 years of age enrolled in prospective studies in Albany, N. Y. and Framingham, Mass. were examined in an effort to identify features associated with sudden death from coronary heart disease. From a coronary profile made up of serum cholesterol concentration, systolic blood pressure, relative body weight, cigarette habit and electrocardiographic evidence of left ventricular enlargement, the likelihood of sudden death could be estimated over a 14-fold range of risk. One third of sudden deaths occurred in men in the topmost decile of risk, but whether or not death from coronary disease was sudden was largely unrelated to the mix of risk factors. The proportion of such deaths that were sudden was equal among men with and without prior overt coronary heart disease. Increasing age was not conclusively associated with the suddenness of death. No combination of risk factors considered separated persons uniquely destined to die suddenly from those who would experience a more protracted death. It is conjectured that sudden death from coronary disease is related more to the exact nature of the pathologic changes in the heart than to the factors predisposing to these changes. The prevention of sudden death from coronary disease requires correction of the antecedents of coronary attacks.     

Arrhythmia control and other factors related to sudden death in coronary disease patients at intermediate risk

Thirty-three patients with coronary artery disease and frequent, complex ventricular arrhythmias (VA) were followed long-term to evaluate factors related to sudden death (SD). Patients with malignant VA (sustained ventricular tachycardia (VT), resuscitated SD, or acute myocardial infarction) were excluded. Baseline data included angiographic ejection fraction (EF), segmental wall motion, and Holter evidence of frequent (greater than 30/hr) and complex (repetitive) ventricular premature beats (VPBs). Control of VA was attempted with conventional or experimental agents and was defined as greater than or equal to 70% reduction in VPBs, greater than or equal to 90% reduction in couplets, and abolition of nonsustained VT on two consecutive Holter tapes. After 24 +/- 15 months of follow-up on the single most effective agent, 18 patients survived while 15 patients died suddenly. There was no difference between these groups with respect to age, sex, or baseline VA. Survivors had a higher EF (51% vs 34%, p less than 0.001), fewer dyskinetic segments (0.05 vs 1.0, p less than 0.01), and better VA control (83% vs 40%, p less than 0.01) than nonsurvivors. By analysis of variance, VA control was not independent of EF (F = 6.98, p less than 0.01). The 1-, 2-, and 3-year survival rates were 90%, 90%, and 82% for patients with EF greater than or equal to 40% and 22%, 11%, and 11%, for those with EF less than 40% and uncontrolled VA.(ABSTRACT TRUNCATED AT 250 WORDS)     

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心脏性猝死是指由心脏事件导致的,发生迅速而意外的死亡。心脏骤停是指心脏泵血突然停止,是心脏性猝死的前期过程。90%以上的心脏骤停是由室性心动过速或心室颤动引起。若不及时抢救,绝大多数心脏骤停将转化为心脏性猝死。心脏性猝死是部分患者心脏疾病的首发表现。1心脏性猝死的流行病学资料和病因在美国,据估计每年猝死人数为30万~35万。我国的统计学资料显示,心脏性猝死的发病率为41.9/10万,年猝死人数54.4万。心脏性猝死的病因繁多,包括各种器质性心脏疾病,心脏大体结构正常的离子通道疾病,以及部分可纠正的病因(如严重的电解质紊乱)等…     

Non-atherosclerotic coronary artery disease and sudden death in the young.

OBJECTIVE--To assess prevalence and type of non-atherosclerotic coronary artery disease in young people (< or = 35 years) who died suddenly. DESIGN--A necropsy study of 150 consecutive cases of sudden death (that is, within 6 h of the onset of symptoms). RESULTS--Death was attributed to coronary artery disease in 48 cases: in 16 (33%) of them the disease was non-atherosclerotic. Twelve subjects (eight males and four females, age range 2-35 years, mean 24.2) had congenital anomalies: a deep intramyocardial course in six, origin from the wrong sinus in three, and ostial obstructions in three. Sudden death was the first manifestation of disease in six cases. The other six had a history of palpitation or syncope or both. An electrocardiogram was available in five cases and showed ventricular arrhythmias in four; none had angina pectoris. Stress testing was available in two cases: neither showed any effort-dependent ST-T abnormalities. In six cases sudden death was related to physical exercise. Acquired non-atherosclerotic coronary artery disease was found in four cases: spontaneous coronary dissection in three previously symptom free patients and Kawasaki coronary arteritis in one child who had had acute myocardial infarction. CONCLUSION--One third of the cases of fatal coronary artery disease were non-atherosclerotic with coronary artery anomalies being the most frequent form. Coronary artery anomalies should be suspected in young patients who have symptoms of ventricular arrhythmias without any overt signs and symptoms of ischaemia.     

实验性冠心病猝死的病理研究

用日本大耳白纯系家兔建立冠心病模型后，再注射肾上腺素诱发心肌病变及猝死。其结果对探讨冠心病猝死原因、心肌病理改变及临床防治冠心病急死均有一定意义     

Factors influencing the presence or absence of acute coronary artery thrombi in sudden ischaemic death

Sudden ischaemic death results either from an episode of acutemyocardial ischaemia consequent upon coronary thrombosis orfrom an arrhythmia arising within a scarred left ventricle.Very different proportions of these two groups have been reportedin both clinical studies in resuscitated subjects with out-of-hospitalventricular fibrillation, and in necropsy series. In 168 casesof sudden death due to ischaemic heart disease coming to necropsy73(43.5%) had mural intraluminal coronary thrombi, 50(29.8%)had occlusive intra-luminal thrombi, and 45(26.7%) had no intraluminalthrombi, giving a ratio of 2.7:1 for those with and withoutcoronary thrombosis. Single vessel disease, the presence ofacute infarction at autopsy and prodromal symptoms were positivelyassociated with the presence of coronary thrombosis. Conversely,the presence of old myocardial infarction at necropsy, a knownclinical history of ischaemic heart disease and triple vesseldisease were associated with the absence of acute thrombosis.The reported variation in the incidence of coronary thrombiin sudden ischaemic death can be largely explained by selectionof subjects with those clinical characteristics which are positivelyor negatively associated with coronary thrombosis.     

Nonobstructive coronary thrombosis in sudden cardiac death

Careful histologic studies were performed on the coronary arteries, myocardium and conduction system of the hearts of six men aged 32 to 44 years who died suddenly with no history of heart disease. All six hearts demonstrated coronary atherosclerosis without evidence of complete obstruction or myocardial Infarction. A nonobstructing mural coronary thrombus was found in all six hearts; in four, the thrombus was located in the left anterior descending coronary artery. Distal microthrombi were found in four hearts.In these six men, the terminal event, often a ventricular arrhythmia, may have been related to the mural coronary thrombus. Small fragments originating from such lesions can obstruct the microcirculation producing sudden lethal arrhythmias. Nonobstructing mural coronary thrombosis may be more prevalent and more significant than previously suspected and should be considered In cases of sudden cardiac death.     

冠状动脉性心脏病与心脏性猝死

1966年Kuller等提出了心脏性猝死(sudden cardiac death,SCD)的初步概念,1997年Braunwald提出并进一步完善了SCD的定义.目前,将由心脏原因导致的1 h之内发生的不可预料的自然死亡定义为SCD.在中国及西方国家,SCD是心血管疾病的主要死亡原因之一,是一个影响人类健康的重要问题.大约40%的猝死患者是在没有旁观者的情况下发生的,因此根据临床症状对猝死的病因进行准确判断非常困难.尽管近年来对SCD的病因、发病机制、危险因素及预防措施都已进行了大量的研究,但辨别高风险病人及预防SCD的措施依然不足.     

Microcirculation in the human hypothalamus in sudden coronary death

A histochemical, cytophotometric and morphometric study of hypothalamic microcirculatory vessels was conducted in 2 samples: 50 sudden cardiac deaths from coronary heart disease and 50 cardiac deaths from clinical myocardial infarction that were not sudden. Non-sudden cardiac death was associated with moderate venous hyperemia and high postcapillary alkaline phosphatase activity. In cases of sudden coronary death, three patterns of microcirculatory changes were identified that differed with respect to the quantity of functionally-inactive capillaries, the markedness of edema in hypothalamic tissues and hypothalamic content of vascular mast cells. Relationships between the said differences and different dates of death are discussed.