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 (≤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.

     

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.     

Predictors of sudden death in coronary artery disease

Although advances in the management of acute myocardial infarction have resulted in a decline in long-term risk of sudden death, it continues to be high in certain subsets of patients. Thus, it is important to identify and treat these patients. Left ventricular ejection fraction less than 0.40, frequent premature ventricular ectopy on Holter monitoring, late potentials on signal-averaged electrocardiogram, impaired heart rate variability, abnormal baroreflex sensitivity and inducible sustained monomorphic ventricular tachycardia during electrophysiological study are predictors of sudden death and arrhythmic events. Although the negative predictive value of each factor is high, the positive predictive accuracy is low. Several tests can be combined to obtain higher positive predictive values. In fact, in some studies combined noninvasive tests have been used to select patients for ventricular stimulation study.Some preventive treatment can be applied in these patients. Available data do not justify prophylactic therapy with amiodarone in high-risk survivors of acute myocardial infarction. Sudden death and total mortality have been significantly reduced in postinfarction patients by long-term beta blockade. Hence, beta blockers should be given to all patients with acute myocardial infarction who do not have contraindications to their use. The MADIT study has shown the beneficial effect of implantable cardioverter defibrillator in reducing mortality in patients with prior myocardial infarction, an ejection fraction less than 0.36, asymptomatic nonsustained ventricular tachycardia, and inducible sustained ventricular tachycardia, unsuppressable by procainamide. Besides, several studies are under way to evaluate the prophylactic use of implantable defibrillator for improving survival in high-risk patients.     

QT离散度与冠心病猝死

目的 :探讨 QTd对猝死的预测价值。方法 :分析 2 3例发生猝死的冠心病患者和 34例住院冠心病患者的 QT离散度及心率校正 QT离散度。结果 :猝死组 QTd明显高于对照组 ,P<0 .0 5。结论 :QT离散度增大有预测猝死的价值     

Electrocardiogram-based predictors of sudden cardiac death in patients with coronary artery disease

Current recommendations on which patients with coronary artery disease (CAD) should be offered an implantable cardioverter defibrillator for the primary prevention of sudden cardiac death (SCD) rely heavily on the presence of depressed left ventricular ejection fraction. Because the majority of SCD victims with CAD have preserved left ventricular function, additional cardiac investigations are likely to play an increasing role in the risk stratification of CAD patients. A number of studies have demonstrated that certain parameters on the traditional 12-lead electrocardiogram (ECG) and other ECG-based investigations (such as signal-averaged ECG, heart rate turbulence, T-wave alternans) can provide important information on the underlying cardiac substrate abnormality that may predispose to ventricular arrhythmias and SCD. This article reviews some of the evidence for these ECG-based tests as predictors of SCD in patients with CAD and addresses their advantages and limitations.     

Non-atherosclerotic aneurysm of the left main coronary artery

Ohne Zusammenfassung

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Non-atherosclerotic aneurysm of the left main coronary artery

     

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.     

Risk of sudden versus nonsudden cardiac death in patients with coronary artery disease

Background Patients at high risk of sudden cardiac death, yet at low risk of nonsudden death, might be ideal candidates for antiarrhythmic drugs or devices. Most previous studies of prognostic markers for sudden cardiac death have ignored the competitive risk of nonsudden cardiac death. The goal of the present study was to evaluate the ability of clinical factors to distinguish the risks of sudden and nonsudden cardiac death. Methods We identified all deaths during a 3.3-year follow-up of 30,680 patients discharged alive after admission to the cardiac care unit of a Seattle hospital. Detailed chart reviews were conducted on 1093 subsequent out-of-hospital sudden deaths, 973 nonsudden cardiac deaths, and 442 randomly selected control patients. Results Patients who died in follow-up (suddenly or nonsuddenly) were significantly different for many clinical factors from control patients. In contrast, patients with sudden cardiac death were insignificantly different for most clinical characteristics from patients with nonsudden cardiac death. The mode of death was 20% to 30% less likely to be sudden in women, patients who had angioplasty or bypass surgery, and patients prescribed β-blockers. The mode of death was 20% to 30% more likely to be sudden in patients with heart failure, frequent ventricular ectopy, or a discharge diagnosis of acute myocardial infarction. A multivariable model had only modest predictive capacity for mode of death (c-index of 0.62). Conclusion Standard clinical evaluation is much better at predicting overall risk of death than at predicting the mode of death as sudden or nonsudden. (Am Heart J 2002;144:390-6.)     

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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 aneurysms: two case reports

Non-atherosclerotic isolated coronary artery aneurysm is not common. Two cases of non-atherosclerotic isolated coronary artery aneurysm, with similar presentations but different management strategies were presented. The patients were well four and six years later, respectively. The definition, incidence, causes, presentation, complications, investigations, management, and prognosis of coronary artery aneurysms are discussed. The difficulties of determining pathogenesis and different management strategies are highlighted. An isolated coronary artery aneurysm should be managed on its merits.

Keywords: coronary artery aneurysms     

Dietary n-3 fatty acid intake and risk of sudden death and coronary artery disease

Opinion statement Based upon the data from observational epidemiologic studies and randomized clinical trials that are summarized in this article, as well as plausible mechanisms for benefit, the American Heart Association and several international health agencies recommend that all adults eat fish, particularly fatty fish, at least two times per week to lower risk of coronary heart disease (CHD). Patients with established CHD are advised to consume 1 g/d of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) combined. However, many individuals may find it difficult to consume 1 g/d of EPA and DHA, which translates into several meals of fish per week. Thus, fish oil in the form of supplements may be a preferable way to achieve compliance with these recommendations. Because only one large-scale secondary-prevention randomized trial of n-3 fatty acid supplements has been published to date, fish oil supplements have not been routinely recommended after myocardial infarction (MI). However, based upon the present evidence, this treatment option could be considered as one possible avenue to decrease risk of sudden cardiac death (SCD) in the early post-MI period when implantable cardioverter-defibrillator (ICD) therapy appears to be less efficacious. n-3 Fatty acid supplements are currently not indicated for prevention of recurrent ventricular arrhythmias in patients with ICDs due to the conflicting and primarily null randomized trial results in this patient population. Finally, based upon the current state of evidence, it is unclear whether dietary intake of α-linolenic acid (ALA), a plant-based intermediate-chain n-3 fatty acid, influences risk of CHD or SCD. Therefore, increasing intake of ALA specifically for the prevention of CHD cannot be recommended at this time.     

Atherosclerosis of coronary arteries, coronary heart disease and sudden coronary death

Correlation between the severity of coronary atherosclerosis, thrombosis and sudden cardiac death was examined in 721 autopsied cases. Severe coronary atherosclerosis with stenosis was found in most of them; however a similar grade of atherosclerosis was discovered in patients with ischaemic heart disease not dying suddenly. Acute coronary thrombosis in the studied subjects was diagnosed post mortem in about 20 percent of those who died suddenly. Other studies indicate frequencies between 4-93%. There was no consistent time dependence.