A Forensic Pathological Approach to Sudden Cardiac Death

Abstract

Sudden cardiac death is reported to occur in 70,000–100,000 individuals per year in Italy and is most prevalent in people between 40 and 65 years of age. In 1998, there were 719,456 cardiac disease deaths among U.S. residents aged 35 years or older, of which 456,076 (63.3%) were defined as sudden cardiac deaths. Sudden cardiac death is a death that is rapid (without any specific chronological limit) and unexpected or unforeseen, both subjectively and objectively, that occurs without prior clinical examination in apparently healthy people (“primary or unexpected or not foreseeable sudden death”) or in patients during an apparent benign phase in the course of a disease (“secondary or expected or foreseeable sudden death”). In children, adolescents, and young adults (21 years of age or younger) myocarditis, cardiomyopathies, and coronary artery anomalies are the most common causes of sudden cardiac death. Coronary atherosclerosis is the most common finding in sudden death in people older than 21 years. Almost all sudden cardiac death investigations require correlation of circumstantial data with autopsy and laboratory data. Relatively few causes of natural death are self-evident at autopsy. A complete autopsy, including detailed neuropathological and cardiovascular examination with toxicological studies, must be performed in the context of all available clinical information and of the circumstances of death, thus excluding noncardiac causes and discovering those that are cardiovascular in origin but not related to coronary causes. A detailed protocol is presented for a practical use in suspected cases of sudden cardiac death. Histology may offer structural details of the cardiac wall and coronary intraluminal changes, particularly when serial section studies are performed. Although some techniques have considerable merit in the research setting, many factors limit their application in daily forensic autopsy practice, particularly when autolysis is present. The possibility that immunohistochemical and biochemical methods, quantitative morphometry, and demonstration of apoptosis in the myocardium might enhance the detection of the early cardiac changes in sudden cardiac death is an exciting field of research.