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Forensic Pathological Study of 334 Cases of Sudden Cardiac Death in Genoa (Italy) District

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Forensic Pathological Study of 334 Cases of Sudden Cardiac Death in Genoa (Italy) District Rom J Leg Med [27] 10-15 [2019] DOI: 10.4323/rjlm.2019.10 © 2019 Romanian Society of Legal Medicine FORENSIC PATHOLOGY Forensic pathological study of 334 cases of sudden cardiac death in Genoa (Italy) district. A seven-year report Rosario Barranco1, Nicolò Vernazza1, Francesco Ventura1,* _________________________________________________________________________________________ Abstract: Background. Sudden cardiac death (SCD) is one of the main causes of death worldwide. The analysis of such cases is a complex and delicate task, which is invariably carried out by the forensic pathologist. Methods. We conducted a retrospective analysis of cases of SCD identified among cases of sudden death on the basis of complete autopsy study at the Institute of Legal Medicine from 2011 to 2017. Objectives. Our aim was to analyze the epidemiological data and etiological distribution. This review is the first study to analyze the etiological distribution and epidemiological data of SCD in an area of north-western Italy from the perspective of forensic identification. Results. In the period considered, 334 cases of SCD were identified; the mean age of the subjects was 65.4 years, and males were clearly predominant (78.14%). In 91.62% of our overall series, the cause of SCD was coronary atherosclerotic disease (CAD), the highest occurrence of which was found in subjects aged over 60 years (98.02%). In over 85% cases of CAD, the left anterior descending artery (LAD) presented sclerotic degeneration and stenosis. A markedly lower percentage of CAD (28.58%; 4 cases) was found in subjects aged less than 40 years, in whom the leading cause of SCD was hypertrophic cardiomyopathy (35.72%; 5 cases). Conclusions. That the leading cause of SCD was CAD. In subjects aged less than 40 years, hypertrophic cardiomyopathy was the most frequent pathology. LAD was the coronary branch most often involved in CAD-related SCD. Key Words: autopsy, sudden cardiac death, necropsy, coronary atherosclerotic heart disease, epidemiology, pathology. INTRODUCTION 60-70% of SCD [6], especially in subjects over 40 years of age, SCD in adolescents and young adults is often caused Sudden cardiac death (SCD) is unexpected by a congenital disease that has gone unrecognized, such natural death due to cardiac causes; it occurs within as cardiomyopathies or pathologies of the conduction a short period of time, generally within one hour after system [7-11]. In these latter cases, autopsy diagnosis is the onset of symptoms, in subjects without a history particularly important in order to implement strategies of potentially fatal heart disease [1]. In the case of that may prevent fatal events among the subject's relatives unwitnessed death, the definition of SCD requires that [12]. the subject be seen in a stable condition within the 24 According to a pathophysiological model, cardiac hours prior to death [2-3]. In general, cases in which arrest may occur as a result of a mechanical cause when pathology examination (macroscopic and histological) the action of the heart and cardio-circulatory system is and toxicological findings are negative are classified as impaired by mechanical factors (i.e. cardiac tamponade) “sudden arrhythmic death syndrome” [4-5]. or as a result of an electrical conduction disorder, as in the Although coronary disease is the cause of over case of arrhythmia (often ventricular fibrillation) [13-14]. 1) University of Genova, Department of Legal and Forensic Medicine, Genova, Italy * Corresponding author: University of Genova, Department of Legal and Forensic Medicine, via De’ Toni 12, 16132, Genova, Italy, Tel.: + 39-010-3537838, Fax: +39-010-3537643, E-mail: [email protected] 10 Romanian Journal of Legal Medicine Vol. XXVII, No 1(2019) Although a great many books, guidelines and Italian, 81 from South America and 32 of African origin. articles have described how an autopsy should be carried out in the case of sudden death [6, 15-17], there is no Pathology of SCD uniform approach in all centers, even within the same The forensic-pathological diagnoses made on country [6]. the basis of thorough post-mortem examination of the A very complex task for the forensic pathologist 334 cases of SCD are reported in Figure 1. is to ascertain the cause and nature of sudden cardiac The most common pathology was coronary death [18-19]. A difficulty inherent in these cases is atherosclerotic heart disease (306 out of 334 cases; the lack of precision in the anamnesis and clinical and 91.62%) in which a mismatch occurred between symptomatic data prior to the 24 hours before death [20]. myocardial oxygen demand (proportional to myocardial The present review is a prospective-observational study effort) and the supply of oxygen (proportional to regarding autopsy and histological analyses of cases of coronary flow). Coronary atherosclerotic heart disease SCD recorded at the Institute of Legal Medicine from was identified as the occurrence of myocardial infarction 2011 to 2017. or critical narrowing. In some of this group, a myocardial infarction MATERIALS AND METHODS with rupture of the left ventricle and cardiac tamponade was observed (22 cases out of 306). Identifying cases Cardiomyopathy accounted for 8 cases (2.40%): In this review, we examined the records of 7 cases of hypertrophic cardiomyopathy and 1 case of diagnoses made on autopsy at the Institute of Legal Medicine in the period 2011-2017, in order to identify cases of sudden cardiac death. We did not consider cases of sudden unexpected infant death, which are analyzed at another regional center. In the period considered, we identified 334 cases of sudden cardiac death on a total of 1153 corpses that had undergone autopsy. In the cases identified, autopsy, including histopathological examination, had been carried out by scrupulously following the recommendations made by Basso et al. [21]. Inclusion and exclusion criteria We considered only those cases in which death occurred within an hour of the onset of symptoms due to cardiovascular pathologies [22]. In cases of unwitnessed death, we included only those cases in which the deceased person's relatives had reported that he/she had apparently been in good health and free from symptoms within 24 hours of the fatal event. Obviously, deaths due to non- cardiac causes, such as accidents, drug and alcohol abuse, poisoning, epilepsy or acute pulmonary embolism were excluded from the analysis. RESULTS Demographics Of the 334 subjects, 261 (78.14%) were male and 73 (21.86%) were female. The youngest subject was 21 years of age; the mean age of the subjects was 65.4 years, and the median age was 65 years. A small percentage of subjects (4.19%) were under 40 years of age: 12 men and 2 women. The 40-60-year age-range comprised 168 subjects (50.30% of the total): 35 women and 133 men. A considerable number of subjects (152; 45.51%) were over 60 years of age: 36 women and 116 men. As to the ethnicity of the subjects, 221 cases were Figure 1. The etiological distributions of sudden cardiac death in the different age groups. 11 Barranco R. et al. Forensic pathological study of 334 cases of sudden cardiac death in Genoa (Italy) district Table 1. Forensic pathological diagnoses of 334 SCD cases <40 year-old age 40-60 year-old age >60 year-old age Etiological distributions Total distributions group group groups, Coronary atherosclerotic 4 cases (28.58%) 153 cases (91.07%) 149 cases (98.02%) 306 cases (91.62%) heart disease Hypertrophic 5 cases (35.72%) 2 cases (1.19%) - 7 cases (2.09%) cardiomyopathy Arrhythmogenic right 1 case (7.14%) - - 1 case (0.30%) ventricular dysplasia Myocarditis - 4 cases (2.38%) - 4 cases (1.19%) Valvular heart disease - 2 cases (1.19%) - 2 cases (0.60%) Pericarditis - 1 case (0.60%) 1 case (0.66%) 2 cases (0.60%) Takotsubo syndrome - - 2 cases (1.32%) 2 cases (0.60%) Sudden unexplained death 4 cases (28.58%) 6 cases (3.57%) - 10 cases (3%) arrhythmogenic right ventricular dysplasia. In these cases valve disease and rupture of the tendinous cords were the diagnosis was made according to the pathological recorded. In 6 cases, the cause of death remained unclear diagnostic criteria and findings [23-27]. (sudden unexplained death), as only nonspecific findings In 2 cases (postmenopausal women), autopsy and emerged. histology findings revealed widespread contraction band The third group (over 60 years) comprised 152 necrosis formed by hypercontracted, deeply eosinophilic subjects. All but 3 had coronary atherosclerotic heart myocardial cells. Moreover, there were a thinning of the disease. In 15 subjects, rupture of the left ventricle and myocardial cells, interstitial edema and fibrosis, mostly at cardiac tamponade were observed. In 1 case, death was the cardiac apex. No obstructive coronary artery lesions caused by left ventricular insufficiency secondary to were present. In both cases, the women suffered from exudative pericarditis. In 2 cases, a Takotsubo syndrome Takotsubo cardiomyopathy. Thus, given the absence of was found (thanks also to anamnestic data and previous other cardiac pathologies, the most likely hypothesis cardiological examinations). was deemed cathecholamine toxicity due to Takotsubo cardiomyopathy, based on reports in the literature from Pathology of coronary atherosclerotic disease authoritative references [28-31]. In the cases reviewed, 91.62% (306/334) of We observed 6 cases of inflammatory/infective sudden cardiac deaths were related to a coronary pathology: 4 of myocarditis (1.19%) (according to the atherosclerotic disease (CAD). The oldest age-group diagnostic findings from the literature [23-24]) and 2 (> 60 years) displayed the highest percentage of CAD of pericarditis (0,60%). Only in 2 cases was mitral valve (98.02%). disease and rupture of the tendinous cords discovered. Pathological findings attributable to myocardial However, in 10 cases (3%), despite thorough post- ischemia (considering both healed myocardial mortem and histological examination according to Basso infarction and early-acute infarction) were detected et al.
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