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(MSL)
[1–6] [PREPRINTER stage]
Med Sci Law OnlineFirst, published on January 26, 2015 as doi:10.1177/0025802414568483
Original article
Sudden cardiac death with stress and restraint: The association with sudden adult death syndrome, cardiomyopathy and coronary artery disease
Medicine, Science and the Law 0(0) 1–6 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025802414568483 msl.sagepub.com
Lydia Krexi1, Roxani Georgiou2, Dimitra Krexi1 and Mary N Sheppard2
Abstract Objective: The aim of this study was to report on sudden cardiac death (SCD) during or immediately after a stressful event in a predominately young cohort. Methods: This study used retrospective non-case-controlled analysis. A total of 110 cases of SCD in relation to a stressful event such as altercation (45%), physical restraint (31%) in police custody (10%), exams/school/job stress (7.27%), receiving bad news (4%), or a car accident without injuries (2.73%) were retrospectively investigated. The majority of the subjects experiencing SCD were male (80.91%). The mean age was 36 16 years (range 5–82 years). Twenty-three cases (20.91%) were psychiatric patients on antipsychotic medication. Results: Fifty-three per cent of cases died with a negative autopsy and a morphologically normal heart, indicating sudden adult death which is linked to cardiac channelopathies predisposing to stress-induced SCD. Cardiomyopathy was found in 16 (14.5%) patients and coronary artery pathology in 19 (17%) patients, with atherosclerosis predominating in older patients. Conclusions: This study highlights SCD during psychological stress, mostly in young males where the sudden death occurred in the absence of structural heart disease. This may reflect the proarrhythmic potential of high catecholamines on the structurally normal heart in those genetically predisposed because of cardiac channelopathy. Structural cardiomyopathies and coronary artery disease also feature prominently. Cases of SCD associated with altercation and restraint receive mass media attention especially when police/other governmental bodies are involved. This study highlights the rare but important risk of SCD associated with psychological stress and restraint in morphologically normal hearts and the importance of an expert cardiac opinion where prolonged criminal investigations and medico-legal issues often ensue. Keywords forensic medicine, forensic pathology, forensic psychiatry, multiple death investigations
Introduction
in the young is becoming increasingly recognised and mainly occurs in the absence of coronary artery disease. Genetic cardiac diseases, including channelopathies and cardiomyopathies, are more prevalent in this younger patient population.7,8 There is also increased risk of sudden death in psychiatric patients and in association with psychotrophic drugs.9,10 This study
It is well established that there is an association between psychological stress and sudden cardiac death (SCD). Both chronic and acute psychological influences have been found to play a role in rhythmic disturbances.1 Sudden death rates increase during a natural disaster, for example an earthquake, a per1 sonal tragedy such as the death/funeral of a family Medical School, Aristotle University of Thessaloniki, Greece 2 CRY Centre for Cardiovascular Pathology, St Georges Medical School, member, and during physical restraint, assault/fightUK ing, verbal arguments and being aggressively chased.2–4 Corresponding author: The main substrate for SCD in the older populaProfessor Mary N Sheppard, CRY Centre for Cardiovascular Pathology, tion is coronary artery disease, and the death can be St George’s Medical School, London, SW17 0RE, UK. 5,6 Email: [email protected] linked to acute psychological stress. However, SCD Downloaded from msl.sagepub.com at UNIV OF GEORGIA LIBRARIES on July 6, 2015
XML Template (2015) [22.1.2015–8:10pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/MSLJ/Vol00000/140063/APPFile/SG-MSLJ140063.3d
(MSL)
[1–6] [PREPRINTER stage]
2 sought to establish the associations and causes of SCD under psychological stress in this younger population. One hundred and ten SCD cases occurring under acute psychological stress are presented.
Methods and materials Study population There is a specialist tertiary cardiac pathology centre for SCD in the UK, with a database of 2400 cases between 2000 and 2013 being established. Analysing the psychological situation of the patient immediately before the death has shown that in 110 cases, SCD occurred during or immediately after an acute stressful event.
Definitions The term ‘sudden cardiac death’ was defined as sudden unexpected death during or immediately after (
(MSL)
[1–6] [PREPRINTER stage]
Med Sci Law OnlineFirst, published on January 26, 2015 as doi:10.1177/0025802414568483
Original article
Sudden cardiac death with stress and restraint: The association with sudden adult death syndrome, cardiomyopathy and coronary artery disease
Medicine, Science and the Law 0(0) 1–6 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025802414568483 msl.sagepub.com
Lydia Krexi1, Roxani Georgiou2, Dimitra Krexi1 and Mary N Sheppard2
Abstract Objective: The aim of this study was to report on sudden cardiac death (SCD) during or immediately after a stressful event in a predominately young cohort. Methods: This study used retrospective non-case-controlled analysis. A total of 110 cases of SCD in relation to a stressful event such as altercation (45%), physical restraint (31%) in police custody (10%), exams/school/job stress (7.27%), receiving bad news (4%), or a car accident without injuries (2.73%) were retrospectively investigated. The majority of the subjects experiencing SCD were male (80.91%). The mean age was 36 16 years (range 5–82 years). Twenty-three cases (20.91%) were psychiatric patients on antipsychotic medication. Results: Fifty-three per cent of cases died with a negative autopsy and a morphologically normal heart, indicating sudden adult death which is linked to cardiac channelopathies predisposing to stress-induced SCD. Cardiomyopathy was found in 16 (14.5%) patients and coronary artery pathology in 19 (17%) patients, with atherosclerosis predominating in older patients. Conclusions: This study highlights SCD during psychological stress, mostly in young males where the sudden death occurred in the absence of structural heart disease. This may reflect the proarrhythmic potential of high catecholamines on the structurally normal heart in those genetically predisposed because of cardiac channelopathy. Structural cardiomyopathies and coronary artery disease also feature prominently. Cases of SCD associated with altercation and restraint receive mass media attention especially when police/other governmental bodies are involved. This study highlights the rare but important risk of SCD associated with psychological stress and restraint in morphologically normal hearts and the importance of an expert cardiac opinion where prolonged criminal investigations and medico-legal issues often ensue. Keywords forensic medicine, forensic pathology, forensic psychiatry, multiple death investigations
Introduction
in the young is becoming increasingly recognised and mainly occurs in the absence of coronary artery disease. Genetic cardiac diseases, including channelopathies and cardiomyopathies, are more prevalent in this younger patient population.7,8 There is also increased risk of sudden death in psychiatric patients and in association with psychotrophic drugs.9,10 This study
It is well established that there is an association between psychological stress and sudden cardiac death (SCD). Both chronic and acute psychological influences have been found to play a role in rhythmic disturbances.1 Sudden death rates increase during a natural disaster, for example an earthquake, a per1 sonal tragedy such as the death/funeral of a family Medical School, Aristotle University of Thessaloniki, Greece 2 CRY Centre for Cardiovascular Pathology, St Georges Medical School, member, and during physical restraint, assault/fightUK ing, verbal arguments and being aggressively chased.2–4 Corresponding author: The main substrate for SCD in the older populaProfessor Mary N Sheppard, CRY Centre for Cardiovascular Pathology, tion is coronary artery disease, and the death can be St George’s Medical School, London, SW17 0RE, UK. 5,6 Email: [email protected] linked to acute psychological stress. However, SCD Downloaded from msl.sagepub.com at UNIV OF GEORGIA LIBRARIES on July 6, 2015
XML Template (2015) [22.1.2015–8:10pm] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/MSLJ/Vol00000/140063/APPFile/SG-MSLJ140063.3d
(MSL)
[1–6] [PREPRINTER stage]
2 sought to establish the associations and causes of SCD under psychological stress in this younger population. One hundred and ten SCD cases occurring under acute psychological stress are presented.
Methods and materials Study population There is a specialist tertiary cardiac pathology centre for SCD in the UK, with a database of 2400 cases between 2000 and 2013 being established. Analysing the psychological situation of the patient immediately before the death has shown that in 110 cases, SCD occurred during or immediately after an acute stressful event.
Definitions The term ‘sudden cardiac death’ was defined as sudden unexpected death during or immediately after (
