[Sudden death during sport activity in Tunisia: autopsy study in 32 cases]

Sudden death in young South European population: a cross-sectional study of postmortem cases

To describe the annual incidence and the leading causes of sudden non-cardiac and cardiac death (SCD) in children and young adult Portuguese population. We retrospectively reviewed autopsy of sudden unexpected deaths reports from the Portuguese National Institute of Legal Medicine and Forensic Sciences' database, between 2012 and 2016, for the central region of Portugal, Azores and Madeira (ages 1-40: 26% of the total population). During a 5-year period, 159 SD were identified, corresponding to an annual incidence of 2,4 (95%confidence interval, 1,5-3,6) per 100.000 people-years. Victims had a mean age of 32 ± 7 years-old, and 72,3% were male. There were 70,4% cardiac, 16,4% respiratory and 7,5% neurologic causes of SD. The most frequent cardiac anatomopathological diagnosis was atherosclerotic coronary artery disease (CAD) (33,0%). There were 15,2% victims with left ventricular hypertrophy, with a diagnosis of hypertrophic cardiomyopathy only possible in 2,7%. The prevalence of cardiac pathological findings of uncertain significance was 30,4%. In conclusion, the annual incidence of SD was low. Atherosclerotic CAD was diagnosed in 33,0% victims, suggesting the need to intensify primary prevention measures in the young. The high prevalence of pathological findings of uncertain significance emphasizes the importance of molecular autopsy and screening of first-degree relatives.

Electrophysiology practice in low- and middle-income countries: An updated review on access to care and health delivery

Concurrent with the epidemiological transition to cardiovascular diseases in low- and middle-income countries (LMICs), the burden of arrhythmias is increasing significantly. However, registries of electrophysiological disorders and their management in LMICs are limited. The advancement of telemedicine technology can play a distinctive role in providing accurate diagnoses in resource-limited settings. The estimated pacemaker implantation requirements (1 million per year) demand an alternate source of pacemakers, including reused permanent pacemakers and implantable cardioverter-defibrillators. In addition, the majority of supraventricular tachycardias and atrial fibrillation can be managed with radiofrequency ablation, which not only is cost-effective but is curative for most patients.

Congenital Coronary Artery Anomalies and Sudden Cardiac Death

Coronary artery anomalies (CAAs) are a heterogeneous group of rare congenital diseases whose features and pathophysiological mechanisms are extremely variable, ranging from silent anomalies to sudden cardiac death (SCD) in the most severe cases. Although rare, congenital CAAs confer a high risk of myocardial ischemia and SCD, especially in young, previously "healthy" athletes during or immediately after vigorous exertion. Although some high-risk features that may lead to SCD have been identified, specific pathophysiological mechanisms related to SCD still remain poorly understood. When a CAA is incidentally diagnosed, optimal SCD risk stratification remains challenging, particularly in cases of anomalous aortic origin of a coronary artery arising from the opposite aortic sinus of Valsalva (ACAOS). In recent times, invasive imaging with intravascular ultrasound has gained a role in further identifying high-risk anatomic features; it has been integrated with traditional, non-invasive anatomic imaging evaluations, typically high-quality echocardiography, and cardiac magnetic resonance. Multidisciplinary programs and specific SCD risk scores should be developed in an endeavor to choose the right therapeutic approach, either clinical or interventional/surgical. Intravascular ultrasound is an extremely useful tool to evaluate vessel stenosis, even if prospective studies are still required to further validate this diagnostic strategy. In the present review, we aimed to analyze the pathophysiology and the clinical impact of ACAOS. We also summarized the predominant mechanisms for interference with normal coronary artery function, which might contribute to the onset of life-threatening arrhythmias and SCD.

Sudden death in the young adult: a Tunisian autopsy-based series

Background

We aim to study the profile, and pathological characteristics of sudden death in young in purpose of recommendations for prevention.

Methods

We performed a retrospective cohort study using autopsy data from the Department of Forensic Medicine of Monastir (Tunisia). A review of all autopsies performed for 28 years was done (August 1990 to December 2018). In each case, clinical information, and circumstances of death were obtained. A complete forensic autopsy and histological, and toxicological investigations were performed. We have included all sudden death in persons aged between 18 and 35 years.

Results

We collected 137 cases of sudden death during the studied period. The mean age of the studied population was 26.47 years. Almost 72% deaths were classified as cardiac death, and was due to ischemic heart disease in 32.32%. Sudden death was attributed to a pleuropulmonary cause in 7.4%, an abdominal cause in 6%, and from a neurological origin in 4.5%. The cause of sudden death in this group was not established by 9.5%.

Conclusion

In this series, sudden death in young adults occurs mainly in a smoking male, aged between 18 and 24 years old, occurring at rest, in the morning, and early in the week. It is more common, especially in summer. Sudden death is most often the first manifestation of pathologies, especially unsuspected heart diseases. The predominance of cardiovascular causes is the common denominator of almost all studies reported in the literature. Our findings suggest that prevention of sudden death among young adults under the age of 35 years should also focus on evaluation for causes not associated with structural heart disease.

Incidence of recreational sports-related sudden cardiac arrest in participants over age 12 in a general African population

Background

The incidence of sports-related sudden cardiac arrest (SrSCA) in sub-Saharan Africa is unknown.

Objective

To determine the incidence of sudden cardiac arrest (SCA) in non-competitive athletes in an urban population of Cameroon, a country in sub-Saharan Africa.

Methods

Two study populations in Cameroon were used. A 12-month, multisource surveillance system of 86 189 inhabitants over 12 years old recorded all deaths in two administrative districts of Douala City. All fields of sports, emergency medical service, local medical examiners and district hospital mortuaries were surveyed. Two blinded cardiologists used a verbal autopsy protocol to determine the cause of death. SCA was identified for all deaths occurring within 1 hour of onset of symptoms. A cross-sectional study was conducted among 793 persons in Yaoundé City, which is the second study population aimed at determining the proportion of people who are physically active.

Results

The mean age in the cross-sectional study was 27.3±10.7, with more men (56.2%). The cross-sectional study showed that 69.0% (95% CI 65.8 to 72.2) of the population could be considered to have at least 3 hours of physical activity per week. The surveillance found that among 288 all-cause deaths, 27 (9.4%) were due to SCA. One SrSCA was registered in a 35-year-old woman while running. Merging both sources revealed an SrSCA incidence of 1.7 (95% CI 0.2 to 12.0) cases per 100 000 athletes per year.

Conclusion

This pioneer study reports the incidence estimates of SrSCA in a sub-Saharan African general population and should be regarded as a first step to a big problem.

Cardiac arrhythmias in low- and middle-income countries

Many low- and middle-income countries (LMICs) are undergoing an epidemiological transition. With an improvement in socioeconomic conditions and an aging population, cardiovascular diseases (CVDs), like cardiac arrhythmias, are expected to increase in these countries. However, there are limited studies on the epidemiology and management of cardiac arrhythmias in LMICs. This review will highlight the unique challenges and opportunities that these countries face when managing cardiac arrhythmias.

Cardiac Arrhythmias in Africa: Epidemiology, Management Challenges, and Perspectives

Africa is experiencing an increasing burden of cardiac arrhythmias. Unfortunately, the expanding need for appropriate care remains largely unmet because of inadequate funding, shortage of essential medical expertise, and the high cost of diagnostic equipment and treatment modalities. Thus, patients receive suboptimal care. A total of 5 of 34 countries (15%) in Sub-Saharan Africa (SSA) lack a single trained cardiologist to provide basic cardiac care. One-third of the SSA countries do not have a single pacemaker center, and more than one-half do not have a coronary catheterization laboratory. Only South Africa and several North African countries provide complete services for cardiac arrhythmias, leaving more than hundreds of millions of people in SSA without access to arrhythmia care considered standard in other parts of the world. Key strategies to improve arrhythmia care in Africa include greater government health care funding, increased emphasis on personnel training through fellowship programs, and greater focus on preventive care.

The forensic pathological analysis of sport-related sudden cardiac death in Southern China

Studies regarding sport-related sudden cardiac death (SCD) mainly focus on competitive athletes; similar data are rare in the general population, especially in China. We conducted a retrospective study (from September 1998 to August 2013) to investigate the aetiological distribution and epidemiological features of sport-related SCD in Southern China. Selections of cases are based on details, and two subgroups were established: one was the sport-related SCD group, and the other was the disease-free accident victims group which was matched with the sport-related SCD group in gender, age and year of death. Among the 3770 sudden-death cases, 1656 cases were SCD cases. A total of 65 cases (57 males) out of 1 656 SCD cases were sport-related. The age range of the 65 sport-related SCD cases was from 12 to 68 years old with a mean (35.92 ± 14.23) years old. Only two of these cases were competitive athletes. The most common circumstances of the 65 sport-related SCD cases were heavy physical labour (46.15%) and running (30.77%). The three leading forensic diagnoses were the coronary atherosclerotic disease (CAD, 28 cases), cardiomyopathy (CM, 14 cases) and sudden unexplained death (7 cases). CM was the most common forensic diagnosis in those ≤35 years old, while CAD was the most common one in those >35 years old. Left anterior descending in which atherosclerotic plaques was most commonly found was the principal artery branch associated with sport-related SCD. There was a statistically significant difference in the weight of hearts between the 65 sport-related SCD cases and 65 diseases-free accidental cases. This study highlights the need to attract public attention to sport-related SCD and to issue a prevention strategy to the public, and to make the SCD-related genetic sequencing a routine tool in both forensic pathological examination and clinic screening.

Sudden cardiac death among general population and sport related population in forensic experience

PURPOSE

The goal of the study was to assess the causes and analyze the cases of sudden cardiac death (SCD) victims referred to the department of forensic medicine in Lausanne, with a particular focus on sports-related fatalities including also leisure sporting activities. To date, no such published assessment has been done nor for Switzerland nor for the central Europe.

METHODS

This is a retrospective study based on autopsy records of SCD victims, from 10 to 50 years of age, performed at the University Centre of Legal Medicine in Lausanne from 1995 to 2010. The study population was divided into two groups: sport-related (SR) and not sport-related (NSR) SCDs.

RESULTS

During the study period, 188 cases of SCD were recorded: 166 (88%) were NSR and 22 (12%) SR. The mean age of the 188 victims was 37.3 ± 10.1 years, with the majority of the cases being male (79%). A cause of death was established in 84%, and the pathology responsible for death varied according to the age of the victims. In the NSR group, the mean age was 38.2 ± 9.2 years and there was 82% of male. Coronary artery disease (CAD) was the main diagnosis in the victims aged 30-50 years. The majority of morphologically normal hearts were observed in the 15-29 year age range. There was no case in the 10-14 year age range. In the SR group, 91% of victims died during leisure sporting activities. In this group the mean age was 30.5 ± 13.5 years, with the majority being male (82%). The main cause of death was CAD, with 6 cases (27%) and a mean age of 40.8 ± 5.5 years. The youngest victim with CAD was 33 years old. A morphologically normal heart was observed in 5 cases (23%), with a mean age of 24.4 ± 14.9 years. The most frequently implicated sporting activities were hiking (26%) and swimming (17%).

CONCLUSION

In this study, CAD was the most common cause of death in both groups. Although this pathology most often affects adults over 35 years of age, there were also some victims under 35 years of age in both groups. SCDs during sport are mostly related to leisure sporting activities, for which preventive measures are not yet usually established. This study highlights also the need to inform both athletes and non athletes of the cardiovascular risks during sport activities and the role of a forensic autopsy and registries involving forensic pathologists for SR SCD.

Genetic profile of hypertrophic cardiomyopathy in Tunisia: Is it different?

We recently performed next generation sequencing (NGS) genetic screening in 11 consecutive and unrelated Tunisian HCM probands seen at Habib Thameur Hospital in Tunis in the first 6 months of 2014, as part of a cooperative study between our Institutions. The clinical diagnosis of HCM was made according to standard criteria. Using the Illumina platform, a panel of 12 genes was analyzed including myosin binding protein C (MYBPC3), beta-myosin heavy chain (MYH7), regulatory and essential light chains (MYL2 and MYL3), troponin-T (TNNT2), troponin-I (TNNI3), troponin-C (TNNC1), alpha-tropomyosin (TPM1), alpha-actin (ACTC1), alpha-actinin-2 (ACTN2) as well as alfa-galactosidase (GLA), 5′-AMP-activated protein (PKRAG2), transthyretin (TTR) and lysosomal-associated membrane protein-2 (LAMP2) for exclusion of phenocopies. Our preliminary data, despite limitations inherent to the small sample size, suggest that HCM in Tunisia may have a peculiar genetic background which privileges rare genes overs the classic HCM-associated MHY7 and MYBPC3 genes.

Genetic variants in KCNE1, KCNQ1, and NOS1AP in sudden unexplained death during daily activities in Chinese Han population

Fifty-six sudden unexplained death (SUD) cases were collected from Chinese Han population, which occurred during daily activities and were autopsy negative in comprehensive postmortem autopsy. The coding exons of potassium channel genes KCNE1, KCNQ1, and nitric oxide synthase gene NOS1AP were sequenced. A synonymous mutation, KCNE1 F54F T>C was identified in 2 SUD cases, which was absent in the control subjects. Neither genotype nor allele frequencies of KCNE1 and KCNQ1 exhibited a significant difference between the SUD and control group. In contrast, the allele frequency (p = 2.7 × 10(-10)) and genotype frequency (p = 5.9 × 10(-7)) of rs3751284, and the genotype frequency (p = 2.9 × 10(-2)) of rs348624 in NOS1AP of SUD were significantly different from that of controls (p < 0.05). Our study suggested that rs3751284 and rs348624 might be susceptibility loci for SUD during daily activities. Larger sample sizes and further molecular studies are needed to confirm or exclude an effect of the NOS1AP SNPs on SUD risk.

Soccer and Sudden Cardiac Death in Young Competitive Athletes: A Review

Sudden cardiac death (SCD) in young competitive athletes (<35 years old) is a tragic event that has been brought to public attention in the past few decades. The incidence of SCD is reported to be 1-2/100,000 per year, with athletes at a 2.5 times higher risk. Soccer is the most popular sport in the world, played by people of all ages. However, unfortunately it is cardiovascular diseases such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy that have subtly missed screening and claimed the lives of soccer stars such as Marc Vivien Foe and Antonio Puerta during live action on the field and on an internationally televised stage. This paper covers the physiological demands of soccer and the relationship between soccer and SCD. It also reviews the most common causes of SCD in young athletes, discusses the current guidelines in place by The Fédération Internationale de Football Association (FIFA) for screening among professional soccer players, and the precautions that have been put in place to prevent SCD on the field in professional soccer.