Estudio poblacional de la muerte súbita cardiovascular extrahospitalaria: incidencia y causas de muerte en adultos de edad mediana

Sudden cardiac death-update

Sudden cardiac death (SCD) is one of the most common causes of death worldwide with a higher frequency especially in the young. Therefore, SCD is represented frequently in forensic autopsy practice, whereupon pathological findings in the heart can explain acute death. These pathological changes may not only include myocardial infarction, coronary thrombosis, or all forms of myocarditis/endocarditis but also rare diseases such as hereditary structural or arrythmogenic anomalies, lesions of the cardiac conduction system, or primary cardiac tumours.

Epidemiology of out-of-Hospital Cardiac Arrests, knowledge of cardiovascular disease and risk factors in a regional setting in India: The Warangal Area out-of-hospital Cardiac Arrest Registry (WACAR)

OBJECTIVE

Out-of-Hospital Cardiac Arrest (OHCA) is a global public health problem. There is inadequate data on OHCA in India. The Warangal Area out-of-hospital Cardiac Arrest Registry (WACAR) was planned to understand OHCA in a regional setting in India.

METHODS

WACAR is a prospective one-year observational cohort study of OHCA in the Warangal area, Telangana, India. The study included 814 subjects of OHCA of presumed cardiac etiology brought to the Mahatma Gandhi Memorial Hospital during January 1, 2018, and December 31, 2018. The data collected included; standard Utstein variables with additional data on clinical characteristics (modified Utstein template).

RESULTS

The majority of OHCA subjects were male with a median age of 60 years, and mostly occurring in residential locations within 1 h of onset of symptoms. Individuals with knowledge of CVD risk factors were more likely to report symptoms before OHCA. Data on resuscitation characteristics were inadequate.

CONCLUSIONS

The WACAR study provides baseline data regarding OHCA in a regional setting in India. The study demonstrated barriers involving data collection, patient knowledge of CVD risk factors and disease, and access to healthcare, which; impacted the data registry.

Incidence of sudden cardiac death in the young: a systematic review

OBJECTIVE

To summarise studies describing incidence of sudden cardiac death in a general population of young individuals to inform screening policy.

DESIGN

Systematic review.

DATA SOURCES

Database searches of MEDLINE, EMBASE and the Cochrane library (all inception to current) on 29 April 2019 (updated 16 November 2019), and forward/backward citation tracking of eligible studies.

STUDY ELIGIBILITY CRITERIA

All studies that reported incidence of sudden cardiac death in young individuals (12-39 years) in a general population, with no restriction on language or date. Planned subgroups were incidence by age, sex, race and athletic status (including military personnel).

DATA EXTRACTION

Two reviewers independently assessed study eligibility, extracted study data and assessed risk of bias using the Joanna Briggs Institute critical appraisal checklist for prevalence studies.

ANALYSIS

Reported incidence of sudden cardiac death in the young per 100 000 person-years.

RESULTS

38 studies that reported incidence across five continents. We identified substantial heterogeneity in population, sudden cardiac death definition, and case ascertainment methods, precluding meta-analysis. Median reported follow-up years was 6.97 million (IQR 2.34 million-23.70 million) and number of sudden cardiac death cases was 64 (IQR 40-251). In the general population, the median of reported incidence was 1.7 sudden cardiac death per 100 000 person-years (IQR 1.3-2.6, range 0.75-11.9). Most studies (n=14, 54%) reported an incidence between one and two cases per 100 000 person-years. Incidence was higher in males and older individuals.

CONCLUSIONS

This systematic review identified variability in the reported incidence of sudden cardiac death in the young across studies. Most studies reported an incidence between one and two cases per 100 000 person-years.

PROSPERO REGISTRATION NUMBER

CRD42019120563.

Asymptomatic Ventricular Pre-excitation: Between Sudden Cardiac Death and Catheter Ablation

Debate about the best clinical approach to the management of asymptomatic patients with ventricular pre-excitation and advice on whether or not to invasively stratify and ablate is on-going. Weak evidence about the real risk of sudden cardiac death and the potential benefit of catheter ablation has probably prevented the clarification of action in this not infrequent and sometimes conflicting clinical situation. After analysing all available data, real evidence-based medicine could be the alternative strategy for managing this group of patients. According to recent surveys, most electrophysiologists invasively stratify. Based on all accepted risk factors - younger age, male, associated structural heart disease, posteroseptal localisation, ability of the accessory pathway to conduct anterogradely at short intervals of ≤250 milliseconds and inducibility of sustained atrioventricular re-entrant tachycardia and/or atrial fibrillation - a shared decisionmaking process on catheter ablation is proposed.

Deregulated hepatic microRNAs underlie the association between non-alcoholic fatty liver disease and coronary artery disease

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) appears to be a new risk factor for the development of coronary artery disease (CAD). Members of a class of non-coding RNAs, termed microRNAs (miRNAs), have been identified as post-transcriptional regulators of cholesterol homoeostasis and can contribute to the development of NAFLD. The aims of this study were to (i) to assess the relationship between NAFLD and sudden cardiac death (SCD) from severe CAD in forensic autopsies and (ii) to quantify several hepatic miRNAs previously associated with lipid metabolism and NAFLD to correlate their expression with the presence of NAFLD, CAD, obesity parameters and postmortem lipid profile.

METHODS

A total of 133 cases of autopsies with SCD and established CAD (patient group, CAD-SCD) and 106 cases of non-CAD sudden death (control group, non-CAD-SD) were included. miRNAs were quantified in frozen liver tissues.

RESULTS

Males predominated in both groups. Patients more frequently exhibited NAFLD and necroinflammatory steatohepatitis (NASH) than controls (62% vs 26%, P = 0.001 and 42% vs 26%, P = 0.001 respectively). In both groups, the presence of NAFLD correlated with body mass index and abdominal circumference (P < 0.05). An increase in miR-34a-5p and a decrease in miR-122-5p and -29c-3p in patients with NASH vs controls without NAFLD were observed (P < 0.05). Finally, significant correlations between miR-122-5p and unfavourable lipid profile and also hs-CRP and miR-34a-5p were noted.

CONCLUSIONS

CAD is associated with NAFLD and NASH. The hepatic miRNAs studied appear to be associated with NAFLD severity and may promote CAD through lipid metabolism alteration and/or promotion of the systemic inflammation.

Survival and Neurologic Outcome After Out-of-hospital Cardiac Arrest. Results of the Andalusian Out-of-hospital Cardiopulmonary Arrest Registry

INTRODUCTION AND OBJECTIVES

There is a paucity of data on prehospital cardiac arrest in Spain. Our aim was to describe the incidence, patient characteristics, and outcomes of out-of-hospital emergency care for this event.

METHODS

We conducted a retrospective analysis of a prospective registry of cardiopulmonary arrest handled by an out-of-hospital emergency service between January 2008 and December 2012. The registry included all patients considered to have a cardiac etiology as the cause of arrest, with a descriptive analysis performed of general patient characteristics and factors associated with good neurologic outcome at hospital discharge.

RESULTS

A total of 4072 patients were included, with an estimated incidence of 14.6 events per 100000 inhabitants and year; 72.6% were men. The mean age was 62.0 ± 15.8 years, 58.6% of cases occurred in the home, 25% of patients had initial defibrillable rhythm, 28.8% of patients arrived with a pulse at the hospital (58.3% of the group with defibrillable rhythm), and 10.2% were discharged with good neurologic outcome. The variables associated with this recovery were: witnessed arrest (P=.04), arrest witnessed by emergency team (P=.005), previous life support (P=.04), initial defibrillable rhythm (P=.0001), and performance of a coronary interventional procedure (P=.0001).

CONCLUSIONS

More than half the cases of sudden cardiac arrest occur at home, and the population was found to be relatively young. Although recovery was satisfactory in 1 out of every 10 patients, there is a need for improvement in the phase prior to emergency team arrival. Coronary interventional procedures had an impact on patient prognosis.

Electrophysiology testing and catheter ablation are helpful when evaluating asymptomatic patients with Wolff-Parkinson-White pattern: the con perspective

The association between asymptomatic Wolff-Parkinson-White (WPW) syndrome and sudden cardiac death (SCD) has been well documented. The inherent properties of the accessory pathway determine the risk of SCD in WPW, and catheter ablation essentially eliminates this risk. An approach to WPW syndrome is needed that incorporates the patient's individualized considerations into the decision making. Patients must understand that there is a trade-off of a small immediate risk of an invasive approach for elimination of a small lifetime risk of the natural history of asymptomatic WPW. Clinicians can minimize the invasive risk by only performing ablation for patients with at-risk pathways.

[The relevance of the ankle-arm index to the reclassification of cardiovascular risk in asymptomatic hypertensive middle-aged males]

BACKGROUND AND OBJECTIVE

The ankle-brachial index allows for the detection of subclinical cardiovascular disease and risk, by diagnosing peripheral arterial disease and arterial calcification. Asymptomatic hypertensive men, between 45-55 years and with the suspicion of low risk, could be an important population group to benefit from this technique. The aim of the study was to compare the frequency of abnormal ankle-brachial index (subclinical peripheral arterial disease and arterial calcification) between asymptomatic hypertensive and non-hypertensive men, of the same age and suspicion of low risk.

PATIENTS AND METHODS

Two hundred and forty-four asymptomatic men (122 hypertensive and 122 non-hypertensive), between 45 and 55 years and an REGICOR index<10, were voluntarily recruited using consecutive sampling. Complete anamnesis, physical examination, laboratory tests and ankle-brachial index determination were carried out on all patients.

RESULTS

We detected abnormal ankle-brachial index values in 9.8% (12 cases) of the hypertensive subjects and in 1.6% (2 cases) of non-hypertensive subjects (P=.006). In the multivariate analysis, hypertension was significantly associated with an abnormal ankle-brachial index (P<.026) (odds ratio [OR] 5.9, 95% confidence interval [95% CI] 1.2-28.3), smoking (P=.018) (OR 2.7; 95% CI 1.2-6.2) and abdominal obesity (P=.005) (OR 2.8; 95% CI 1.3-5.9).

CONCLUSIONS

The population group analyzed in this study might be considered as an overriding segment for detecting subclinical cardiovascular disease and risk with the ankle-brachial index. Further studies are needed to establish the prevalence of abnormal ankle-brachial index in this population in order to assess its efficiency.

Trends in out-of-hospital ischemic heart disease mortality for the 25-64 year old population of Kaunas, Lithuania, based on data from the 1988-2012 Ischemic Heart Disease Registry

AIM

The aim of the study was to evaluate trends in out-of-hospital ischemic heart disease (IHD) mortality in the Kaunas, Lithuania population aged 25-64, from 1988 to 2012.

METHODS

The registry was maintained according to the World Health Organisation (WHO) recommendations for the multinational MONICA (MONItoring of trends and determinants in CArdiovascular disease) project. We analysed out-of-hospital deaths from IHD, by sex and age groups, using the linear logistic regression model for identifying trends.

RESULTS

In 1988-2012, the out-of-hospital IHD deaths in Kaunas accounted for 78.4% and 68.4%, on average, of all IHD deaths in men and women aged 25-64, respectively. During the study period, the out-of-hospital IHD mortality for the Kaunas population aged 25-64 was 134.5 per 100,000 men and 18.2 per 100,000 women. From 1988 to 2012, the out-of-hospital IHD mortality for men and women aged 25-64 tended to decline by, on average, 8.3% per year (p = 0.269) and 16.2% per year (p = 0.101), respectively; whereas the corresponding rates for men aged 25-44 were declining significantly, by 22.5% per year (p = 0.047). The most significant changes in out-of-hospital IHD mortality were among men aged 25-44 with no previous history of acute myocardial infarction (AMI), in whom the out-of-hospital IHD mortality was significantly declining, by 21.3% per year (p = 0.015); whereas the corresponding rates for men aged 45-54 with a previous history of AMI tended to decline by 20.4% per year (p = 0.114).

CONCLUSIONS

In 1988-2012, the out-of-hospital IHD deaths of younger men and middle-aged women accounted for the highest percentage of all IHD deaths; and a higher proportion of both men and women with no previous history of AMI, as compared to the proportion of those with a previous history of AMI.

[Epidemiological characteristics of out-of-hospital cardiorespiratory arrest recorded by the 061 emergencies system (SAMU) in the Balearic Islands (Spain), 2009-2012]

OBJECTIVE

To describe the epidemiology of out-of-hospital cardiorespiratory arrest (OHCA) and identify factors associated with recovery of spontaneous circulation (ROSC).

DESIGN

Observational study of OHCA registered on a continuous basis in the Emergency Medical Services (EMS) database during 2009-2012.

SETTING

The islands of Mallorca, Ibiza, Menorca and Formentera (Balearic Islands, Spain).

PATIENTS

OHCA in patients ≥ 18 years of age. The main variables were: Patient sex, age, probable cause, place of arrest, bystander, witnessed, basic life support (BLS), shockable rhythm, intervention time, semi-automatic defibrillator (AED), duration of cardiopulmonary arrest (CA), and ROSC. Independent variables were defined according to the Utstein protocol, and the dependent variable was defined as ROSC.

RESULTS

The EMS treated 1170 OHCAs (28/100,000 persons-year). We included 1130 CA. The mean age was 61.4 years (73.4% males). Most CA (72.3%) were of cardiac etiology, and 84.7% were witnessed. A total of 840 (74.3%) received BLS and 400 (47.6%) did so before arrival of the EMS (45 by bystander relatives). AED was available in 330 cases CA (29.2%) (96 with shockable rhythm). The interval between emergency call and BLS and between emergency call and advanced life support was 8.4 and 15.8min, respectively. Shockable rhythm was monitored in 257 CAs (22.7%). ROSC occurred in 261 (23.1%). Factors associated with ROSC were age, shockable rhythm, BLS before EMS arrival, and CA duration less than 30min.

CONCLUSION

The incidence rate of the OHCA is low. The proportion of patients receiving BLS from relatives was low. Age, shockable rhythm and BSL before EMS arrival were associated with ROSC.

The autopsy study of 553 cases of sudden cardiac death in Chinese adults

Despite a recent epidemiological study reporting a lower incidence of sudden cardiac death (SCD) in China as compared with that in Western countries, the exact causes of SCD are still unknown. Using a uniform review protocol and diagnostic criteria, a retrospective autopsy study identified 553 cases of SCD in 14,487 consecutive autopsies from eight regions in China representing different geographic and population features. Their ages ranged from 18 to 80 years (median 43.0 years) with a ratio of 4.3/1.0 for male/female. Out-of-hospital deaths and unwitnessed cases accounted for 74.3 and 22.6 %, respectively. The main causes of death were coronary atherosclerotic disease (CAD 50.3 %), myocarditis (14.8 %), and hypertrophic cardiomyopathy (4.5 %), with unexplained sudden death accounting for 12.1 % of the cases. CAD had a proportion of 10.4 % in victims <35 years, lower as compared with 59.0 and 83.0 % in victims aged 35-54 and in victims ≥55 years. On the other hand, myocarditis and unexplained sudden death were major causes and accounted for 34.7 and 22.5 % in victims <35 years. In order to differentiate the degree of the cause-effect relationship between autopsy findings and sudden death, a grading method was used in this series and characterized 24.3 % of findings as certain, 52.9 % as highly probable, and 22.8 % as uncertain. Our data indicated that there most likely are less CAD but more myocarditis and unexplained sudden death in Chinese youth with SCD than in populations from Western countries. Molecular genetic testing should be conducted in those cases with uncertain findings and unexplained sudden death in routine autopsy.

Factors associated with mortality in out-of-hospital cardiac arrests attended in basic life support units in the Basque Country (Spain)

INTRODUCTION AND OBJECTIVES

To describe the epidemiological characteristics of cardiac arrests attended in basic life support units in the Basque Country (Spain) and look for factors associated with failure of cardiopulmonary resuscitation.

METHODS

We conducted an observational study during 18 months, including all out-of-hospital cardiopulmonary resuscitation provided by basic life support units. The variables defined in the Utstein-style were considered as independent and mortality as the dependent variable. We applied descriptive and analytical statistics and evaluated the magnitude of the association using a logistic regression model, which included variables with P<.05 in the bivariate analysis.

RESULTS

Of 1050 cardiac arrests attended, 15.7% of patients were revived in situ. The presumed etiology was cardiac in 55.3% of cases and 71.4% occurred at home. Cardiopulmonary resuscitation was started before the arrival of the ambulance in 22.9% of cases and in 18.2% the rhythm of presentation was shockable. Variables associated with lower mortality were: shockable rhythms (relative risk=0.44; P=.003), patient aged<65 years (relative risk=0.44; P=.002), time to cardiopulmonary resuscitation<8 min (relative risk=0.56; P=.039), and out-of-home events (relative risk=0.55; P=.031).

CONCLUSIONS

Cardiac arrest survival was low. Cardiopulmonary resuscitation before the arrival of the ambulance was rare. A shockable rhythm, age younger than 65 years, early cardiopulmonary resuscitation efforts, and a location away from home were associated with longer survival. It is necessary to develop strategies designed to reduce ambulance response time and educate the public in basic resuscitation.

Distension of the ischemic region predicts increased ventricular fibrillation inducibility following coronary occlusion in swine

INTRODUCTION AND OBJECTIVES

Distension of the ischemic region has been related to an increased incidence of spontaneous ventricular arrhythmias following coronary occlusion. This study analyzed whether regional ischemic distension predicts increased ventricular fibrillation inducibility after coronary occlusion in swine.

METHODS

In 18 anesthetized, open-chest pigs, the left anterior descending coronary artery was ligated for 60 min. Myocardial segment length in the ischemic region was monitored by means of ultrasonic crystals. Programmed stimulation was applied at baseline and then continuously between 10 and 60 min after coronary occlusion.

RESULTS

Coronary occlusion induced a rapid increase in end-diastolic length in the ischemic region, which reached 109.4% (0.9%) of baseline values 10 min after occlusion (P<.001). On average, 6.6 (0.5) stimulation protocols were completed and 5.4 (0.6) ventricular fibrillation episodes induced between 10 and 60 min of coronary occlusion. Neither baseline serum potassium levels nor the size of the ischemic region were significantly related to ventricular fibrillation inducibility. In contrast, the increase in end-diastolic length 10 min after coronary occlusion was associated directly (r=0.67; P=.002) with the number of induced ventricular fibrillation episodes and inversely (r=-0.55; P=.018) with the number of extrastimuli needed for ventricular fibrillation induction.

CONCLUSIONS

Regional ischemic expansion predicts increased ventricular fibrillation inducibility following coronary occlusion. These results highlight the potential influence of mechanical factors, acting not only on the triggers but also on the substrate, in the genesis of malignant ventricular arrhythmias during acute ischemia.

[Sudden cardiac death. Selected forensic aspects]

Sudden cardiac death is one of the most common causes of death and a significant number of sudden deaths occurs especially in young people. Sudden cardiac death is also frequently represented in forensic autopsy practice. In such cases pathological findings in the heart can often explain the reason for the acute death. These pathological changes include not only myocardial infarction, coronary thrombosis and all forms of myocarditis/endocarditis but also rare diseases, such as hereditary structural or arrythmogenic anomalies, lesions of the cardiac conduction system or primary cardiac tumors.

Asymptomatic Wolff-Parkinson-White Syndrome: Who Should Be Treated?

This article discusses the merits of electrophysiology study (EPS) and/or ablation for asymptomatic preexcitation Wolff-Parkinson-White (WPW) ECG pattern. Sudden deaths in asymptomatic patients are too few to merit broad screening and aggressive intervention. It also discusses the risks of ablation and the low predictive accuracy of EPS. When WPW is an incidental finding, the decision to proceed with investigation and ablation can be made considering patients' situations and preferences. An invasive strategy is targeted at patients concerned about the low risk of life-threatening arrhythmia as a first presentation after a discussion of the risks and benefits.

Risk of Arrhythmia and Sudden Death in Patients With Asymptomatic Preexcitation

Background—

The incidence of sudden cardiac death (SCD) and the management of this risk in patients with asymptomatic preexcitation remain controversial. The purpose of this meta-analysis was to define the incidence of SCD and supraventricular tachycardia in patients with asymptomatic Wolff-Parkinson-White ECG pattern.

Methods and Results—

We performed a systematic search of prospective, retrospective, randomized, or cohort English-language studies in EMBASE and Medline through February 2011. Studies reporting asymptomatic patients with preexcitation who did not undergo ablation were included. Twenty studies involving 1869 patients met our inclusion criteria. Participants were primarily male with a mean age ranging from 7 to 43 years. Ten SCDs were reported involving 11 722 person-years of follow-up. Seven studies originated from Italy and reported 9 SCDs. The risk of SCD is estimated at 1.25 per 1000 person-years (95% confidence interval [CI], 0.57–2.19). A total of 156 supraventricular tachycardias were reported involving 9884 person-years from 18 studies. The risk of supraventricular tachycardia was 16 (95% CI, 10–24) events per 1000 person-years of follow-up. Children had numerically higher SCD (1.93 [95% CI, 0.57–4.1] versus 0.86 [95% CI, 0.28–1.75]; P =0.07) and supraventricular tachycardia (20 [95% CI, 12–31] versus 14 [95% CI, 6–25]; P =0.38) event rates compared with adults.

Conclusion—

The low incidence of SCD and low risk of supraventricular tachycardia argue against routine invasive management in most asymptomatic patients with the Wolff-Parkinson-White ECG pattern.

What is Sudden Cardiac Death?

Sudden cardiac death (SCD) is a rapid, unexpected death due to cardiac causes. The differential diagnosis includes diseases from all four structural divisions of the heart: the blood vessels, myocardium, valves, and conduction system. Although ischemic heart disease is a common cause of SCD, acute myocardial infarcts and/or coronary thromboses are not always detected and are not required to make the diagnosis of death due to atherosclerotic coronary disease. Some people die suddenly from heart disease with a grossly and microscopically normal heart. Molecular analysis of some of these autopsy-negative, sudden unexplained deaths (SUD) may detect putative cardiac channel mutations.

There are three SCD scenarios that are of particular interest to forensic pathologists: sudden cardiac deaths in young athletes, during criminal altercations (homicide by heart attack), and in other hostile environments. In young athletes, most sudden deaths involve cardiac disease and include cardiomyopathies, congenital coronary artery anomalies, myocarditis, and channelopathies. One must, however, consider other causes in these deaths (e.g., commotio cordis, hyperthermia, sickle cell trait). Homicide-by-heart-attack deaths are those in which the cause of death is an acute exacerbation of underlying cardiac disease, however, the manner is homicide because a criminal act triggered the lethal pathologic cascade. A sudden cardiac arrest may occur in hostile locations with resultant trauma (e.g., while driving a motor vehicle). When the event occurs in the bathtub or other body of water, the question of whether the person died naturally from heart disease or unnaturally from trauma (e.g., drowning) often arises. One should not be mislead by the initial physical surroundings of the death (i.e., in a motor vehicle collision, or swimming pool) and fail to distinguish a natural sudden death from an accidental one.