Sudden death in young Aboriginal adults with rheumatic heart disease

Mortality due to rheumatic heart disease in the Kimberley 2001–2010

OBJECTIVE

To determine the mortality burden of rheumatic heart disease (RHD) in the Kimberley.

METHODS

A retrospective medical record audit was conducted for patients identified by the Western Australian (WA) RHD Program as deceased between 2001 and 2010. Patients with documented evidence strongly suggesting or confirming RHD were included in the study. Crude and age-standardised death rates were calculated.

RESULTS

A total of 34 patients were identified as having RHD, 15 of whom died of RHD-attributable causes and 93% of whom were Aboriginal. The most common causes of death were arrhythmias and heart failure. The mean age at death of Aboriginal people was 41 years. The age-standardised death rate in Aboriginal people attributable to RHD in the Kimberley was 12.5 per 100,000 people per year, which is 1.6 times the rate of Indigenous Australians nationally. RHD contributed to 342 potential life years lost over the 10-year period.

CONCLUSION

RHD contributes to significant premature mortality and higher rates of death in Aboriginal people in the Kimberley, which is consistent with other areas of northern Australia. While the recent establishment of the WA RHD Program will endeavour to improve mortality and morbidity due to RHD in the Kimberley, further research and investment is needed to address this disease of socioeconomic disadvantage.

Sudden adult death

In the investigation of sudden death in adults, channelopathies, such as long QT syndrome, have risen to the fore in the minds of forensic pathologists in recent years. Examples of these disorders are touched upon in this review as an absence of abnormal findings at postmortem examination is characteristic and the importance of considering the diagnosis lies in the heritable nature of these conditions. Typically, a diagnosis of a possible channelopathy is evoked as an explanation for a 'negative autopsy' in a case of apparent sudden natural death. However, the one potential adverse effect of this approach is that subtle causes of sudden death may be overlooked. The intention of this article is to review and discuss potential causes of sudden adult death (mostly natural) that should be considered before resorting to a diagnosis of possible channelopathy. Nonetheless, it becomes apparent that many of the potential causes of sudden death can have a genetic basis. Thus, it becomes an important consideration that there may be a genetic basis to sudden death that extends beyond the negative autopsy.

The high burden of rheumatic heart disease found on autopsy in Fiji

Rheumatic heart disease causes more than 200,000 deaths worldwide annually, with the vast majority of these deaths occurring in developing countries, yet there are few autopsy studies of rheumatic heart disease in these countries. We performed a retrospective review of 6218 autopsies performed during the period from 1990 through 2006, searching for cases of rheumatic heart disease based upon the macroscopic pathologic examination of the heart. We found 147 cases (2.4%) of rheumatic heart disease. There was an apparent increase in the number of cases in the past 5 years. There were 95 deaths that were directly attributable to rheumatic heart disease, with congestive cardiac failure being the most common cause of death in 75 cases. The mean age at death due to rheumatic heart disease was 38 years. There were more cases of rheumatic heart disease in Indigenous Fijians than Indo-Fijians, with an adjusted relative risk of 1.26 (95% confidence intervals from 0.87 to 1.86). Our findings reflect the high burden and early age of death due to rheumatic heart disease in Fiji and the Pacific region generally, and underline the need for early detection and adequate secondary penicillin prophylaxis in this region.

Cardiac pathology and adult aboriginal mortality: a coronial study of sudden and external cause deaths in the top end of the Northern Territory in 1990

A retrospective review of coronial records was performed for 179 adult decedents who came to coronial autopsy in 1990 and who had been living in the Top End of the Northern Territory at the time of death. The directly standardized rate of autopsy-examined sudden death was 7.4 times higher for Aboriginal people than for non-Aboriginal people. Coronary atherosclerosis was the cause of 37% (14/38) of the Aboriginal sudden deaths and 52% (16/31) of the non-Aboriginal sudden deaths. Evidence of coronary atherosclerosis rose with age and was seen more frequently in those dying suddenly compared to those dying of external causes. When directly standardized, the rate of autopsy-examined sudden death attributable to ischemic heart disease was 5.5 times higher for Aboriginal people than for non-Aboriginal people. Contrary to a previously published statement, there is considerable overlap between Aboriginal and non-Aboriginal heart weights, with 75% (55/73) of Aboriginal decedents and 84% (89/106) of non-Aboriginal decedents having heart weights between 250 and 500 g. We concluded that the rate of autopsy-examined sudden death from all causes, and specifically from ischemic heart disease, was much higher in Aboriginal people. However in a case of sudden death a presumptive clinical diagnosis of ischemic heart disease prior to autopsy is not justified in either Aboriginal or non-Aboriginal people, due to the high prevalence of other fatal conditions. The diagnosis of pathologically increased heart weight, which is critical in the assessment of sudden death, should be made on the same basis in both Aboriginal and non-Aboriginal people.