Sudden Cardiac Death in the Young: Incidence, Trends, and Risk Factors in a Nationwide Study

BACKGROUND

Sudden cardiac death (SCD) in the young is devastating. Contemporary incidence remains unclear with few recent nationwide studies and limited data addressing risk factors for causes. We aimed to determine incidence, trends, causes, and risk factors for SCD in the young.

METHODS AND RESULTS

The National Coronial Information System registry was reviewed for SCD in people aged 1 to 35 years from 2000 to 2016 in Australia. Subjects were identified by the International Classification of Diseases, Tenth Revision code relating to circulatory system diseases (I00-I99) from coronial reports. Baseline demographics, circumstances, and cause of SCD were obtained from coronial and police reports, alongside autopsy and toxicology analyses where available. During the study period, 2006 cases were identified (median age, 28±7 years; men, 75%; mean body mass index, 29±8 kg/m²). Annual incidence ranged from 0.91 to 1.48 per 100 000 age-specific person-years, which was the lowest in 2013 to 2015 compared with previous 3-year intervals on Poisson regression model (P=0.001). SCD incidence was higher in nonmetropolitan versus metropolitan areas (0.99 versus 0.53 per 100 000 person-years; P<0.001). The most common cause of SCD was coronary artery disease (40%), followed by sudden arrhythmic death syndrome (14%). Incidence of coronary artery disease-related SCD decreased from 2001-2003 to 2013-2015 (P<0.001). Proportion of SCD related to sudden arrhythmic death syndrome increased during the study period (P=0.02) although overall incidence was stable (P=0.22). Residential remoteness was associated with coronary artery disease-related SCD (odds ratio, 1.44 [95% CI, 1.24-1.67]; P<0.001). For every 1-unit increase, body mass index was associated with increased likelihood of SCD from cardiomegaly (odds ratio, 1.08 [95% CI, 1.05-1.11]; P<0.001) and dilated cardiomyopathy (odds ratio, 1.04 [95% CI, 1.01-1.06]; P=0.005).

CONCLUSIONS

Incidence of SCD in the young and specifically coronary artery disease-related SCD has declined in recent years. Proportion of SCD related to sudden arrhythmic death syndrome increased over the study period. Geographic remoteness and obesity are risk factors for specific causes of SCD in the young.

P812Takotsubo cardiomyopathy: phenotypic diversity and contemporary management

Background

Takotsubo Cardiomyopathy represents an acute transient decline in left ventricular (LV) function occurring in the absence of obstructive coronary artery disease or acute plaque rupture. Therapeutic strategies vary due to a paucity of evidence-based guidelines.

Purpose

To evaluate clinical and biochemical characteristics, management approach and outcomes in a contemporary cohort of patients with Takotsubo Cardiomyopathy across two tertiary centres in Victoria, Australia. Neurohormonal associations were explored by characterising the prevalence of pre-existing endocrinopathies and malignancy.

Methods

We conducted a retrospective study of 240 patients with Takotsubo Cardiomyopathy diagnosed between 2008–2018, utilising data from electronic medical records.

Results

Patients were predominantly female (91.3%, mean age 66±12 years), smokers (48.3%), and hypertensive (55.0%). A small proportion (16.7%) had pre-existing malignancy (breast 30%, gastrointestinal 23%, genitourinary 19%, lung 9%, other 19%) or endocrine disease (12.5%), largely driven by thyroid disease (94%).

Troponin rise was common (94.6%; peak troponin 6.4±13μg/L), though few presented with ST-elevation (21.7%). Psychosocial stress was prevalent (44.6%) compared with physical illness (39.2%) or an unidentified precipitant (16.7%).

Management was heterogeneous. Many were discharged on aspirin (37.7%), dual antiplatelet therapy (34%) or statins (35.9%) in the absence of obstructive coronary disease or other clinical indication and were frequently continued beyond 1 year. ACE inhibitors or angiotensin receptor blockers were prescribed in 83.7%, beta blockers in 84.9% or both in 74.9% (continuing beyond 1 year in 60.4%). LV dysfunction occurred in 81.7% at diagnosis (mean LV ejection fraction (LVEF) 45±11%), recovering in 91.3% (mean LVEF 62±8%; 17.2% increase, p<0.001) on repeat echocardiography (mean 107±154 days). Follow up occurred in 81.4%, though most patients with normalised LV function continued heart failure therapy (83.6%). 12-month mortality was rare (7%) as was recurrence (5.1%).

Conclusions

Management of Takotsubo Cardiomyopathy remains challenging due to phenotypic diversity, variable therapeutic approach and unclear treatment duration. Pre-existing illness, including malignancy and endocrinopathy, may provide a substrate for the development of Takotsubo Cardiomyopathy or amplify cardiac adrenoreceptor sensitivity. Enhanced understanding of possible neurohormonal and cellular mechanisms may facilitate targeted management and preventive strategies. The role of antiplatelets or lipid lowering therapy is not supported in existing literature, however, as this study highlights, they continue to feature heavily in the Takotsubo treatment armamentarium. Further studies are needed to enhance understanding of underlying mechanisms and establish a standardised treatment approach with targeted therapy to promote LV recovery and prevent recurrence.

Acknowledgement/Funding

None

Granulomatous tonsillitis. A rare extraintestinal manifestation of Crohn's disease

Oral lesions, varying in nature and location, appear to be one of the common extraintestinal manifestation of Crohn's disease. In particular, oral involvement preceding intestinal disease may lead to the diagnosis of Crohn's disease. The present case report of a 17-year-old male patient describes a very rare nonintestinal manifestation of Crohn's disease with severe granulomatous involvement of the tonsils. A sore throat caused by hyperplastic tonsils with granulomatous inflammation as an oral manifestation of Crohn's disease was the leading symptom in this case.

[Injuries of the central base of the skull]

In different types of lesions, especially in frontobasal and laterobasal ones, the central base of the skull is injured, too (in about 20% of severe frontabasal lesions). Surgical treatment is necessary. Examination of intra- and infrabasal structures and localized intracranial operations may be performed by transthemoidal-transphenoidal or transpyramidal approaches. Main problems are the treatment of dura lesions, the control of hemorrhages, the examination of the optic nerve, and the compensation of disturbances of central regulation. The above experiences we gathered from patients in the ORL Clinic of Jena University.

[Rhinomanometric findings during brine aerosol inhalations (author's transl)]

Brine aerosol inhalations cause reactions of the nasal mucous membrane and the submucousal vascular bed as is shown by rhinomanometric examinations of healthy persons and patients suffering from various kinds of rhinitis. Changes in the resistance as a whole differ from those in partial resistances. The reactions are depending on the form of inhalation, the spectrum and concentration of the aerosol, climatic parameters and the pathophysiologic condition of the nasal mucosa.

[Enzyme diagnosis of human parotid glands and its problems]

The gland-specific enzymes amylase, lysozyme and kallikrein the activities and their dependence on the speed of salivation were studied in normal persons. In these investigations the specification or standard ranges for differentiated secretion states is useful. In contrast to amylase activity, the activities of lysozyme and kallikrein weaken appreciably with increasing speed of salivation. The activity secreted, as measured in time units, increases. In the case of a diseased parotis, a comparison of enzyme activities with the standard values will show a significant reduction of lysozyme and amylase activity in the chronic processes. Acute inflammation affects the amylase activity slightly, but raises the lysozyme activity significantly. Parotid mixed tumours probably do not lead to any changes in the enzyme activities. The splitting up of amylase into isoenzymes by polyacrylamide gel electrophoresis and its possible importance for the diagnosis of pathological processes are discussed. First results of the splitting up of the parotid lysozyme are reported.

[The effect of various aerosols on nasal ventilation (rhinomanometric investigations (author's transl)]

Rhinomanometry is useful for estimating the reactions of nasal mucosa to saline aerosol inhalations. The resistance of the whole nose provides insufficient evidence. Reactions on one side of the nose clearly show that--it is possible to differentiate qualitatively and quantitatively between the first and the second stage after inhalation. The reaction on one side of the nose may be opposite in character to the other side. The same person may respond in a contrary manner on different days both qualitatively and quantitatively. Patients with rhinitis and allergy react particularly briskly. The problems of nasal dynamics are indicated.