Download Protocol of investigation of sudden cardiac death at post

Sudden Cardiac Death
The AECVP Protocol
Patrick J Gallagher
Southampton University Hospitals
The Investigation of Sudden Death
• Practice in the EU is highly variable, even
within the same country
• There are no international guidelines on
which cases should have autopsies
• The proportion of sudden deaths that have
autopsies is not known
• The care with which these autopsies are
performed is variable
Why Perform an Autopsy?
• To determine whether death was of
cardiac or non cardiac origin
• What is the exact nature of the cardiac
disease?
• Is the cardiac disease inherited? Do
relatives require screening or treatment?
• Did drugs of any sort play a role in death?
Southampton University
Hospitals
900 adult autopsies
600 sudden deaths
350 sudden cardiac deaths
60
50
40
Male
Female
30
20
10
0
40s
50s
60s
70s
80s
90s
Age of sudden cardiac death patients in Southampton
Why another Protocol?
• After all there are excellent chapters in
forensic and autopsy textbooks
• Cardiologists are unhappy about the
standard of post mortem reports
• This is especially important in young
sudden deaths
• In England an independent audit has
shown that 25% of reports are poor
Virchows Archiv 2008;452:11-18
Four Essential Steps
Four Aspects of the Protocol
• Clinical information is valuable and desirable
• All post mortems should be full sequential
structured examinations. The exact nature of the
underlying cardiac disease should be
determined
• Histology and other laboratory investigations are
essential
• Pathologists must accept that there are grades
of diagnostic certainty and gray areas. They
must take great care in formulating a diagnosis
Dissection of the Heart
• We have written a detailed method
• But attention to detail is more important
than precise methodology!
• In everyday practice there are technical
problems such as calcification of the
coronary arteries and decomposition
• Most patients die of ischaemia or heart
failure BUT always think of the certainty
scale
40
35
30
25
Male
Female
20
15
10
5
0
Grade 1
Grade 2
Grade 3
HF
Causes of sudden cardiac death
?
First degree of
certainty of IHD
Second and third
degrees of certainty
Heart Failure
First Level of Certainty
• With very detailed histology acute
coronary thrombosis was identified in 47%
of 202 out of hospital sudden cardiac
deaths in Nottingham UK.
• Last year we identified 70 patients who
died at home with coronary thrombosis or
acute infarction. What prevents these
patients getting to hospital?
Leach et al Eur Heart J 1995;16:1181-5
Second degree of certainty
Third degree of certainty
• Coronary artery
narrowing
• No acute or healed
infarct
• Did the narrowing
cause death?
Diagnosis of Heart Failure
• The jugular venous pulse and an echo are
useful for diagnosis in life
• Symmetrical pleural effusions and hepatic
congestion are the best autopsy signs
• Good treatment prevents decompensation
and the associated pathological signs
• Sudden death can occur in the early
stages of heart failure even when
symptoms are well controlled
Cardiomyopathies
• Dilated cardiomyopathy is
the commonest type in
autopsy practice
• HOCM affects patients of
all ages
• Unexplained left ventricular
hypertrophy is a real entity
• Arrhythmogenic right
ventricular cardiomyopathy
(index cardiomyopathy)
Unexplained Cardiac Deaths
• Sudden arrhythmic death syndrome
• Not only a disease of the young:
25F,26M,37F,38F,40M,41F,45M,46M,
46F,64M
• Pathologists must consider and exclude
other important cardiac disorders
• Unexplained deaths also occur in
anorexia, obesity, alcohol abuse and
diabetes (dead in bed in diabetes)
The Gray Zones
• Coronary artery narrowing without
thrombosis, old or recent infarction
• Hypertensive heart disease, unexplained
left ventricular hypertrophy and HOCM
• Focal interstitial fibrosis and lymphocytic
inflammation
• Degenerative disease of the mitral valve
• Adipose tissue infiltration of the right
ventricle
The Final Diagnosis
• State clearly the most likely cause of death
• List the contributory causes
• Write a clinical comment indicating the
degree of diagnostic certainty
• Provide a recommendation for further study
of the patients records and for screening of
relatives
• Make a data base entry
We hope …
• That you agree that a full protocol driven
autopsy is essential in all sudden deaths in
patients less than 50 years
• That histology, biochemistry and
toxicology are essential and valuable
• That you will read our paper and provide
us with your comments
• That you will join us for our next meeting in
Lisbon
Fourth Biennial Meeting
Lisbon 21-23 October 2010
Local Organiser
Rosa Henriques de Gouveia MD PhD