Skip to main content

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

Heart and Vessels volume 29, pages 486–495 (2014)Cite this article

Abstract

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.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

References

  1. Hua W, Zhang LF, Wu YF, Liu XQ, Guo DS, Zhou HL, Gou ZP, Zhao LC, Niu H, Chen KP, Mai JZ, Chu LN, Zhang S (2009) Incidence of sudden cardiac death in China analysis of 4 regional populations. J Am Coll Cardiol 54:1110–1118

    PubMed  Article  Google Scholar 

  2. Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C (2006) ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): Developed in Collaboration With the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 114:e385–e484

    PubMed  Article  Google Scholar 

  3. Tunstall-Pedoe H, Kuulasmaa K, Amouyel P, Arveiler D, Rajakangas A-M, Pajak A (1994) Myocardial infarction and coronary deaths in the World Health Organization MONICA Project: registration procedures, event rates, and case-fatality rates in 38 populations from 21 countries in four continents. Circulation 90:583–612

    CAS  PubMed  Article  Google Scholar 

  4. di Gioia CRT, Autore C, Romeo DM, Ciallella C, Aromatario MR, Lopez A, Pagannone E, Giordano C, Gallo P, d’Amati G (2006) Sudden cardiac death in younger adults: autopsy diagnosis as a tool for preventive medicine. Hum Pathol 37:794–801

    PubMed  Article  Google Scholar 

  5. Wu Z, Yao C, Zhao D, Wu G, Wang W, Liu J, Zeng Z, Wu Y (2001) Sino-MONICA project a collaborative study on trends and determinants in cardiovascular diseases in China, part I: morbidity and mortality monitoring. Circulation 103:462–468

    CAS  PubMed  Article  Google Scholar 

  6. Editorial Board (1998) Conference on the importance of autopsy under modern medical conditions. Zhonghua Yixue Zazhi (National J Med China) 78:649–652 [in Chinese]

    Google Scholar 

  7. Basso C, Burke M, Fornes P, Gallagher PJ, de Gouveia RH, Sheppard M, Thiene G, van der Wal A, on behalf of the Association for European Cardiovascular Pathologists (2008) Guidelines for autopsy investigation of sudden cardiac death. Virchows Arch 452:11–18

    PubMed  Article  Google Scholar 

  8. Huang GZ (2002) GA/T170-1997 The standards for public security pathological examination of sudden deaths. In: The Bureau of Science and Technology Ministry of Public Security (eds) The collections of standards for social and public security category of criminal science and forensic examination. China Standards Press, Beijing, pp 51–53 [in Chinese]

  9. Song Y, Zhu J, Laaksonen H, Saukko P (1997) A modified method for examining the cardiac conduction system. Forensic Sci Intl 86:135–138

    CAS  Article  Google Scholar 

  10. Eckart RE, Shry EA, Burke AP, McNear JA, Appel DA, Castillo-Rojas LM, Avedissian L, Pearse LA, Potter RN, Tremaine L, Gentlesk PJ, Huffer L, Reich SS, Stevenson WG (2011) Sudden death in young adults: an autopsy-based series of a population undergoing active surveillance. J Am Coll Cardiol 58:1254–1261

    PubMed  Article  Google Scholar 

  11. Aretz HT (1987) Myocarditis: the Dallas criteria. Hum Pathol 18:619–624

    CAS  PubMed  Article  Google Scholar 

  12. Knight B (1991) Forensic pathology. Edward Arnold, London, pp 487–516

    Google Scholar 

  13. Drory Y, Turetz Y, Hiss Y, Lev B, Fisman E, Pines A, Kramer M (1991) Sudden unexpected death in persons less than 40 years of age. Am J Cardiol 68:1388–1392

    CAS  PubMed  Article  Google Scholar 

  14. Basso C, Thiene G, Corrado D (1996) Arrhythmogenic right ventricular cardiomyopathy dysplasia, dystrophy, or myocarditis? Circulation 94:983–991

    CAS  PubMed  Article  Google Scholar 

  15. Basso C, Thiene G (2005) Adipositas cordis, fatty infiltration of the right ventricle, and arrhythmogenic right ventricular cardiomyopathy. Just a matter of fat? Cardiovasc Pathol 14:37–41

    PubMed  Article  Google Scholar 

  16. Soilleux EJ, Burke MM (2009) Pathology and investigation of potentially hereditary sudden cardiac death syndromes in structurally normal hearts. Diagn Histopathol (Oxf) 15:1–26

    Article  Google Scholar 

  17. Basso C, Calabrese F, Corrado D, Thiene G (2001) Postmortem diagnosis in sudden cardiac death victims: macroscopic, microscopic and molecular findings. Cardiovasc Res 50:290–300

    CAS  PubMed  Article  Google Scholar 

  18. Burke AP, Farb A, Virmani R, Goodin J, Smialek JE (1991) Sports-related and non-sports-related sudden cardiac death in young adults. Am Heart J 121:568–575

    CAS  PubMed  Article  Google Scholar 

  19. Doolan A, Langlois N, Semsarian C (2004) Causes of sudden cardiac death in young Australians. Med J Australia 180:110–112

    PubMed  Google Scholar 

  20. Morentina B, Audicanab C (2011) Population-based study of out-of-hospital sudden cardiovascular death: incidence and causes of death in middle-aged adults. Rev Esp Cardiol 64:28–34

    Article  Google Scholar 

  21. Bowker TJ, Wood DA, Davies MJ, Sheppard MN, Cary NRB, Burton JDK, Chambers DR, Dawling S, Hobson HL, Pyke SDM, Riemersma RA, Thompson SG (2003) Sudden, unexpected cardiac or unexplained death in England: a national survey. Q J Med 96:269–279

    CAS  Article  Google Scholar 

  22. Chugh SS, Reinier K, Teodorescu C, Evanado A, Kehr E, Samara MA, Mariani R, Gunson K, Jui J (2008) Epidemiology of sudden cardiac death: clinical and research implications. Prog Cardiovasc Dis 51:213–228

    PubMed Central  PubMed  Article  Google Scholar 

  23. Zipes DP, Wellens HJJ (1998) Sudden cardiac death. Circulation 98:2334–2351

    CAS  PubMed  Article  Google Scholar 

  24. Moore MJ, Glover BM, McCann CJ, Cromie NA, Ferguson P, Catney DC, Kee F, Adgey AAJ (2006) Demographic and temporal trends in out of hospital sudden cardiac death in Belfast. Heart 92:311–315

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  25. Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G (2003) Does sports activity enhance the risk of sudden death in adolescents and young adults? J Am Coll Cardiol 42:1959–1963

    PubMed  Article  Google Scholar 

  26. Winkel BG, Holst AG, Theilade J, Kristensen IB, Thomsen JL, Ottesen GL, Bundgaard H, Svendsen JH, Haunsø S, Tfelt-Hansen J (2011) Nationwide study of sudden cardiac death in persons aged 1–35 years. Eur Heart J 32:983–990

    PubMed  Article  Google Scholar 

  27. Zheng Z-J, Croft JB, Giles WH, Mensah GA (2001) Sudden cardiac death in the United States, 1989 to 1998. Circulation 104:2158–2163

    CAS  PubMed  Article  Google Scholar 

  28. Fontaine G, Fornes P, Fontaliran F, Zipes DP, Wellens HJJ (2001) Myocarditis as a cause of sudden death. Circulation 103:e12

    CAS  PubMed  Article  Google Scholar 

  29. Abe T, Tsuda E, Miyazaki A, Ishibashi-Ueda H, Yamada O (2012) Clinical characteristics and long-term outcome of acute myocarditis in children. Heart Vessels. doi:10.1007/s00380-00012-00296-00388

  30. Ikeda N, Nakamura M, Yazaki Y, Ono T, Yamamoto M, Ito S, Yokouchi I, Yajima S, Iijima R, Hara H, Takagi T, Hara H, Asahara T, Sakai H, Sugi K (2011) A slightly elevated level of N-terminal pro-brain natriuretic peptide can predict coronary artery disease in a population with normal left ventricular function. Heart Vessels 26:473–479

    PubMed  Article  Google Scholar 

  31. Tester DJ, Ackerman MJ (2006) The role of molecular autopsy in unexplained sudden cardiac death. Curr Opin Cardiol 21:166–172

    PubMed  Article  Google Scholar 

  32. Ackerman MJ, Priori SG, Willems S, Berul C, Brugada R, Calkins H, Camm AJ, Ellinor PT, Gollob M, Hamilton R, Hershberger RE, Judge DP, Le Marec H, McKenna WJ, Schulze-Bahr E, Semsarian C, Towbin JA, Watkins H, Wilde A, Wolpert C, Zipes DP (2011) HRS/EHRA expert consensus statement on the state of genetic testing for the channelopathies and cardiomyopathies. Europace 13:1077–1109

    PubMed  Article  Google Scholar 

  33. Davies MJ (1999) The investigation of sudden cardiac death. Histopathology 34:93–98

    CAS  PubMed  Article  Google Scholar 

  34. Ahronheim JC, Bernholc AS, Clark WD (1983) Age trends in autopsy rates, striking decline in late life. JAMA 250:1182–1186

    CAS  PubMed  Article  Google Scholar 

  35. Smilowitz NR, Sampson BA, Abrecht CR, Siegfried JS, Hochman JS, Reynolds HR (2011) Women have less severe and extensive coronary atherosclerosis in fatal cases of ischemic heart disease: an autopsy study. Am Heart J 161:681–688

    PubMed  Article  Google Scholar 

Download references

Acknowledgments

The authors thank the many pathologists from the eight cities of China for their work in collecting data and specimens. The authors also thank Prof. Guangzhao Huang and Prof. Xinshan Chen from Tongji Medical College, Wuhan, for reviewing this manuscript. We appreciate Prof. Laifeng Song and Prof. Yingmao Ruan from Fuwai Hospital, Beijing, for their helpful consultation on cardiac pathology. The statistics analysis was aided by Dr. Zuo Chen from China National Center for Cardiovascular Diseases, Beijing. This work was supported by the National Basic Research Program of China (973 project, Grant no. 2007CB512000 and 2007CB512008 to J. Pu).

Author information

Affiliations

  1. Department of Pathology and Physiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishilu Road, Xicheng District, Beijing, 100037, China

    Hongyue Wang & Jielin Pu

  2. Guangzhou Institute of Criminal Technology, Guangzhou, China

    Qingsong Yao

  3. Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

    Shaohua Zhu

  4. School of Forensic Medicine, China Medical University, Shenyang, China

    Guohua Zhang

  5. Department of Forensic Medicine, Xian Jiangtong University School Medicine, Xi’an, China

    Zhenyuan Wang

  6. Department of Forensic Medicine, Kunming Medical University, Kunming, China

    Zhen Li

  7. Department of Pathology, Wuxi People’s Hospital, Nanjing Medical University, Wuxi, China

    Rongchao Sun

  8. Department of Pathology, West China Hospital, Sichuan University, Chengdu, China

    Changli Lu

  9. Forensic Medical Examination Center of Beijing Public Security Bureau, Beijing, China

    Changrong Li

Authors
  1. Hongyue Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Qingsong Yao
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shaohua Zhu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Guohua Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Zhenyuan Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Zhen Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Rongchao Sun
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Changli Lu
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Changrong Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Jielin Pu
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jielin Pu.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Wang, H., Yao, Q., Zhu, S. et al. The autopsy study of 553 cases of sudden cardiac death in Chinese adults. Heart Vessels 29, 486–495 (2014). https://doi.org/10.1007/s00380-013-0388-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00380-013-0388-0

Keywords

  • Sudden cardiac death
  • Autopsy
  • Coronary artery disease
  • Myocarditis