Sudden Cardiac Death

  • S. Kim SuvarnaEmail author


Sudden death from cardiac disease is common across the world. This chapter considers the range of cardiac pathology causing sudden death, as well as the strategies to confirm cardiac disease as the cause of the death. It also considers non-cardiac conditions that may mimic cardiac disease. A pragmatic approach to the common disorders of ischemic heart disease, valvular pathology, cardiomyopathy, myocarditis and other lesions is given. A commentary of channelopathies is provided together with consideration of abnormal conduction pathways. Issues regarding medico-legal deaths, affecting those with cardiac pathology following stressful events, are debated. Some aspects of post-operative deaths are also described. The role of obesity in sudden cardiac death is also presented along with rarer causes of sudden death (thrombotic thrombocytopenic purpura, commotio cordis and muscular dystrophy). A tabular analysis of the likelihood of cardiac pathology being implicated in the cause of death is provided.


Sudden cardiac death Ischemic heart disease Valve disease Cardiomyopathy Myocarditis Channelopathy Muscular dystrophy Cardiac surgery Congenital heart disease Obesity Anorexia Slimming agents Stress Microangiopathy Commotio cordis Sudden adult death syndrome (SADS) Resuscitation-related pathology 


  1. 1.
    Thiene G, Basso C, Corrado D. Cardiovascular causes of sudden death. In: Silver MD, Gotlieb AI, Schoen FJ, editors. Cardiovascular pathology. 3rd ed. New York, NY: Churchill Livingstone; 2001. p. 326–74.Google Scholar
  2. 2.
    Virmani R, Burke A, Farb A, Atkinson JB. Sudden cardiac death. In: Cardiovascular pathology. 2nd ed. Philadelphia, PA: WB Saunders; 2001. p. 340–85.Google Scholar
  3. 3.
    Soilleux EJ, Burke MM. Pathology and investigation of potentially hereditary sudden cardiac death syndrome in structurally normal hearts. Diagn Histopathol. 2009;15:1–26.CrossRefGoogle Scholar
  4. 4.
    Basso C, Aguilera B, Banner J, et al. Guidelines for autopsy investigation of sudden cardiac death: 2017 update from the Association for European Cardiovascular Pathology. Virchows Arch. 2017;47:691. Scholar
  5. 5.
    Kannel W, Thomas H. Sudden death: the Framingham study. Ann N Y Acad Sci. 1982;382:3–21.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Basso C, Corrado D, Thiene G. Cardiovascular causes of sudden death in young individuals including athletes. Cardiol Rev. 1999;7:127–35.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Bowker TJ, Wood DA, Davies MJ, Sheppard MN, Cary NR, Burton DJ, et al. Sudden, unexpected cardiac or unexplained death in England: a national survey. QJM. 2003;96(4):269–79.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    2005 Mortality statistics: cause (England and Wales). Health Stat Q. 2007:89–92.Google Scholar
  9. 9.
    Maron BJ, Shirani J, Poliac LC, et al. Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles. JAMA. 1996;276:199–204.CrossRefGoogle Scholar
  10. 10.
    Sheppard MN, Suvarna SK. Guidelines on autopsy practice - Scenario 1: sudden death with likely cardiac disease. London: Royal College of Pathologists; 2015. Google Scholar
  11. 11.
    Rutty GN, Burton JL, editors. The hospital autopsy. 3rd ed. London: Arnold; 2010.Google Scholar
  12. 12.
    Burton J, Saunders S, Hamilton S. Atlas of adult autopsy pathology. Boca Raton, FL: CRC Press; 2015.CrossRefGoogle Scholar
  13. 13.
    Suvarna SK, editor. Atlas of adult autopsy. A guide to modern practice. Cham: Springer International Publishing; 2016.Google Scholar
  14. 14.
    Davies MJ. Coronary artery remodelling and the assessment of stenosis by pathologists. Histopathology. 1998;33:497–500.PubMedCrossRefGoogle Scholar
  15. 15.
    Davies MJ. Coronary disease – the pathophysiology of acute coronary syndromes. Heart. 2000;83:361–6.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Dorries CP. Coroner’s courts. A guide to law and practice. 3rd ed. Oxford: Oxford University Press; 2014.Google Scholar
  17. 17.
    Silvanto A, de Noronha SV, Sheppard MN. Myocardial infarction with normal coronary arteries. J Clin Pathol. 2012;65:512–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Fletcher A, Ho SY, McCarthy KP, Sheppard MN. Spectrum of pathological changes in both ventricles of patients dying suddenly with arrhythmogenic right ventricular dysplasia. Relation of changes to age. Histopathology. 2006;48(4):445–52.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Tansey DK, Aly Z, Sheppard MN. Fat in the right ventricle of the normal heart. Histopathology. 2005;46:98–104.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Jefferies JL, Towbin JA. Dilated cardiomyopathy. Lancet. 2010;375(9716):752–62.PubMedCrossRefGoogle Scholar
  21. 21.
    Fatkin D, MacRae C, Sasaki T, et al. Missense mutations in the rod domain of the lamin A/C gene as causes of dilated cardiomyopathy and conduction-system disease. N Engl J Med. 1999;341:1715–24.PubMedCrossRefGoogle Scholar
  22. 22.
    Kabbani SS, LeWinter MM. Diastolic heart failure. Constrictive, restrictive, and pericardial. Cardiol Clin. 2000;18(3):501–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Angelini A, Calzolari V, Thiene G, Boffa GM, Valente M, Daliento L, et al. Morphologic spectrum of primary restrictive cardiomyopathy. Am J Cardiol. 1997;80(8):1046–50.PubMedCrossRefGoogle Scholar
  24. 24.
    Mogensen J, Arbustini E. Restrictive cardiomyopathy. Curr Opin Cardiol. 2009;24:214–20.PubMedCrossRefGoogle Scholar
  25. 25.
    Veinot JP, Johnston B. Cardiac sarcoidosis-an occult cause of sudden death: a case report and literature review. J Forensic Sci. 1998;43:715–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Sekhri S, Sanal S, DeLorenzo LJ, Aranow WS, Maguire GP. Cardiac sarcoidosis: a comprehensive review. Arch Med Sci. 2011;7(4):546–54.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Ramaraj R, Sorrell VL. Peripartum cardiomyopathy: causes, diagnosis, and treatment. Cleve Clin J Med. 2009;76(5):289–96.PubMedCrossRefGoogle Scholar
  28. 28.
    Hilfiker-Kleiner D, Sliwa K. Pathophysiology and epidemiology of peripartum cardiomyopathy. Nat Rev Cardiol. 2014;11:364–70.PubMedCrossRefGoogle Scholar
  29. 29.
    Schimpf R, Veltmann C, Wolpert C, Borggrefe M. Channelopathies: Brugada syndrome, long QT syndrome, short QT syndrome, and CPVT. Herz. 2009;34:281–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Kaufman ES. Mechanisms and clinical management of inherited channelopathies: long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, and short QT syndrome. Heart Rhythm. 2009;6:S51–5.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Modell SM, Lehmann MH. The long QT syndrome family of cardiac ion channelopathies: a HuGE review. Genet Med. 2006;8:143–55.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Ackerman MJ. Cardiac channelopathies: it’s in the genes. Nat Med. 2004;10:463–4.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Wang Q, Shen J, Splawski I, Atkinson D, Li Z, Robinson JL, et al. SCN5A mutations associated with an inherited cardiac arrhythmia, long QT syndrome. Cell. 1995;80:805–11.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Marban E. Cardiac channelopathies. Nature. 2002;415:213–8.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Postema PG, Wolpert C, Amin AS, Probst V, Borggrefe M, Roden DM, Priori SG, Tan HL, Hiraoka M, Brugada J, Wilde AA. Drugs and Brugada syndrome patients: review of the literature, recommendations and an up-to-date website ( Heart Rhythm. 2009;6:1335–41.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Minoura Y, Kobayashi Y, Antzelovitch C. Drug-induced Brugada syndrome. J Arrhythm. 2013;29:88–95.CrossRefGoogle Scholar
  37. 37.
    Hosseini SM, Kim R, Udupa S, et al. Reappraisal of reported genes for sudden cardiac death. Circulation. 2018;118:1195–205.CrossRefGoogle Scholar
  38. 38.
    Bell MD, Barnhart JS Jr, Martin JM. Thrombotic thrombocytopenic purpura causing sudden, unexpected death – a series of eight patients. J Forensic Sci. 1990;35:601–13.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Lucas SL. Derivation of new reference tables for human heart weights in light of increasing body mass index. J Clin Pathol. 2011;64:279–80.CrossRefGoogle Scholar
  40. 40.
    Gaitskell K, Perera R, Soilleux EJ. Derivation of new reference tables for human heart weights in light of increasing body mass index. J Clin Pathol. 2011;64:358–62.PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Strack C, Fessman D, Fenk S, et al. QT prolongation is frequently observed in obesity with and without the metabolic syndrome and can be reversed by long term weight reduction. Eur Heart J. 2013;34(Suppl 1.1):P4287.CrossRefGoogle Scholar
  42. 42.
    Grundlingh J, Dargan PI, El-Zanfaly M, Wood DM. 2,4-Dinitrophenol (DNP): a weight loss agent with significant acute toxicity and risk of sudden death. J Med Toxicol. 2011;7:205–12.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Song H, Fang F, Arnberg FK, et al. Stress related disorders and the risk of cardiovascular disease. BMJ. 2019;365:l1255.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Meisel SR, Dayan KI, Pauzner H, Chetboun I, Arbel Y, David D, Kutz I. Effect of Iraqi missile war on incidence of acute myocardial infarction and sudden death in Israeli civilians. Lancet. 1991;338:660–1.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Cebelin MS, Hirsch CS. Human stress cardiomyopathy. Myocardial lesions in victims of homicidal assaults without internal injuries. Hum Pathol. 1980;11:123–32.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Lecomte D, Fornes P, Nicolas G. Stressful events as a trigger of sudden death. A study of 43 medico-legal autopsy cases. Forensic Sci Int. 1996;79:1–10.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Trichopoulos D, Katsouyanni K, Zavitsanos X, et al. Psychological stress and fatal heart attack: the Athens (1981) earthquake natural experiment. Lancet. 1983;26:441–3.CrossRefGoogle Scholar
  48. 48.
    Engel GL. Sudden and rapid death during psychological stress. Ann Intern Med. 1971;74:771–83.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Young DB, et al. Potassium and catecholamine concentrations in the immediate post exercise period. Am J Med Sci. 1992;304:150–3.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Lindinger M. Potassium regulation during exercise and recovery in humans: implications for skeletal and cardiac muscle. J Mol Cell Cardiol. 1995;27:1011–22.PubMedCrossRefGoogle Scholar
  51. 51.
    Dimsdale JE, et al. Post exercise peril: plasma catecholamine and exercise. JAMA. 1984;252:630–2.CrossRefGoogle Scholar
  52. 52.
    Glass RI, Zack MM Jr. Increase in deaths from ischaemic heart disease after blizzards. Lancet. 1979;1:485–7.PubMedCrossRefGoogle Scholar
  53. 53.
    Rasanen S, Hakko H, Kaisa V, et al. Avoidable mortality in long stay psychiatric patient of northern Finland. Nord J Psychiatry. 2005;52:103–8.CrossRefGoogle Scholar
  54. 54.
    Solimene MC. Electroconvulsive therapy and the heart. Int J Cardiol. 2007;114:103.PubMedCrossRefGoogle Scholar
  55. 55.
    Lee AH, Gallagher PJ. Post-mortem examination after cardiac surgery. Histopathology. 1998;33:399–405.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Hickling MF, Pontefract DE, Gallagher PJ, Livesey AS. Post mortem examinations after cardiac surgery. Heart. 2007;93:761–5.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Madias C, Maron BJ, Weinstock J, Estes NA, Link MS. Commotio cordis – sudden cardiac death after chest wall impact. J Cardiovasc Electrophysiol. 2007;18:115–22.PubMedCrossRefGoogle Scholar
  58. 58.
    Miller AC, Rosatis SF, Suffredini AF, et al. A systemic review and pooled analysis of CPR-associated cardio and thoracic injuries. Resuscitation. 2014;85(6):724–31.PubMedPubMedCentralCrossRefGoogle Scholar
  59. 59.
    Natsuaki M, Yamasaki A, Morishige N, et al. Right ventricular rupture induced by cardiopulmonary resuscitation. J Cardiol Cases. 2010;1:E42–4.PubMedCrossRefPubMedCentralGoogle Scholar
  60. 60.
    Kaldrim U, Toygar M, Karbeyaz K, et al. Complications of cardiopulmonary resuscitation in non-traumatic cases and factors affecting complications. Egypt J Forensic Sci. 2016;6:270–4.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Sheffield Teaching HospitalsRoyal Hallamshire Hospital Sheffield Teaching Hospitals SheffieldSouth YorkshireUK

Personalised recommendations