Introduction Sudden unexpected death is a leading cause of cardiovascular mortality worldwide. Coronary plaque rupture is the most frequent cause of all cardiac deaths, however the assessment of coronary artery disease at autopsy is remains a technical challenge. The use of post-mortem computed tomography coronary angiography (CTCA) has been shown to increase the diagnostic accuracy of post-mortem autopsy findings. This study aims to assess the validity of vulnerable plaque imaging using post-mortem CTCA.

Methods A cohort of sudden death victims underwent double contrast-enhanced CT coronary angiography. Cannulation of the right common carotid artery with Foley catheter balloon occlusion of the ascending aorta facilitated air injection and contrast enhancement (10% Iohexol, Omnipaque 300, GE Healthcare) of the aortic root and coronary arteries. Contrast enhanced CT images were assessed for features of coronary plaque vulnerability including positive remodelling, spotty calcification, low CT attenuation, napkin ring sign and intra-coronary thrombus in proximal coronary artery segments.

Results Eight sudden death victims had a mean age of 63.6 (±8.8) years and 37.5% (n=3) were male. Features of vulnerable plaque (Positive remodelling and low attenuation) were present in 50% of sudden death victims. Obstructive coronary artery disease with vulnerable plaque features were the most frequent observation in sudden death victims.

Conclusion Vulnerable plaque can be detected in victims of sudden death. Post-mortem CTCA can be used to identify the coronary pathophysiological mechanisms that result in sudden cardiac death.