• Coronary artery disease
• sudden cardiac death

Sudden cardiac death in the young is mostly a problem of cardiomyopathies, with either mechanical or electrical dysfunction (hypertrophic and arrhythmogenic, ion channel diseases), whereas in the adult–elderly population it is usually associated with coronary atherosclerosis and inherent ischaemic heart disease (coronary thrombosis, obstructive mutivessel disease, myocardial scars with decreased ejection fraction).1 In this issue of Heart, Hill and Sheppard,2 with a retrospective study on an impressive number (1800 cases) of sudden cardiac deaths, report 50 cases (2.7%) in which a coronary artery pathology other than atherosclerosis was the only plausible cause of death (see page 1119). In nearly 50% of non-atherosclerotic coronary sudden deaths, the morbid entity was congenital (anomalous origin and course of the coronary arteries), whereas the remaining were acquired. The age span was from infancy to old age. The authors should be congratulated for this commendable study, which draws attention to a neglected cause of sudden death. The results point to the need for in-vivo investigation to recognise and treat patients at risk. A similar paper was published years ago by our group, limited to a young population (≤35 years).3

The main issue that deserves comment is how can we be sure that these non-atherosclerotic coronary diseases were ‘responsible’ for sudden death, as resulting from the title of the paper. In the guidelines for autopsy diagnosis of sudden death, recently published by the Association for European Cardiovascular …