Clinical Investigation
Acute Ischemic Heart Disease
Etiology of sudden death in the community: Results of anatomical, metabolic, and genetic evaluation

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Background

Identifying persons at risk for sudden cardiac death (SCD) is challenging. A comprehensive evaluation may reveal clues about the clinical, anatomical, genetic, and metabolic risk factors for SCD.

Methods

Seventy-one patients who had SCD (25-60 years old) without an initially apparent cause of death were evaluated at the Hennepin County Medical Examiner's office (Minneapolis, MN) from August 2001 to July 2004. We reviewed their clinic records conducted next-of-kin interviews and performed autopsy, laboratory testing, and genetic analysis for mutations in genes associated with the long QT syndrome.

Results

Mean age was 49.5 ± 7 years, 86% were male, and 2 subjects had history of coronary heart disease (CHD). Coronary risk factors were highly prevalent in comparison to individuals of the same age group in this community (eg, smoking 61%, hypertension 27%, hyperlipidemia 25%) but inadequately treated. On autopsy, 80% of the subjects had high-grade coronary stenoses. Acute coronary lesions and previous silent myocardial infarction (MI) were found in 27% and 34%, respectively. Furthermore, 32% of the subjects had recently smoked cigarettes, and 50% had ingested analgesics. Possible deleterious mutations of the ion channel genes were detected in 5 subjects (7%). Of these, 4 were in the sodium channel gene SCN5A.

Conclusions

Most of the persons who had SCD in the community had severe subclinical CHD, including undetected previous MI. Traditional coronary risk factors were prevalent and undertreated. Mutations in the long QT syndrome genes were detected in a few subjects. These findings imply that improvements in the detection and treatment of subclinical CHD in the community are needed to prevent SCD.

Section snippets

Setting

Hennepin is the largest county (population > 1.2 million) in the 7-county metropolitan area of Minneapolis-St Paul, MN, and includes the city of Minneapolis, as well as suburban and rural areas. By statute, all sudden or unexpected deaths in Hennepin County must be reported to the office of the county Medical Examiner (ME). Deaths due to other causes (eg, violence, burns, foul play, and others) and deceased persons with special circumstances (eg, inmates, organ donors, and others) also need to

Clinical characteristics and circumstances of SCD

The study participants were 49.5 ± 7 years old (range 27-60 years), and 86% were male (Table I). History of hypertension, diabetes mellitus, and/or hyperlipidemia were common. Smoking and obesity were highly prevalent. Overall, 61% of the participants were current (48%) or past (13%) smokers, and 80% had a body mass index in the overweight or obese range (Table I). Only 2 participants had a history of CHD, and 1 had a documented previous MI. Family history of MI and sudden death were present in

Discussion

The objective of the present investigation was to perform a detailed examination of adult patients who had SCD without an initially apparent cause of death, to uncover potential clinical, anatomical, metabolic, and genetic risk factors for SCD. We found that >80% of the subjects had previously undiagnosed but anatomically severe CHD on autopsy, including 27% with acute ischemic lesions and 34% with previous silent MI. Many also had signs of chronic cardiac disease characterized by LV

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