Guidelines for Forensic Assessment of Natural Unexpected Cardiovascular

Death

Kyung-Moo Yang1, Sang-Yong Lee2, Yoon-Shin Kim1, Joong-Seok Seo1, Yoon Seong Lee3 and Jeong-Wook Seo4

orensic Medicine Division, National Institute of Scientific Investigation, Seoul; 2Clinic of Forensic Medicine, Pusan National University; Departments of 3Forensic Medicine and 4Pathology, Seoul National University,

Korea

Pembimbing:

Dr.dr.H.Taufik Suryadi Sp.F

Abstract

Sudden unexpected deaths due to cardiovascular diseases make up almost half of all natural deaths. Practical guidelines are needed for forensic autopsy practice in cases of natural unexpected deaths due to ischemic heart disease or other cardiovascular diseases in Korea. An evaluation of the clinical history is the first step, including the collection of all available information on the subject. As a standard autopsy procedure, every subsystem of the heart and vessels should be thoroughly studied including the coronary arteries, the myocardium, the cardiac valves, and the conducting system. In addition, histological, toxicological, biochemical and molecular analysis need to be applied to the detection of myocardial infarction from the medico-legal point of view. Also important is the assessment of risk factors for natural unexpected cardiac death (NUCD) in order to establish a cause effect relationship. There are three groups of ischemic conditions of heart leading to NUCD, those being acute myocardial infarction, atherosclerotic heart disease and critical coronary atherosclerosis. Additionally, there are practical concerns on formulating the report. Pathologists may use sudden cardiac death or NUCD as a main diagnosis when there is no alternative diagnosis, though they would do better to comment on conditions contributing to the death. Finally, pathologists should be encouraged to suspect unexplained causes of death in order to find clearer answers.

INTRODUCTION

Natural deaths continue to represent a large portion of the forensic cases, being more common than unnatural deaths. Sudden unexpected deaths due to cardiovascular diseases occupy almost a half (51.8%) of those natural death and more than 80% of cardiovascular deaths are associated with coronary atherosclerosis.

Guidelines required in the routine autopsy practice for the adequate assessment of sudden cardiac death (SCD) include not only a protocol for heart examination, histological sampling, toxicology and molecular investigation but also for formulating the report.

From the viewpoint of the forensic pathologist, it is important to prove a natural death instead of an unnatural one. Also important is determining whether the death was unexpected, as the death may in fact not have been a sudden event but a gradual deterioration of cardiac function.

EVALUATION ON THE CLINICAL HISTORY Six groups of information, proposed by Association for

European Cardiovascular Pathology, should be collected.

Basic personal data

Circumstances of death

Medical history

Medication use

Family history of cardiac diseases

Previous test results

Natural Unexpected Cardiovascular Death- Neural Arrhytmia-Mechanical Infarct Congestive Failure

Natural Unexpected Nervous Death- Neural Reflex, seizure-Mechanical herniation infarct

Natural Unexpected Respiratory Death- Neural apnea-Mechanical embolism asphyxia

Natural Unexpected Death

Un-natural Death

-Suicide-Accident-Criminal

UNEXPECTED DEATH

As for the symptoms and signs before death, symptoms possibly related cardiac problem were present in 60% of cases reviewed, these being syncope/presyncope, chest pain, palpitations or dyspnea. Among them syncope/presyncope was the most common (30%). Nonspecific symptoms such as fatigue, influenza, headache.

History of abnormal ECG should be checked carefully because major or minor ECG abnormalities were present in 82% of the victims of sudden death Common changes were T-wave abnormalities (35%), ST segment changes (32%) and conduction defects (20%).

MORPHOLOGICAL FINDINGS AT FORENSIC AUTOPSY

Atherosclerotic narrowing of coronary arteries is the most common and important finding in sudden unexpected deaths due to ischemic heart disease at forensic autopsies.

Myocardial scar

Dissection of coronary arteries

Secondary lesion of atherosclerotic plaque

Acute plaque disruption/thrombosis

FORENSIC PATHOLOGY REPORTING AND FORMULATION OF A

DIAGNOSIS AND THE SUMMARY We propose three groups of ischemic conditions of heart leading to sudden unexpected death.

1) Acute myocardial infarction is the most definitive diagnosis as a cause of sudden death regardless of the presence of old myocardial infarct or other cardiac lesions.

2) Atherosclerotic heart disease, the second category, has a definitive ischemic lesion and coronary arterial lesion and it is highly probable that this combination caused this particular death.

3) The third group, critical coronary atherosclerosis, describes a definitive lesion in coronary artery but its relation to death is uncertain because the myocardial ischemia is not proven at this time.

Deaths that remain unexplained after careful macroscopic, microscopic and laboratory investigation should be recorded and searched for further analysis. Some of them are classified as sudden arrhythmic death syndrome. We strongly suspect that the numbers of these unexplained deaths have been underestimated in the past. Some may have genetic cause known or unknown.

THANK YOU