Pathology of sudden death during recreational sports activity: an autopsy study of 31 cases

Congenital Coronary Artery Anomalies and Sudden Cardiac Death

Coronary artery anomalies (CAAs) are a heterogeneous group of rare congenital diseases whose features and pathophysiological mechanisms are extremely variable, ranging from silent anomalies to sudden cardiac death (SCD) in the most severe cases. Although rare, congenital CAAs confer a high risk of myocardial ischemia and SCD, especially in young, previously "healthy" athletes during or immediately after vigorous exertion. Although some high-risk features that may lead to SCD have been identified, specific pathophysiological mechanisms related to SCD still remain poorly understood. When a CAA is incidentally diagnosed, optimal SCD risk stratification remains challenging, particularly in cases of anomalous aortic origin of a coronary artery arising from the opposite aortic sinus of Valsalva (ACAOS). In recent times, invasive imaging with intravascular ultrasound has gained a role in further identifying high-risk anatomic features; it has been integrated with traditional, non-invasive anatomic imaging evaluations, typically high-quality echocardiography, and cardiac magnetic resonance. Multidisciplinary programs and specific SCD risk scores should be developed in an endeavor to choose the right therapeutic approach, either clinical or interventional/surgical. Intravascular ultrasound is an extremely useful tool to evaluate vessel stenosis, even if prospective studies are still required to further validate this diagnostic strategy. In the present review, we aimed to analyze the pathophysiology and the clinical impact of ACAOS. We also summarized the predominant mechanisms for interference with normal coronary artery function, which might contribute to the onset of life-threatening arrhythmias and SCD.

Is physical activity a trigger factor for subarachnoid hemorrhage?

INTRODUCTION

Subarachnoid hemorrhage (SAH) is a serious pathology, associated with 43% mortality and significant disability. In the absence of relevant guidelines, some teams advocate that patients harboring an unruptured intracranial aneurysm (ICA) abstain from all sports activity, as a prophylactic precaution. The aim of the present study was to evaluate the impact of physical activity as a risk factor for SAH, through a review of the literature.

METHOD

A systematic literature review was performed for the period 2000 to 2020 in accordance with the PRISMA guidelines. Prospective and retrospective articles reporting more than 50 patients whose physical activity was associated with onset of SAH were included. The main end-point was prevalence of SAH occurring after physical activity. For comparison purposes, the prevalences of other circumstances were calculated to establish a range of frequency.

RESULTS

Physical activity appeared to be quite rarely associated with onset of SAH, with a prevalence of 3%, compared to 30% at rest, 7.3% in association with defecation and 4.5% in association with sexual activity. Age under 60 years, male gender (M/F ratio 1.38) and smoking (67.1%) were associated with onset of SAH during physical activity.

CONCLUSION

Physical activity appears to be a rare trigger factor for SAH. These results are in contrast to the idea that physical activity should, as a precaution, be avoided in patients with unruptured ICA. There is at present no scientific evidence of an association with aneurysmal SAH.

Impact of endurance exercise on the heart of cyclists: A systematic review and meta-analysis

OBJECTIVE

To compare heart structure and function in endurance athletes relative to participants of other sports and non-athletic controls in units relative to body size. A secondary objective was to assess the association between endurance cycling and cardiac abnormalities.

PATIENTS AND METHODS

Five electronic databases (CINAHL, Cochrane Library, Medline, Scopus, and SPORTdiscus) were searched from the earliest record to 14 December 2019 to identify studies investigating cardiovascular structure and function in cyclists. Of the 4865 unique articles identified, 70 met inclusion criteria and of these, 22 articles presented 10 cardiovascular parameters in units relative to body size for meta-analysis and five presented data relating to incidence of cardiac abnormalities. Qualitative analysis was performed on remaining data. The overall quality of evidence was assessed using GRADE. Odds ratios were calculated to compare the incidence of cardiac abnormality.

RESULTS

Heart structure was significantly larger in cyclists compared to non-athletic controls for left ventricular: mass; end-diastolic volume, interventricular septal diameter and internal diameter; posterior wall thickness, and end-systolic internal diameter. Compared to high static and high dynamic sports (e.g., kayaking and canoeing), low-to-moderate static and moderate-to-high dynamic sports (e.g., running and swimming) and moderate-to-high static and low-to-moderate dynamic sports (e.g., bodybuilding and wrestling), endurance cyclists end-diastolic left ventricular internal diameter was consistently larger (mean difference 1.2-3.2 mm/m²). Cardiac abnormalities were higher in cyclists compared to controls (odds ratio: 1.5, 95%CI 1.2-1.8), but the types of cardiac abnormalities in cyclists were not different to other athletes.

CONCLUSION

Endurance cycling is associated with a larger heart relative to body size and an increased incidence of cardiac abnormalities relative to controls.

Myocardial bridge pathology and preventable accidents during physical activity of healthy subjects: A case report and a literature review

Myocardial bridging is a congenital coronary pathology described as a segment of coronary artery which courses through the myocardial wall under the muscle bridge. Although the prognosis of myocardial bridging is benign, sports medicine recognises myocardial bridging as a leading cause of sudden death among young basketball, football and soccer players. The authors report a case of a 42-year-old man who collapsed while playing football. He died notwithstanding prompt medical assistance and cardiopulmonary resuscitation. At autopsy, gross examination of the heart revealed the intramural course of the left anterior descending coronary artery to be 2 cm from its coronary ostial origin. Histological examination of ventricular septal and left myocardium showed early signs of ischaemic injury without disease of small coronary vessels and hypertrophic cardiomyopathy. The cause of the death was due to malignant ventricular arrhythmia during intense physical activity.

The impact of a 21-day ultra-endurance ride on the heart in young, adult and older adult recreational cyclists

BACKGROUND

This study assessed the acute effect of 21 days of challenging exercise on heart structure and function in recreationally active people across a range of age categories.

METHODS

15 recreationally active people completed a 21-day fundraising cycling ride (MADRIDE) over a distance of 3515 km. Twenty-four hour Holter electrocardiography and blood biochemistry analyses were performed before and after the MADRIDE.

RESULTS

Incidence of cardiac arrhythmia was higher after MADRIDE (OR: 5.93; 95% CI: 5.68-6.19), with increases in both ventricular arrhythmias (OR: 9.90; 95% CI: 9.27-10.57) and supraventricular arrhythmias (OR: 3.09; 95% CI: 2.91-3.29). Adults (OR: 11.45; 95% CI: 7.41-17.69) and older adults (OR: 10.42 95% CI 9.83-11.05) were approximately 10 times more likely to experience arrhythmias after the MADRIDE. Whereas, young participants experienced 18% less cardiac arrhythmias after MADRIDE (OR: 0.82; 95% CI: 0.75-0.90). Aortic valve max velocity was reduced (MD: -0.12 m/s; 95% CI: -0.19-0.05 m/s) and mitral valve deceleration time was slower (MD: -28.91 m/s; 95% CI: -50.97-6.84 m/s) after MADRIDE. Other structural and functional characteristics along with heart rate variability were not different after MADRIDE.

CONCLUSIONS

Multi-day challenging exercise increased the incidence of both supraventricular and ventricular arrhythmias in active adults and older adults. Increases in arrhythmia rates after MADRIDE occurred without changes in cardiac structure and autonomic control. Further exploration is necessary to identify the causes of exercise-induced cardiac arrhythmia in adult and older adults.

The forensic pathological analysis of sport-related sudden cardiac death in Southern China

Studies regarding sport-related sudden cardiac death (SCD) mainly focus on competitive athletes; similar data are rare in the general population, especially in China. We conducted a retrospective study (from September 1998 to August 2013) to investigate the aetiological distribution and epidemiological features of sport-related SCD in Southern China. Selections of cases are based on details, and two subgroups were established: one was the sport-related SCD group, and the other was the disease-free accident victims group which was matched with the sport-related SCD group in gender, age and year of death. Among the 3770 sudden-death cases, 1656 cases were SCD cases. A total of 65 cases (57 males) out of 1 656 SCD cases were sport-related. The age range of the 65 sport-related SCD cases was from 12 to 68 years old with a mean (35.92 ± 14.23) years old. Only two of these cases were competitive athletes. The most common circumstances of the 65 sport-related SCD cases were heavy physical labour (46.15%) and running (30.77%). The three leading forensic diagnoses were the coronary atherosclerotic disease (CAD, 28 cases), cardiomyopathy (CM, 14 cases) and sudden unexplained death (7 cases). CM was the most common forensic diagnosis in those ≤35 years old, while CAD was the most common one in those >35 years old. Left anterior descending in which atherosclerotic plaques was most commonly found was the principal artery branch associated with sport-related SCD. There was a statistically significant difference in the weight of hearts between the 65 sport-related SCD cases and 65 diseases-free accidental cases. This study highlights the need to attract public attention to sport-related SCD and to issue a prevention strategy to the public, and to make the SCD-related genetic sequencing a routine tool in both forensic pathological examination and clinic screening.

Hypertrophic Cardiomyopathy as a Cause of Sudden Cardiac Death in the Young: A Meta-Analysis

BACKGROUND

Sudden cardiac death is often linked with hypertrophic cardiomyopathy in young athletes, but with a divergence of study results. We performed a meta-analysis to compare the prevalence of sudden cardiac deaths associated with hypertrophic cardiomyopathy vs sudden cardiac deaths associated with structurally normal hearts.

METHODS

A structured search of MEDLINE was conducted for studies published from 1990 through 2014. Retrospective cohort studies, patient registries, and autopsy series examining sudden cardiac death etiology in young individuals (age ≤35 years) were included. A random-effects model was applied to generate pooled summary estimates of the percentage of sudden cardiac deaths with structurally normal hearts at postmortem vs those caused by hypertrophic cardiomyopathy. Heterogeneity was assessed using I(2). Subgroup analyses were conducted based on study location, patient age groups, and population types.

RESULTS

Thirty-four studies were included, representing a combined sample of 4605 subjects. The overall pooled percentage of sudden cardiac deaths caused by hypertrophic cardiomyopathy was 10.3% (95% confidence interval [CI], 8.0%-12.6%; I(2) = 87.2%), while sudden cardiac deaths with structurally normal hearts at death were more common (P <.001) at 26.7% (95% CI, 21.0%-32.3%; I(2) = 95.3%). In nonathlete subjects, the pooled percentage of sudden cardiac deaths associated with structurally normal hearts (30.7%; 95% CI, 23.0%-38.4%; I(2) = 96.3%) were significantly more common (P <.001) than sudden cardiac death caused by hypertrophic cardiomyopathy (7.8%; 95% CI, 5.8%-9.9%; I(2) = 80.1%). Among athletes, there was no significant difference between summary estimates of hypertrophic cardiomyopathy and structurally normal hearts (P = .57), except in Europe where structurally normal hearts were more common (P = .01).

CONCLUSIONS

Hypertrophic cardiomyopathy is not a more common finding at death than structurally normal hearts in young subjects with sudden cardiac death. Increased attention should be directed toward identifying causes of death associated with a structurally normal heart in subjects with sudden cardiac death.

[Sudden death during sport activity in Tunisia: autopsy study in 32 cases]

PURPOSE

To develop profile of the victims and to study circumstances, causes of death and autopsy findings.

METHODS

Retrospective study of cases of sudden death in sport activity whose autopsy was performed in forensic department of Tunis, between January 2005 and December 2009.

RESULTS

During study period, 32 cases of SD in sport activity were recorded. These are amateur athletes predominantly male (84% of cases). Victims are aged between 15 and 79 years with an average age of about 33.16 years. Young subjects whose age is less than 35 years representing 68.7% of cases. 9.3% of victims had a family history of SD and 18.7% of cases had a known cardiac history. The sports most involved are running (40.6% of cases), football (31.3% of cases) and dance (12.5% of cases). Sixty-nine percent of victims died during sports activities. Presence of witnesses was noted in all cases; however, none of these witnesses has begun resuscitation. Cause of death was cardiac in 84.4% of cases. In young athletes, hypertrophic cardiomyopathy is the leading cause (nine cases), followed by arrhythmogenic right ventricular dysplasia (three cases). Among other causes, there is the myocardial bridge, congenital anomalies of the coronary arteries, aortic dissection and dilated cardiomyopathy. Beyond 35 years, coronary artery diseases represent the cause of death (nine cases). Only case of death secondary to non-cardiac disease occurred after a severe asthma attack. In four cases (12.5%), no cause of death was identified after a complete autopsy accompanied by further investigations. The cause of the death was imputed to a rhythmic pathology.

CONCLUSION

This is the first study dealing with autopsy in SD in sport have provided a specific profile of victims. Other studies on larger samples and using standardized autopsy protocols are needed.

What is Sudden Cardiac Death?

Sudden cardiac death (SCD) is a rapid, unexpected death due to cardiac causes. The differential diagnosis includes diseases from all four structural divisions of the heart: the blood vessels, myocardium, valves, and conduction system. Although ischemic heart disease is a common cause of SCD, acute myocardial infarcts and/or coronary thromboses are not always detected and are not required to make the diagnosis of death due to atherosclerotic coronary disease. Some people die suddenly from heart disease with a grossly and microscopically normal heart. Molecular analysis of some of these autopsy-negative, sudden unexplained deaths (SUD) may detect putative cardiac channel mutations.

There are three SCD scenarios that are of particular interest to forensic pathologists: sudden cardiac deaths in young athletes, during criminal altercations (homicide by heart attack), and in other hostile environments. In young athletes, most sudden deaths involve cardiac disease and include cardiomyopathies, congenital coronary artery anomalies, myocarditis, and channelopathies. One must, however, consider other causes in these deaths (e.g., commotio cordis, hyperthermia, sickle cell trait). Homicide-by-heart-attack deaths are those in which the cause of death is an acute exacerbation of underlying cardiac disease, however, the manner is homicide because a criminal act triggered the lethal pathologic cascade. A sudden cardiac arrest may occur in hostile locations with resultant trauma (e.g., while driving a motor vehicle). When the event occurs in the bathtub or other body of water, the question of whether the person died naturally from heart disease or unnaturally from trauma (e.g., drowning) often arises. One should not be mislead by the initial physical surroundings of the death (i.e., in a motor vehicle collision, or swimming pool) and fail to distinguish a natural sudden death from an accidental one.

"Grown-up" congenital heart disease and sudden death in a medical examiner's population

Despite advances in the management of congenital heart disease (CHD), children with CHD who survive into adulthood are at increased risk of sudden death. Sudden death may also be the initial presentation of undiagnosed CHD in some adults. This retrospective descriptive study outlines the spectrum of CHD presenting as sudden death in adults in a medical examiner's population. Despite its rarity (0.2% of all cases investigated between 1991 and 2007), CHD remains an important cause of sudden cardiac death to be recognized at adult autopsy. Bicuspid aortic valve and anomalous coronary anomalies were the most common malformations, comprising 36.9% and 26.2% of cases, respectively. However, a wide spectrum of simple to complex malformations can be seen, with or without prior surgery, and over a wide age spectrum. Once solely a pediatric entity, CHD is now "grown-up" and will likely be diagnosed by forensic pathologists with increased frequency in the future.

State of the art in forensic investigation of sudden cardiac death

The sudden death of a young person is a devastating event for both the family and community. Over the last decade, significant advances have been made in understanding both the clinical and genetic basis of sudden cardiac death. Many of the causes of sudden death are due to genetic heart disorders, which can lead to both structural (eg, hypertrophic cardiomyopathy) and arrhythmogenic abnormalities (eg, familial long QT syndrome, Brugada syndrome). Most commonly, sudden cardiac death can be the first presentation of an underlying heart problem, leaving the family at a loss as to why an otherwise healthy young person has died. Not only is this a tragic event for those involved, but it also presents a great challenge to the forensic pathologist involved in the management of the surviving family members. Evaluation of families requires a multidisciplinary approach, which should include cardiologists, a clinical geneticist, a genetic counselor, and the forensic pathologist directly involved in the sudden death case. This multifaceted cardiac genetic service is crucial in the evaluation and management of the clinical, genetic, psychological, and social complexities observed in families in which there has been a young sudden cardiac death. The present study will address the spectrum of structural substrates of cardiac sudden death with particular emphasis given to the possible role of forensic molecular biology techniques in identifying subtle or even merely functional disorders accounting for electrical instability.

Blood pressure in patients with intermittent claudication increases continuously during walking

OBJECTIVES

The purpose of this study was to compare the circulatory responses to walking in patients with peripheral atherosclerotic disease (PAD) and healthy controls.

METHODS

The participants were eleven patients with diagnosed PAD, and a control group of six healthy age-matched adults. Blood pressure, heart rate (HR), and acral skin perfusion were recorded continuously before, during and after a walking exercise on a treadmill.

RESULTS

The patients walked to maximum claudication distance (MCD) on a treadmill, median walking distance 103 (34-223) metres [median (range)], at 3.3 (1.0-4.5) km/h. There was a steep increase in HR and mean arterial pressure (MAP) while the patients were walking. At claudication the median rise in MAP was 46.6 (10.3-61.3) mmHg, systolic blood pressure (SP) increased by 84.9 (31.4-124.9) mmHg, and diastolic blood pressure (DP) by 21.7 (-2.1-31.7) mmHg. HR increased by 34.9 (12.9-48.1) beats/min. The control group walked for 5 minutes at 3.2 (3.0-3.3) km/h. In the control group the blood pressure initially increased moderately but stabilised thereafter. Median rise in MAP during walking was 8.5 (5.6-14.6) mmHg, SP increased by 30.9 (6.6-41.5) mmHg, and DP was reduced by -1.4 (-5.4-1.5) mmHg. HR increased by 27.1 (18.8-34.9) beats/min. We found no significant differences in acral skin perfusion during walking exercise between the patients and control group.

CONCLUSIONS

In patients with PAD, blood pressure increased continuously and significantly when walking to MCD (dynamic exercise). The level of increase in blood pressure was similar to that caused in response to isometric exercise.