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Stiles MK, Wilde AAM, Abrams DJ, Ackerman MJ, Albert CM, Behr ER, Chugh SS, Cornel MC, Gardner K, Ingles J, James CA, Juang JMJ, Kääb S, Kaufman ES, Krahn AD, Lubitz SA, MacLeod H, Morillo CA, Nademanee K, Probst V, Saarel EV, Sacilotto L, Semsarian C, Sheppard MN, Shimizu W, Skinner JR, Tfelt-Hansen J, Wang DW. 2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families. J Arrhythm 2021; 37:481-534. [PMID: 34141003 PMCID: PMC8207384 DOI: 10.1002/joa3.12449] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 12/26/2022] Open
Abstract
This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.
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Affiliation(s)
- Martin K Stiles
- Waikato Clinical School Faculty of Medicine and Health Science The University of Auckland Hamilton New Zealand
| | - Arthur A M Wilde
- Heart Center Department of Clinical and Experimental Cardiology Amsterdam University Medical Center University of Amsterdam Amsterdam the Netherlands
| | | | | | | | - Elijah R Behr
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute St George's University of London, and St George's University Hospitals NHS Foundation Trust London UK
| | | | - Martina C Cornel
- Amsterdam University Medical Center Vrije Universiteit Amsterdam Clinical Genetics Amsterdam Public Health Research Institute Amsterdam the Netherlands
| | | | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute The University of Sydney Sydney Australia
| | | | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology Department of Internal Medicine National Taiwan University Hospital and National Taiwan University College of Medicine Taipei Taiwan
| | - Stefan Kääb
- Department of Medicine I University Hospital LMU Munich Munich Germany
| | | | | | | | - Heather MacLeod
- Data Coordinating Center for the Sudden Death in the Young Case Registry Okemos MI USA
| | | | - Koonlawee Nademanee
- Chulalongkorn University Faculty of Medicine, and Pacific Rim Electrophysiology Research Institute at Bumrungrad Hospital Bangkok Thailand
| | | | - Elizabeth V Saarel
- Cleveland Clinic Lerner College of Cardiology at Case Western Reserve University Cleveland OH USA
- St Luke's Medical Center Boise ID USA
| | - Luciana Sacilotto
- Heart Institute University of São Paulo Medical School São Paulo Brazil
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute The University of Sydney Sydney Australia
| | - Mary N Sheppard
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute St George's University of London, and St George's University Hospitals NHS Foundation Trust London UK
| | - Wataru Shimizu
- Department of Cardiovascular Medicine Nippon Medical School Tokyo Japan
| | | | - Jacob Tfelt-Hansen
- Department of Forensic Medicine Faculty of Medical Sciences Rigshospitalet Copenhagen Denmark
| | - Dao Wu Wang
- The First Affiliated Hospital of Nanjing Medical University Nanjing China
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Re-evaluation of single nucleotide variants and identification of structural variants in a cohort of 45 sudden unexplained death cases. Int J Legal Med 2021; 135:1341-1349. [PMID: 33895855 PMCID: PMC8205883 DOI: 10.1007/s00414-021-02580-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 03/16/2021] [Indexed: 12/30/2022]
Abstract
Sudden unexplained death (SUD) takes up a considerable part in overall sudden death cases, especially in adolescents and young adults. During the past decade, many channelopathy- and cardiomyopathy-associated single nucleotide variants (SNVs) have been identified in SUD studies by means of postmortem molecular autopsy, yet the number of cases that remain inconclusive is still high. Recent studies had suggested that structural variants (SVs) might play an important role in SUD, but there is no consensus on the impact of SVs on inherited cardiac diseases. In this study, we searched for potentially pathogenic SVs in 244 genes associated with cardiac diseases. Whole-exome sequencing and appropriate data analysis were performed in 45 SUD cases. Re-analysis of the exome data according to the current ACMG guidelines identified 14 pathogenic or likely pathogenic variants in 10 (22.2%) out of the 45 SUD cases, whereof 2 (4.4%) individuals had variants with likely functional effects in the channelopathy-associated genes SCN5A and TRDN and 1 (2.2%) individual in the cardiomyopathy-associated gene DTNA. In addition, 18 structural variants (SVs) were identified in 15 out of the 45 individuals. Two SVs with likely functional impairment were found in the coding regions of PDSS2 and TRPM4 in 2 SUD cases (4.4%). Both were identified as heterozygous deletions, which were confirmed by multiplex ligation-dependent probe amplification. In conclusion, our findings support that SVs could contribute to the pathology of the sudden death event in some of the cases and therefore should be investigated on a routine basis in suspected SUD cases.
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Diagnostic Yield of Genetic Testing in Sudden Cardiac Death with Autopsy Findings of Uncertain Significance. J Clin Med 2021; 10:jcm10091806. [PMID: 33919104 PMCID: PMC8122344 DOI: 10.3390/jcm10091806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 01/05/2023] Open
Abstract
Background: Sudden death (SD) in the young usually has an underlying genetic cause. In many cases, autopsy reveals unspecific and inconclusive results, like idiopathic left ventricular hypertrophy (LVH), nonsignificant coronary atherosclerosis (CA), and primary myocardial fibrosis (PMF). Their pathogenicity and their relation to SD cause is unknown. This study aims to evaluate the diagnostic yield of genetic testing in these cases. Methods: SD cases, between 1 and 50 years old, with findings of uncertain significance (idiopathic LVH, nonsignificant CA and PMF) on autopsy were evaluated prospectively, including information about medical and family history and circumstances of death. Genetic testing was performed. Results: In a series of 195 SD cases, we selected 31 cases presenting idiopathic LVH (n = 16, 51.61%), nonsignificant CA (n = 17, 54.84%), and/or PMF (n = 24, 77.42%) in the autopsy. Mean age was 41 ± 7.2 years. Diagnostic yield of genetic test was 67.74%, considering variants of unknown significance (VUS), pathogenic variants (PV) and likely pathogenic variants (LPV); 6.45% including only PV and LPV. Structural genes represented 41,93% (n = 13) of cases, while 38,7% (n = 12) were related to channelopathies. Conclusion: Molecular autopsy in SD cases between 1 and 50 years old, with findings of uncertain significance, has a low diagnostic yield, being VUS the most frequent variant observed.
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Primorac D, Odak L, Perić V, Ćatić J, Šikić J, Radeljić V, Manola Š, Nussbaum R, Vatta M, Aradhya S, Sofrenović T, Matišić V, Molnar V, Skelin A, Mirat J, Brachmann J. Sudden Cardiac Death-A New Insight Into Potentially Fatal Genetic Markers. Front Med (Lausanne) 2021; 8:647412. [PMID: 33829027 PMCID: PMC8019733 DOI: 10.3389/fmed.2021.647412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/01/2021] [Indexed: 01/13/2023] Open
Abstract
Sudden cardiac death (SCD) is an unexpected and dramatic event. It draws special attention especially in young, seemingly healthy athletes. Our scientific paper is based on the death of a young, 23-year-old professional footballer, who died on the football field after a two-year history of cardiac symptoms. In this study we analyzed clinical, ECG and laboratory data, as well as results of genetic testing analysis in family members. To elucidate potential genetic etiology of SCD in this family, our analysis included 294 genes related to various cardiac conditions.
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Affiliation(s)
- Dragan Primorac
- St. Catherine Specialty Hospital, Zagreb, Croatia.,Eberly College of Science, The Pennsylvania State University, University Park, State College, Philadelphia, PA, United States.,The Henry C. Lee College of Criminal Justice and Forensic Sciences, University of New Haven, West Haven, CT, United States.,Medical School, University of Split, Split, Croatia.,Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia.,Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia.,Medical School, University of Rijeka, Rijeka, Croatia.,Medical School REGIOMED, Coburg, Germany.,Medical School, University of Mostar, Mostar, Bosnia and Herzegovina
| | - Ljubica Odak
- St. Catherine Specialty Hospital, Zagreb, Croatia.,Children's Hospital Zagreb, Zagreb, Croatia
| | | | - Jasmina Ćatić
- St. Catherine Specialty Hospital, Zagreb, Croatia.,Department of Cardiology, Clinical Hospital Dubrava, Zagreb, Croatia
| | - Jozica Šikić
- Department of Cardiology, Clinical Hospital Sveti Duh, Zagreb, Croatia
| | - Vjekoslav Radeljić
- Department of Cardiology, Clinical Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | - Šime Manola
- Department of Cardiology, Clinical Hospital Center Sestre Milosrdnice, Zagreb, Croatia
| | | | | | | | | | - Vid Matišić
- St. Catherine Specialty Hospital, Zagreb, Croatia
| | - Vilim Molnar
- St. Catherine Specialty Hospital, Zagreb, Croatia
| | | | - Jure Mirat
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Johannes Brachmann
- Medical School, University of Split, Split, Croatia.,Medical School REGIOMED, Coburg, Germany
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Stiles MK, Wilde AAM, Abrams DJ, Ackerman MJ, Albert CM, Behr ER, Chugh SS, Cornel MC, Gardner K, Ingles J, James CA, Jimmy Juang JM, Kääb S, Kaufman ES, Krahn AD, Lubitz SA, MacLeod H, Morillo CA, Nademanee K, Probst V, Saarel EV, Sacilotto L, Semsarian C, Sheppard MN, Shimizu W, Skinner JR, Tfelt-Hansen J, Wang DW. 2020 APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families. Heart Rhythm 2021; 18:e1-e50. [PMID: 33091602 PMCID: PMC8194370 DOI: 10.1016/j.hrthm.2020.10.010] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/09/2020] [Indexed: 12/13/2022]
Abstract
This international multidisciplinary document intends to provide clinicians with evidence-based practical patient-centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.
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Affiliation(s)
- Martin K Stiles
- Waikato Clinical School, Faculty of Medicine and Health Science, The University of Auckland, Hamilton, New Zealand
| | - Arthur A M Wilde
- Amsterdam University Medical Center, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, Amsterdam, the Netherlands
| | | | | | | | - Elijah R Behr
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sumeet S Chugh
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Martina C Cornel
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Clinical Genetics, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | | | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Stefan Kääb
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | | | - Andrew D Krahn
- The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Heather MacLeod
- Data Coordinating Center for the Sudden Death in the Young Case Registry, Okemos, Michigan, USA
| | | | - Koonlawee Nademanee
- Chulalongkorn University, Faculty of Medicine, and Pacific Rim Electrophysiology Research Institute at Bumrungrad Hospital, Bangkok, Thailand
| | | | - Elizabeth V Saarel
- Cleveland Clinic Lerner College of Cardiology at Case Western Reserve University, Cleveland, Ohio, and St Luke's Medical Center, Boise, Idaho, USA
| | - Luciana Sacilotto
- Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Mary N Sheppard
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George's, University of London, and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - Jonathan R Skinner
- Cardiac Inherited Disease Group, Starship Hospital, Auckland, New Zealand
| | - Jacob Tfelt-Hansen
- Department of Forensic Medicine, Faculty of Medical Sciences, Rigshospitalet, Copenhagen, Denmark
| | - Dao Wu Wang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Second opinion system for sudden cardiac death cases in forensic practice. Int J Legal Med 2020; 134:1255-1263. [PMID: 31915964 DOI: 10.1007/s00414-019-02225-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/04/2019] [Indexed: 01/17/2023]
Abstract
Sudden cardiac death (SCD) represents a considerable percentage of cardiovascular deaths worldwide. The most frequent pathological substrate of SCD is atherosclerotic coronary artery disease (CAD). The other, less common, pathologies which can cause SCD include cardiomyopathies, congenital diseases (including abnormal anatomy), and arrhythmias such as channelopathies, many of which are genetically determined. Autopsies of SCD victims are generally performed by forensic pathologists. In some cases, a third person responsibility could be invoked. While CAD diagnosis at post-mortem examination is not a major challenge for the forensic pathologist, the other rarer diseases may be. In such instances, referral of the hearts to specialized centers with recognized expertise is recommended, and this is particularly important in cases of SCDs of young people. Moreover, in order to avoid the frequent overdiagnosis of a pathological heart, an expert opinion should be sought for even in the presence of a morphologically normal heart. In cases where retention of the heart is not feasible, it is essential to provide an extensive photographic documentation, with the indication of the sampling sites for histological examination. However, some practical aspects, as the criteria for case selection in routine forensic practice are missing. In this paper, we present the recommendations for heart retention for a second expert opinion and the alternative of documentation and sampling for cases where retention is not possible.
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