Sudden death related to sexual activity: A multicenter study based on forensic autopsies (2010-2021)

INTRODUCTION AND OBJECTIVES

To investigate the epidemiological characteristics, clinic-pathological findings and recent use of substances of abuse and prescribed drugs in sexual activity-related sudden death (SArSD).

METHODS

Multicenter population-based study on forensic autopsies conducted in 27 provinces of Spain over 12 years (2010-2021).

RESULTS

Out of 18046 autopsied natural deaths, 64 cases (0.35 %) of SArSD were investigated (87 % males). Women were younger than males (50.5 ± 13.4 years vs 37.2 ± 14.2; p = 0.017). Sudden cardiac deaths (SCD) accounted for 87 % of cases. Ischemic heart disease was the predominant pathology (58 %), mainly affecting men ≥ 36 years of age. Cerebral haemorrhage (8 %) and asthma (5 %) were the leading non-cardiac causes. In young adults, SADS (36 %) and asthma (27 %) were the main causes The disease responsible of SCD was diagnosed in life in 7 subjects. In 64 % there were cardiovascular risk factors, mainly obesity. Toxicological analysis detected illicit drugs (23 %), mainly cocaine, medications for erectile dysfunction (9 %), and ethanol ≥ 0.5 g/L (8 %). Deaths occurred usually in the context of heterosexual intercourse and during or immediately after sexual activity. The most common location was at home (63 %). In 12 men the sexual partner was a sex worker.

CONCLUSIONS

SArSD has a low incidence in the general population affecting middle-aged males during intercourse with a heterosexual partner. It is of cardiovascular origin, mainly due to ischemic heart disease that frequently remained silent during life. There is a frequent association with obesity, use of cocaine (and, to a lesser extent, medications for erectile dysfunction) and performing unconventional sexual practices. Forensic investigation is useful for developing prevention strategies.

A positive toxicology screen is a rare finding in sports-related sudden cardiac deaths

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): University of Copenhagen

Introduction

Sports-related sudden cardiac deaths (SrSCD) are rare events often occurring in healthy individuals. An underlying cardiac disease may, in combination with strenuous exercise, trigger lethal arrhythmias. Intake of drugs (legal and illicit) increases the risk of sudden cardiac death (SCD), but knowledge on toxicological findings in SrSCD remains sparse.

Purpose

This study aimed to characterize the SrSCD population in an international consortium by investigating the epidemiology and autopsy findings in SrSCD.

Methods

Participating centers of the consortium (Denmark, Australia, England, Spain) provided data on all forensically autopsied SCDs aged 12—49 years in their respective cohorts, spanning from 2000—2019. Demographics, autopsy findings, and toxicology screen were assessed. A toxicology screen was considered positive if any drug was detected, except drugs related to resuscitation.

Results

Of all 5,029 SCDs, we identified 435 (9%) SrSCD. The majority (88%) died during sports while the remaining 12% died within one hour from exercise. SrSCD occurred more often in males (91% vs 71%, p<0.001) who were younger (32 vs 36 years). In SrSCD, the autopsy more frequently revealed an underlying structural cardiac cause of death (64% vs 54%, p<0.001); the most frequent causes of death among SrSCDs were sudden unexpected death (SUD), ischemic heart disease (IHD), and arrhythmogenic cardiomyopathy (ACM). Toxicological screens were performed in approx. 90% of cases, regardless of relation to sport. Among SrSCD cases, the rate of a positive toxicology was less than half compared to other SCDs (18% vs 44%, p<0.001). The most frequent toxicological findings among SrSCDs were ethanol, central stimulants, cannabinoids, and non-opioid analgesics.

Conclusions

Sports-related SCD accounted for 9% of all SCDs in our population aged 12—49 years. The majority of sports-related deaths (88%) occurred during exercise activity. SrSCDs more often had an underlying structural cardiac disease, mainly IHD and ACM. Positive toxicology screens were half as frequent in SrSCDs compared with non-SrSCDs.

[Sudden unexpected death in epilepsy in children and adolescents]

INTRODUCTION

Sudden unexpected death in epilepsy (SUDEP) is an important cause of death in young epileptic patients. However, it is relatively unknown to neurologists.

OBJECTIVE

To analyze the frequency and clinicopathological characteristics of SUDEP as a cause of sudden death (SD) in young persons.

PATIENTS AND METHODS

An observational study of all SD due to SUDEP in persons aged 1 35 years occurring between 1991 and 1998 in Bizkaia, in whom medico legal autopsy was done. In all cases a full autopsy was done and the previous clinical history was investigated.

RESULTS

Eight of the 107 cases of SD (7.5%) were due to SUDEP. Five were aged between 25 and 29 years and in this age group it was the commonest cause of death (22%). Six had been diagnosed as having idiopathic epilepsy and two as having posttraumatic epilepsy. Generalized convulsions occurred in 75%. Four patients died when they were alone. Two patients had epileptic seizures hours before their death. At necropsy no structural changes were seen in the brain except in the two patients with posttraumatic epilepsy. Pulmonary oedema was a frequent finding. In 50% of the dead patients, chemico toxicological study showed there to be no trace of the drugs they had been prescribed.

CONCLUSIONS

Although SD is rare, SUDEP is an important cause of mortality in young epileptics. Violent death in relation to epilepsy causes problems in forensic medicine. Although the mechanisms of SUDEP are not clear, it would seem necessary to increase medical control of this disorder, especially in young people.

[Sudden death caused by atheromatous coronary disease in the young]

INTRODUCTION AND OBJECTIVES

Atheromatous coronary disease (ACD) is the most frequent cause of sudden death (SD) in adults. Few studies have focused in SD due to ACD in those patients under 35 years old. The aim of this study is to analyze the incidence, and clinical and pathological characteristics of ACD as a cause of death in young people.

MATERIAL AND METHODS

We reviewed all SD cases in people from 1-35 years old which occurred in Bizkaia and in which there was a legal-medical autopsy from 1991 to 1998. A complete autopsy was performed in each case. SD due to ACD were analyzed, including pathological antecedents.

RESULTS

19 out of 107 SD (18%) occurred by ACD. All of them were males from 27 to 35 years of age. According to the male population from 30 to 35 years, the incidence was 3.7/100,000/year. In two patients ACD was diagnosed before death. Coronary risk factors were obtained in 10 cases and prodromal symptoms were described in 5 (chest pain in 4). In 79% death occurred during routine activity. None of the 19 patients arrived alive to hospital. In 6 cases multiple coronary disease was observed; coronary thrombosis in 8; recent acute ischemic myocardial necrosis in 4 and old ischemic damage in 7. 18 cases showed cardiac hypertrophy.

CONCLUSIONS

ACD is an important cause of SD in young males, frequently being the first manifestation of the disease. As identification of groups at risk is so difficult and death occurs so quickly, primary prevention of ACD, rapid intervention of emergency services and educational programs in cardiopulmonar resuscitation for normal population are fundamental in reducing the mortality.

Sudden unexpected non-violent death between 1 and 19 years in north Spain

AIMS

To study the epidemiological, clinical, and pathological characteristics of sudden unexpected non-violent deaths between 1 and 19 years.

METHODS

Population based observational study of all sudden unexpected non-violent deaths between 1 and 19 years, from 1990 to 1997, in a north Spain county (Bizkaia). In each case, clinical information and circumstances of death were obtained and a complete forensic autopsy was performed.

RESULTS

There were 34 sudden unexpected non-violent deaths. The mortality rate was 1.7 per 100 000 persons per year (representing 9% of the mortality rate of all non-violent deaths). In 10 cases the cause of death was cardiac, in 13 cases extracardiac, and 11 cases were unexplained. In 17 cases there were no pathological antecedents and in nine cases death occurred in patients with known disorders. Syncopes prior to death were present in five cases. Exercise related deaths occurred in seven cases (mainly associated with cardiac causes). Eight cases were "death in bed".

[Sudden death due to an anomalous origin of the left anterior descending coronary artery from the pulmonary trunk in a 9-year-old boy]

A 9-year-old healthy boy is presented, who complained of dizziness and to being exhausted after climbing numerous stairs, collapsing immediately after. Advanced resuscitation efforts were unsuccessful. At autopsy an isolated congenital anomaly in the origin of the left anterior descending coronary artery from the pulmonary trunk was found, with the origin of the right and left circumflex coronary arteries from the aorta, accompanied by with cardiac hypertrophy and chronic ischemic changes in the myocardium irrigated by the anterior descending artery. This represents a very infrequent variant that allows a longer survival and less functional repercussion if compared with those cases in which the main left coronary is originated from the pulmonary trunk.

Supravalvular aortic stenosis, Williams syndrome and sudden death. A case report

Supravalvular aortic stenosis (SVAS) is an uncommon but well characterized congenital narrowing of the ascending aorta above the level of the coronary arteries. It can be a familial disorder, can occur sporadically, or associated with Williams syndrome (WS) which is a neurodevelopmental disorder affecting connective tissue and the central nervous system. Sudden death is a well-known complication of non-syndromic SVAS but few cases have been reported associated with WS. We present a case of sudden death in a woman with the diagnosis of SVAS and WS since the age of 3 years who refused surgical correction and died at the age of 27 years. At autopsy, the aorta and pulmonary trunk were narrowed and the walls showed peculiar microscopical characteristics. In the cardiac conduction system the His bundle was small and intramyocardial. The incidence, pathology, pathogenesis and prognosis of both conditions (SVAS and WS) are reviewed.

[Arrhythmogenic cardiomyopathy as cause of sudden death in Spain. Report of 21 cases]

INTRODUCTION AND OBJECTIVES

Arrhythmogenic cardiomyopathy is a myocardial disease of unknown origin characterized by progressive replacement of right and/or left ventricular myocardium by fibrofatty tissue. Young adult people are more frequently affected and symptoms include palpitations, syncopes or sudden death. The objective of this study is to assess the frequency and characteristics of arrhythmogenic cardiomyopathy as a cause of sudden death in a series of cases in Spain.

MATERIAL AND METHODS

Among the sudden death cases studied at the Toxicology Institute of Madrid between 1991 and 1997, those with arrhythmogenic cardiomyopathy diagnosis were analysed.

RESULTS

21 cases were diagnosed (0.62% of all sudden deaths and 6.8% of sudden deaths under 35 years). There were 20 males and one female (mean age 24.5 +/- 9.37 years); eleven (52.3%) died during sport activity and 8 (38%) had previous exercise related symptoms. In only two cases other members of the family had died suddenly and only one had been diagnosed in life. Biventricular involvement was observed in 13 cases; isolated involvement of the left ventricle in 4, and isolated involvement of the right ventricle in 4.

CONCLUSIONS

Arrhythmogenic cardiomyopathy is a relatively frequent cause of sudden death in the young population in Spain. It is very often the first manifestation of the disease. The myocardial involvement is more frequently biventricular than isolated in the right ventricle. The diagnosis could be difficult for cardiologists, pathologists and forensic doctors.

Differences in criminal activity between heroin abusers and subjects without psychiatric disorders--analysis of 578 detainees in Bilbao, Spain

The association between drug abuse and criminal activity has been deeply established, but the nature of this relationship is controversial. The incidence and types of criminal activity were analyzed in 837 arrests of 578 subjects who were also interviewed for psychiatric diagnosis and evaluation of criminal responsibility. There was a significant prevalence of heroin abuse/dependence (50.5%) in the sample. Another 124 subjects (21.5%) in whom no psychiatric disorder could be observed were considered as the control group. Heroin abusers were younger (26 years, SD 5.9) than controls (29 years, SD 11.2) and showed some different ethnic characteristics. Heroin abuse/dependence was the most important risk factor (O.R. = 10.15) for criminal recidivism. Females were more related to nonviolent criminal activity than males. There was a higher incidence of offenses against property among heroin abusers (burglary 57.8%; robbery 19.5%) than in the control group (burglary 15.3% robbery 4.8%). In contrast, aggression or resistance to police authorities and nonfatal offenses against persons were more frequent among controls (12% and 13.7%, respectively) than among heroin abusers (3.7% and 3%, respectively). The results of this study confirm the hypothesis of a relationship between criminal activity and heroin abuse/dependence, probably based on financial needs. However, the association seems not to be a single and direct cause-effect relationship, as other factors show influence on the criminal activity.