Sudden natural death

Objectives
Definition of sudden natural death.
the incidence and distribution of SND.
Major causes of sudden natural death.
working approach.
 definition of sudden death
 Sudden death (WHO –ICD10- ): death from
natural diseases occurring within 24 hours of the
onset of symptom .
Sudden death divided into:
1-Unnatural death ( exp : suicidal , accident , criminal ,
violent deaths)
2-Natural unexpected death : sudden death of an
individual who appears healthy due to pre-existing
disease or functional disorder or known with natural
disease hadn't explain death .
terms
Sudden unexplained death syndrome (SUDS): Sudden death
in an otherwise healthy individual with no cause identified following a
complete and detailed autopsy and death investigation; also known as "sudden
adult death syndrome" or "sudden arrhythmogenic death syndrome" (SADS).

Sudden cardiac death (SCD) : the unexpected natural death from a

cardiac cause within a short time period, generally ≤1 hour from the onset of
symptoms, in a person without any prior condition that would appear fatal.

Sudden infant death syndrom (SIDS) : The sudden death of an

infant younger than 1 year that cannot be explained after a thorough
investigation is conducted, including a complete autopsy, examination of the
death scene, and review of the clinical history .
Epidemiology

SND Occur in all age groups with different etiologies

by age .
The incidence of SND in the general population ages
20 to 75 years is 1 in 1000 individuals ( 18.5 % of all
deaths) .
The incidence of SND in 1 to 40 year age group is
approximately 1.3 to 8.5 per 100 000 person-years
( highest in the first 5 years) .
The incidence increases with age in both sexes .
 less in women than in men at all ages
 Etiologies
Diseases of cardiovascular system ( account the major
cause of SND in adult )
Diseases of respiratory system (most commonly seen
to lead SND in neonate and children)
Diseases of central nervous system
Diseases of gastrointestinal system
Disease of genitourinary system
Sudden death from cardiac
diseases
  Heart diseases

 Valvular heart diseases

 Arteries diseases
: Disease of the heart
Coronary artery disease
1-Coronary atherosclerosis:
-The most common cause of sudden death .
Mostly affects :-
* Left Anterior Descending Artery (LADA)
Right Coronary Artery (RCA)*
left circumflex artery (LCX)*
- complications :
1-Most common scenario : rupture of ulcer
atheromatous plaque  then exposure of
sub-endothelial collagen  then activation of
coagulation cascade  then Thrombosis
formation
2-sub-intimal hemorrhage .
eccentric atherosclerosis concentric atherosclerosis

hemorrhage of atherosclerosis
: Myocardial Infarction -2
Myocardial infarction occurs when there is severe -
stenosis 80% or more of the lumen of a major
branch - OR complete occlusion of a coronary
artery . but death can be attributed to coronary
artery disease (CAD) with less stenosis if other
signs of chronic myocardial ischemia are
apparent (left ventricular hypertrophy [LVH],
.fibrosis, previous infarct)
 Deadly Complications of MI :
1- ventricular arrythmia : Occurs within the first few days
after MI. Important cause of death before reaching the
hospital and within the first 24 hours post-MI.
2- Cardiogenic shock (if massive infarction) (occurs from 0
to 4 hours post MI) =  inadequate blood flow to organs due
to the dysfunction of the ventricles of the heart
3-Rupture of myocardial infarct :
The area of the myocardial infarct is weakest between 3 to
14 days and after the clinical onset of the infarct and it
is at this time that the weakened area of myocardium
may rupture, leading to sudden death from : cardiac
tamponade
hrs post MI 12-24
weeks post MI 2
4- Cardiac aneurysm :
- 3 to 14 days post MI .
- may form at sites of infarction; they may calcify and they
may rupture. So cardiac tamponade
risk of arrhythmia OR embolus from mural thrombus - 
3-Papillary muscle rupture :
 3 -14 days post MI .

- allow part of the mitral valve to prolapse , or

may present as a sudden onset of severe mitral
regurgitation.
Hypertensive heart disease:
 This condition may lead to sudden cardiac death
from left ventricular hypertrophy(500-700
grams).
 Associated with atherosclerosis.
Aortic stenosis:
- classically affects older individuals with calcified
tricuspid aortic valves
- may also be seen in younger people
who have a congenital bicuspid aortic valve.
- leading to left ventricular hypertrophy . {600-800
grams}
: Myocarditis
 Myocarditis (due to many infective diseases
mostly by viruses )
 sudden death may occur some days or even
weeks after the main clinical symptoms .
 Causes of death : arrhythmias, heart block,

mural thrombus with systemic emboli.

histopathology show inflammatory and (
.)infiltrative degenerative or necrotic myocytes
 Cardiomyopathies:
 DCM (dilated cardiomyopathy) : Most common cardiomyopathy

(90% of cases). Often idiopathic or familial. Other etiologies

include chronic Alcohol abuse, Coxsackie B viral myocarditis, chronic
Cocaine use, Doxorubicin toxicity {chemotherapy}, hemochromatosis,
sarcoidosis, thyrotoxicosis, peripartum cardiomyopathy.
characterized by dilatation of the chambers with thinning of the
ventricular walls.
Most common cause of death is sudden ventricular arrythmia
 RCM (restrictive cardiomyopathy ):

evident fibrotic thickening of the endomyocardium which lead to

decrease the myocardial compliance.
Cardiomyopathies:
 HCM (hypertrophic cardiomyopathy):
 60 - 70% of cases are familial {autosomal dominant}
and 30% sporadic mutation (most commonly due to
mutations in genes encoding sarcomere proteins,
most commonly characterized by asymmetrical
hypertrophy, {i.e. Septal hypertrophy  outflow
obstruction }
 Histologic findings : Myofibrillar disarray and fibrosis.
 leading cause of sudden cardiac death in young
athletes during exercise due to ventricular
arrhythmia.
asymmetric massive thickening of
ventricular walls {septal predominance}

fibrosis and myocardial disarray in

.hypertrophic cardiomyopathy
Ion channelopathies

Pathologically, there are no ‘naked eye’ or

microscopic abnormalities in the heart as the
defects are at a molecular level.
 Long QT syndrome (LQTS).

 Brugada syndrome ( It is the major  cause of

sudden unexplained death syndrome (SUDS)

in young men)
 Other less common causes :
 Embolism
 Vasculitis
 Coronary artery vasospasm ( negative autopsy with
normal patent vessels in postpartum examination)
Valvular heart diseases
 Bacterial endocarditis = Inflammation of endocardium that lines the
surface of cardiac valves; usually due to bacterial infection
 A) Streptococcus viridans is the most common overall cause. It is
a low-virulence organism that infects previously damaged valves
(e.g., chronic rheumatic heart disease and mitral valve prolapse).
Results in small vegetations that do not destroy the valve (subacute
endocarditis)

destruction of the mitral valve, with

extensive vegetations (arrows) from
infectious endocarditis
 B) Staphylococcus aureus is the most common cause in IV drug
abusers : High-virulence organism that infects normal valves,
most commonly the tricuspid  Results in large vegetations that
destroy the valve (acute endocarditis)
 In both : Damaged endocardial surface develops thrombotic
vegetations (platelets and fibrin).

 Most common cause of death due to embolization of septic

vegetations to brain
Calcific aortic stenosis:valve is Myxomatous degeneration of the
thickened , rigid with fusion of mitral valve, ballooning of thick,
commissure redundant valve leaflets
Diseases of the arteries
 Aortic Dissection
 Intimal tear with dissection of blood through media of the aortic wall.
 Occurs in the proximal 10 cm of the aorta (high stress region) with
preexisting weakness of the media .
 Most common cause is hypertension (older adults); also associated
with inherited defects of connective tissue (younger individuals)
 1. Hypertension results in hyaline arteriosclerosis of the vasa
vasorum; decreased flow causes atrophy of the media.
 2. Marfan syndrome and Ehlers-Danlos syndrome classically lead to
weakness of the connective tissue in the media (cystic medial
necrosis).
 Deadly complications : 1) cardiac tamponade (most common cause
of death), 2) rupture with fatal hemorrhage, and 3) obstruction of
branching arteries (e.g, coronary arteries  MI)
 Asthmatic patients : may die
suddenly and unexpectedly, without
necessarily being in status
asthmaticus or even in an acute
asthmatic attack.
May be due to Hypoxia and
respiratory acidosis. autopsy little or
nothing is found, except confirmation

Respiratory of the chronic asthmatic state.

causes Pulmonary embolism (most common

cause of death in pregnancy) :
In almost every case, the source of the
emboli is in the leg veins and pelvic veins.
After any tissue trauma, or even surgical
operation, especially where immobility or
bed rest occurs, deep vein thrombosis
massive develops.
hemoptysis from
cavitating
pulmonary
Pneumonia tuberculosis or
from a
malignant
tumor
Sudden infant death syndrome(SIDS)
Crib death, syndrome in which healthy infants(1 month to a
year) die from unknown causes (usually during sleep).

Most deaths due to SIDS occur between 2 and 4 months of age,

and incidence increases during cold weather.

More boys than girls fall victim to SIDS..

:SIDS risk factors
Smoking, drinking, or drug use during pregnancy.
Poor prenatal care.
Poor prenatal nutrition.
Prematurity or low birth-weight.
No breast feeding.
Mothers younger than 20.
Smoke exposure following birth.
Overheating from excessive sleepwear and bedding.
Stomach sleeping.