Death In Young Individuals Research Articles

Cardiovascular causes of sudden death in young individuals including athletes.

From 1978 to 1993 in the Veneto region, we collected 200 cases of sudden death in the young (</=35 years). Sudden death was cerebral in 15 cases (7.5%), respiratory in 10 (5%), and cardiovascular in 163 (81.5%), whereas it remained unexplained in 12 cases (6%). Among cardiovascular sudden death, obstructive coronary atherosclerosis accounted for 23% of cases, arrhythmogenic right ventricular cardiomyopathy for 12.5%, mitral valve prolapse for 10%, conduction system abnormalities for 10%, congenital coronary artery anomalies for 8.5%, myocarditis for 7.5%, hypertrophic cardiomyopathy for 5.5%, aortic rupture for 5.5%, dilated cardiomyopathy for 5%, nonatherosclerotic-acquired coronary artery disease for 3.5%, postoperative congenital heart disease for 3%, aortic stenosis for 2%, pulmonary embolism for 2%, and other causes for 2%. Cardiac arrest remained unexplained in 6% of the cases. Specific pathology and pathogenetic mechanisms of each disease were investigated and correlated with clinical signs and symptoms in detail. A large spectrum of cardiovascular disorders, both congenital and acquired, may represent the organic substrate of sudden death in the young. The underlying abnormality is frequently concealed and discovered only at postmortem examination. Most of the diseases, although asymptomatic, are potentially detectable during life with proper imaging tests.

The Young Competitive Athlete with Heart Disease

Over the past several years, there has been heightened awareness that highly trained young individuals participating in competitive sporting activities can harbor underlying structural cardiovascular disease. A broad spectrum of disease has been incriminated encompassing virtually all lesions known to cause sudden death in young individuals. The most common single cardiovascular abnormality among these is hypertrophic cardiomyopathy, usually in the nonobstructive form, which is responsible for about 35% of athletic field deaths. Second in importance and frequency to hypertrophic cardiomyopathy is a spectrum of congenital vascular malformations of the coronary arterial tree (responsible for about 20% of the deaths), the most common of which appears to be anomalous origin of the left main coronary artery from the right sinus of Valsalva. Other lesions occur with lesser (and relatively low) frequency, including Marian's syndrome, myocarditis, dilated cardiomyopathy, aortic valve stenosis, mitral valve prolapse, sarcoidosis, and arrhythmogenic right ventricular dysplasia. In about 2% of cases, the standard medical examiner autopsy examination fails to show a cardiovascular lesion that could account for sudden death. Preparticipation cardiovascular screening of high school-and college-aged athletes traditionally has been performed in the context of a standard personal and family-history and physical examination. Such standard evaluations very frequently fail to identify cardiovascular abnormalities in those competitive athletes who ultimately die of underlying diseases. An American Heart. Association expert panel recently has recommended that a more focused and standardized history and physical preparticipation screening process, and more systematic implementation is most likely to enhance identification of many potentially lethal abnormalities. The consensus guidelines of the 26th Bethesda Conference provide unbiased recommendations for clinical decision-making regarding disqualification from competitive sports for the purpose of reducing risk, which can be useful when cardiovascular abnormalities are identified in competitive athletes.

Arrhythmogenic right ventricular cardiomyopathy. Dysplasia, dystrophy, or myocarditis?

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a frequent cause of sudden death in young individuals and athletes. Although familial occurrence has been documented and a gene defect was recently localized on chromosome 14q23-q24 the etiopathogenesis of the disease is still obscure. A pathological study was conducted in 30 hearts with ARVC (age range, 15 to 65 years; mean, 28 years). In the 27 autopsy cases, the mode of death was sudden in 24 and congestive heart failure in 3. ECG, available in 19 cases, showed inverted T waves in the right precordial leads in 15 cases (79%) and ventricular arrhythmias in 15 (79%). Right ventricular aneurysms were present in 15 hearts (50%) and located in the inferior wall in 12. Left ventricle and ventricular septum were involved in 14 (47%) and 6 (20%) cases, respectively. Scattered foci of lymphocytes with myocardial death were observed in 20 cases (67%). Electron microscopy studies, although confirming the myocardial death and lymphocyte infiltrates, did not show any specific ultrastructural substrate. Two pathological patterns, fatty (40%) and fibrofatty (60%), were identified. The fibrofatty pattern was associated with a thinner right ventricular wall (P < .0001) and a higher occurrence of focal myocarditis (P < .001). In sections of right ventricular free wall with maximal fatty infiltration, the mean percentage area of fatty tissue was 35.9 +/- 11.1% in control versus 80.4 +/- 9.6% in the ARVC, fatty variety (P < .00001). Involvement of the left ventricle and/or ventricular septum, right ventricular aneurysms, and inflammation were found almost exclusively in the fibrofatty variety. In the fibrofatty variety of ARVC, the myocardial atrophy appears to be the consequence of acquired injury (myocyte death) and repair (fibrofatty replacement), mediated by patchy myocarditis. Whether the inflammation is a primary event or a reaction to spontaneous cell death remains unclear.

Sports-related and non-sports-related sudden cardiac death in young adults

Sports-related sudden cardiac deaths were compared with non-sports-related sudden cardiac death in individuals (14 to 40 years old) who were autopsied from 1981 to 1988 at the Maryland Medical Examiner's Office. Thirty-four of 690 total cases of sudden cardiac death were sports-related, which represents 5% of sudden cardiac death in this age group. Causes of death were severe atherosclerosis (nine), hypertrophic cardiomyopathy with asymmetry (eight), coronary artery anomalies (four), idiopathic concentric left ventricular hypertrophy (three), myocarditis (two), arrhythmogenic right ventricle (one), Kawasaki disease (one), and unknown (six); two of the cases with unknown causes had tunnel arteries. Exercise-related deaths were more likely due to hypertrophic cardiomyopathy (p = 0.0007) compared with 102 age-, sex-, and race-matched controls in the nonexercise group; there was no difference in the incidence of severe atherosclerosis (p = 0.4). The mean age of individuals with hypertrophic cardiomyopathy with asymmetry was less than that of those with severe atherosclerosis (24 vs 32 years, p = 0.03). Thus exercise precipitates sudden cardiac death in younger individuals with hypertrophic cardiomyopathy.

Cardiac Sarcoidosis: A Major Cause of Sudden Death in Young Individuals

Cardiac Sarcoidosis: A Major Cause of Sudden Death in Young Individuals