Soo Shih Sheng, Siti Balkis Budin, Ismarulyusda Ishak, Faridah Mohd Nor, Nur Najmi Mohamad Anuar


Sudden death is an unexpected natural death within the one-hour onset of a symptom or unwitnessed death that occurs within 24 hours. This definition is most often used to describe death caused by cardiac failure as it is one of the well-known causes of natural death. Various aetiologies are leading to sudden death, and myocardial infarction is reported to be one of the leading causes either due to coronary atherosclerosis and/ or thrombosis. An autopsy is a procedure routinely performed by the pathologist to determine the cause and manner of death which provides valuable information such as, demographic factors comprises gender, age, ethnic and lifestyle that were strongly linked to sudden deaths. This article review will discuss on autopsy in sudden death, as well as the aetiology of sudden death associated with cardiac abnormalities. Further, the contribution of demographic factors to sudden death will also be discussed and highlighted.


Autopsy, atherosclerosis, myocardial infarction, sudden death, cardiac abnormalities

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Luepker, R. V. 2005. Epidemiology of Sudden Death. Cardiopulmonary Resuscitation. 11-20.

Kuller, L., Cooper, M., and Perper, J. 1972. Epidemiology of Sudden Death. Arch Intern Med. 129: 714-719. DOI: 10.1001/archinte.1972.00320050038003.

Virmani, R., Burke, A. P., and Farb, A. 2001. Sudden Cardiac Death. Cardiovascular Pathology. 10: 275-282. DOI: 10.1016/S1054-8807(01)00091-6.

Rao, D. S. 2008. Sudden and Unexpected Natural Deaths-a Four-year Autopsy Review. J Punjab Acad Forensic Med Toxicol. 8: 20-4.

Tunstall-Pedoe, H., Kuulasmaa, K., Amouyel, P., Arveiler, D., Rajakangas, A., Pajak, A., and Project, W. M. 1994. Myocardial Infarction and Coronary Deaths in the World Health Oganization MONICA Project. Registration Procedures, Event Rates and Case-Fatality Rates in 38 Populations from 21 Countries in Four Continents. Circulation.

Torp-Pedersen, C., Kober, L., Elming, H., and Burchart, H. 1997. Classification of Sudden and Arrhythmic Death. Pacing and Clinical Electrophysiology. 20: 2545-2552.

Nisha, M., Bhawna, S., Sumiti, G., Amrita, D., Sunita, S., and Rajeev, S. 2011. Histomorphological Spectrum of Various Cardiac Changes in Sudden Death: An Autopsy Study.

Adelson, L. and Hoffman, W. 1961. Sudden Death from Coronary Disease: Related to a Lethal Mechanism Arising Independently of Vascular Occlusion or Myocardial Damage. Jama. 176: 129-135 DOI: 10.1001/jama.1961.03040150045011.

Rao, D., Sood, D., Pathak, P., and Dongre, S. D. 2014. A Cause of Sudden Cardiac Deaths on Autopsy Findings. A Four-Year Report. Emergency. 2: 12.

de Luna, A. B., Coumel, P., and Leclercq, J. F. 1989. Ambulatory Sudden Cardiac Death: Mechanisms of Production of Fatal Arrhythmia on the Basis of Data from 157 Cases. American Heart Journal. 117: 151-159 DOI: 10.1016/0002-8703(89)90670-4.

1Harmon, K. G., Asif, I. M., Maleszewski, J. J., Owens, D. S., Prutkin, J. M., Salerno, J. C., Zigman, M. L., Ellenbogen, R., Rao, A., and Ackerman, M. J. 2015. Incidence, Etiology, and Comparative Frequency of Sudden Cardiac Death in NCAA Athletes: A Decade in Review. Circulation. CIRCULATIONAHA. 115.015431.

Basso, C., Burke, M., Fornes, P., Gallagher, P. J., de Gouveia, R. H., Sheppard, M., Thiene, G., and van der Wal, A. 2008. Guidelines for Autopsy Investigation of Sudden Cardiac Death. Virchows Archiv. 452: 11-18. DOI: 10.1007/s00428-017-2221-0.

Basso, C., Calabrese, F., Corrado, D., and Thiene, G. 2001. Postmortem Diagnosis in Sudden Cardiac Death Victims: Macroscopic, Microscopic and Molecular Findings. Cardiovascular Research. 50: 290-300. DOI: 10.1016/S0008-6363(01)00261-9.

Brinkmann, B. 1999. Harmonisation of Medico-legal Autopsy Rules. International Journal of Legal Medicine. 113: 1-14 DOI: 10.1007/s004140050271.

Davies, M. 1999. The Investigation of Sudden Cardiac Death. Histopathology. 34: 93-98 DOI: 10.1046/j.1365-2559.1999.00648.x.

Schoen, F. 2001. Pathology of Heart Valve Substitution with Mechanical and Tissue Prostheses. Cardiovascular Pathology. 3.

Kotabagi, R., Charati, S., and Jayachandar, D. 2005. Clinical Autopsy vs Medicolegal Autopsy. Medical Journal Armed Forces India. 61: 258-263 DOI: 10.1016/S0377-1237(05)80169-8.

Saukko, P. and Knight, B. 2015. Knight's Forensic Pathology Fourth Edition. CRC Press.

Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., de Ferranti, S., Després, J.-P., Fullerton, H. J., Howard, V. J. 2015. Executive Summary: Heart Disease and Stroke Statistics—2015 Update. A Report From the American Heart Association. 131: 434-441 DOI: 10.1161/cir.0000000000000157.

Mehra, R. 2007. Global Public Health Problem Of Sudden Cardiac Death. Journal of Electrocardiology. 40: S118-S122 DOI: 10.1016/j.jelectrocard.2007.06.023.

Hurt, R. D., Weston, S. A., Ebbert, J. O., McNallan, S. M., Croghan, I. T., Schroeder, D. R., and Roger, V. L. 2012. Myocardial Infarction and Sudden Cardiac Death in Olmsted County, Minnesota, Before and After Smoke-free Workplace Laws. Archives of Internal Medicine. 172: 1635-1641 DOI: 10.1001/2013.jamainternmed.46.

Dreyer, R. P., Ranasinghe, I., Wang, Y., Dharmarajan, K., Murugiah, K., Nuti, S. V., Hsieh, A. F., Spertus, J. A., and Krumholz, H. M. 2015. Sex Differences in the Rate, Timing and Principal Diagnoses of 30-Day Readmissions in Younger Patients with Acute Myocardial Infarction. Circulation. DOI: 10.1161/circulationaha.114.014776.

Statistics, N.C.f.H. 2011. Health, United States: With special Feature on Socioeconomic Status and Health. 2012.

Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Blaha, M. J., Dai, S., Ford, E. S., Fox, C. S., Franco, S. 2014. Executive Summary: Heart Disease and Stroke Statistics—2014 Update. A Report from the American Heart Association. 129: 399-410 DOI: 10.1161/01.cir.0000442015.53336.12.

Stecker, E. C., Reinier, K., Marijon, E., Narayanan, K., Teodorescu, C., Uy-Evanado, A., Gunson, K., Jui, J., and Chugh, S. S. 2014. Public Health Burden of Sudden Cardiac Death in the United States. Circulation: Arrhythmia and Electrophysiology. DOI: 10.1161/circep.113.001034.

Shanthi, B., Saravanan, S., Elangovan, R. S., and Sudha, V. 2016. Sudden Death Causes: An Autopsy Study in Adults. International Journal of Scientific Study. 4: 176-179. DOI: 10.17354/ijss/2016/401.

Reddy, K. S. 2006. Cardiovascular Diseases in the Developing Countries: Dimensions, Determinants, Dynamics and Directions for Public Health Action. Public Health Nutrition. 5: 231-237 DOI: 10.1079/PHN2001298.

Tezcan, S., Altıntaş, H., Sönmez, R., Akinci, A., Doğan, B., Çakır, B., Bilgin, Y., Klör, H., and Razum, O. 2003. Cardiovascular Risk Factor Levels in a Lower Middle‐class Community in Ankara, Turkey. Tropical Medicine & International Health. 8: 660-667 DOI: 10.1046/j.1365-3156.2003.01057.x.

Siraj Ahmed, S. and Begum, A. 2013. Atherosclerosis of Coronary Arteries-An Autopsy Study. Global Journal of Medical Research.

Falk, E. 2006. Pathogenesis of Atherosclerosis. Journal of the American College of Cardiology. 47: C7-C12.

Luqman, M., Sattar, A., Abbasi, S., and Satti, T. 1995. Pattern of Sudden Deaths in Armed Forces Personnel-Postmortem Study. Pak Armed Forces Med J. 45: 66-71.

Witztum, J. 2001. Atherosclerosis. The Road Ahead. Cell. 104: 503-16 DOI: 10.1016/S0092-8674(01)00238-0.

Lewis, G. F. and Rader, D. J. 2005. New Insights into the Regulation of HDL Metabolism and Reverse Cholesterol Transport. Circulation Research. 96: 1221-1232 DOI: 10.1136/hrt.2003.026476.

Srikanth, S. and A Ambrose, J. 2012. Pathophysiology of Coronary Thrombus Formation and Adverse Consequences of Thrombus during PCI. Current Cardiology Reviews. 8: 168-176 DOI: 10.2174/157340312803217247.

Steg, P. G., Bhatt, D. L., Wilson, P. W., D’Agostino, R., Ohman, E. M., Röther, J., Liau, C.-S., Hirsch, A. T., Mas, J.-L., and Ikeda, Y. 2007. One-year Cardiovascular Event Rates in Outpatients with Atherothrombosis. Jama. 297: 1197-1206 DOI: 10.1001/jama.297.11.1197.

Maseri, A., Chierchia, S., and Davies, G. 1986. Pathophysiology of Coronary Occlusion in Acute Infarction. Circulation. 73: 233-239.

Schwartz, S. M., Galis, Z. S., Rosenfeld, M. E., and Falk, E. 2007. Plaque Rupture in Humans and Mice. Arteriosclerosis, Thrombosis, and Vascular Biology. 27: 705-713 DOI: 10.1161/01.ATV.0000261709.34878.20.

Wong, C. P., Loh, S. Y., Loh, K. K., Ong, P. J. L., Foo, D., and Ho, H. H. 2012. Acute Myocardial Infarction: Clinical Features and Outcomes in Young Adults in Singapore. World Journal Of Cardiology. 4: 206 DOI: 10.4330/wjc.v4.i6.206.

D’Agostino, R.B., Vasan, R.S., Pencina, M.J., Wolf, P.A., Cobain, M., Massaro, J.M., and Kannel, W.B. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation, 2008. 117, 743-753 DOI: 10.1161/CIRCULATIONAHA.107.699579.

Zipes, D. P. and Wellens, H. J. 1998. Sudden Cardiac Death. Circulation. 98: 2334-2351.

Safford, M. M., Brown, T. M., Muntner, P. M., Durant, R. W., Glasser, S., Halanych, J. H., Shikany, J. M., Prineas, R. J., Samdarshi, T., Bittner, V. A. 2012. Association of Race and Sex With Risk of Incident Acute Coronary Heart Disease EventsIncident Acute Coronary Heart Disease Events. Jama. 308: 1768-1774 DOI: 10.1001/jama.2012.14306.

Mendis, S., Thygesen, K., Kuulasmaa, K., Giampaoli, S., Mähönen, M., Ngu Blackett, K., Lisheng, L., and infarction, W.g.o.b.o.t.p.e.o.t.W.c.f.r.o.W.d.o.m. 2010. World Health Organization Definition of Myocardial Infarction: 2008–09 Revision. International Journal of Epidemiology. 40: 139-146 DOI: 10.1093/ije/dyq165.

Thygesen, K., Alpert, J. S., Jaffe, A. S., Simoons, M. L., Chaitman, B. R., White, H. D., Infarction, W.G.o.b.o.t.J.E.A.A.W.T.F.f.t.U.D.o.M., Chairpersons, A. T. F. M., Thygesen, K., and Alpert, J. S. 2012. Third universal Definition of Myocardial Infarction. European Heart Journal. 33: 2551-2567 DOI: 10.1093/eurheartj/ehs184.

Lie, J. and Titus, J. 1975. Pathology of the Myocardium and the Conduction System in Sudden Coronary Death. Circulation. 52: III41-52.

Monserrat, L., Elliott, P. M., Gimeno, J. R., Sharma, S., Penas-Lado, M., and McKenna, W. J. 2003. Non-sustained Ventricular Tachycardia in Hypertrophic Cardiomyopathy: an Independent Marker of Sudden Death Risk in Young Patients. Journal of the American College of Cardiology. 42: 873-9 DOI: 10.1016/S0735-1097(03)00827-1.

McWilliam, J. A. 1887. Fibrillar Contraction of the Heart. The Journal of Physiology. 8: 296-310 DOI: 10.1113/jphysiol.1887.sp000261.

Walker, M., Curtis, M., Hearse, D., Campbell, R., Janse, M., Yellon, D., Cobbe, S., Coker, S., Harness, J., and harron, d. 1988. the lambeth conventions: guidelines for the Study of Arrhythmias in Ischaemia, Infarction, and Reperfusion. Cardiovascular Research. 22: 447-455.

Ahmad, M., Afzal, S., Malik, I.A., Mushtaq, S., and Mubarik, A. 2005. An Autopsy Study of Sudden Cardiac Death. Journal-Pakistan Medical Association. 55: 149.

Dreifus, L. S., Haiat, R., Watanabe, Y., Arriaga, J., and Reitman, N. 1971. Ventricular fibrillation: A Possible Mechanism of Sudden Death in Patients with Wolff-Parkinson-White Syndrome. Circulation. 43: 520-527.

Adabag, A. S., Luepker, R. V., Roger, V. L., and Gersh, B. J. 2010. Sudden Cardiac Death: Epidemiology and Risk Factors. Nature Reviews. Cardiology. 7: 216-225 DOI: 10.1038/nrcardio.2010.3.

Reinier, K., Rusinaru, C., and Chugh, S. S. 2019. Race, Ethnicity, and the Risk of Sudden Death. Trends in Cardiovascular Medicine. 29: 120-126 DOI: 10.1016/j.tcm.2018.07.001.

Chakrabarti, S., Morton, J. S., and Davidge, S. T. 2014. Mechanisms of Estrogen Effects on the Endothelium: An Overview. Canadian Journal of Cardiology. 30: 705-712 DOI: 10.1016/j.cjca.2013.08.006.

Khalil, R. A. 2005. Sex Hormones as Potential Modulators of Vascular Function in Hypertension. Hypertension. 46: 249-254 DOI: 10.1161/01.HYP.0000172945.06681.a4.

Mendelsohn, M. E. and Karas, R. H. 1999. The Protective Effects of Estrogen on the Cardiovascular System. New England Journal of Medicine. 340: 1801-1811 DOI: 10.1056/NEJM199906103402306.

Hermenegildo, C., Oviedo, P., and Cano, A. 2006. Cyclooxygenases Regulation by Estradiol on Endothelium. Current Pharmaceutical Design. 12: 205-215 DOI: 10.2174/138161206775193136.

Mercuro, G., Longu, G., Zoncu, S., and Cherchi, A. 1999. Impaired Forearm Blood Flow and Vasodilator Reserve in Healthy Postmenopausal Women. American Heart Journal. 137: 692-697.

Hemingway, H., Malik, M., and Marmot, M. 2001. Social and Psychosocial Influences on Sudden Cardiac Death, Ventricular Arrhythmia and Cardiac Autonomic Function. European Heart Journal. 22: 1082-1101 DOI: 10.1053/euhj.2000.2534.

Towfighi, A., Markovic, D., and Ovbiagele, B. 2011. National Gender-specific Trends in Myocardial Infarction Hospitalization Rates among Patients Aged 35 to 64 Years. The American Journal of Cardiology. 108: 1102-7 DOI: 10.1016/j.amjcard.2011.05.046.

Anand, S. S., Yusuf, S., Vuksan, V., Devanesen, S., Teo, K. K., Montague, P. A., Kelemen, L., Yi, C., Lonn, E., and Gerstein, H. 2000. Differences in Risk Factors, Atherosclerosis, and Cardiovascular Disease between Ethnic Groups in Canada: The Study of Health Assessment and Risk in Ethnic Groups (SHARE). The Lancet. 356: 279-284 DOI: 10.1016/S0140-6736(00)02502-2.

Lanza, G. 2004 Ethnic Variations in Acute Coronary Syndromes. BMJ Publishing Group Ltd.

Burke, A. P., Tracy, R. P., Kolodgie, F., Malcom, G. T., Zieske, A., Kutys, R., Pestaner, J., Smialek, J., and Virmani, R. 2002. Elevated C-reactive Protein Values and Atherosclerosis in Sudden Coronary Death: Association wth Different Pathologies. Circulation. 105: 2019-23 DOI: 10.1161/01.CIR.0000015507.29953.38.

Ajay, V. S. and Prabhakaran, D. 2010. Coronary Heart Disease in Indians: Implications of the INTERHEART Study. Indian J Med Res. 132: 561-6.

Howard, B. V., Lee, E. T., Cowan, L. D., Devereux, R. B., Galloway, J. M., Go, O. T., Howard, W. J., Rhoades, E. R., Robbins, D. C., Sievers, M. L. 1999. Rising Tide of Cardiovascular Disease in American Indians. The Strong Heart Study. 99: 2389-2395 DOI: 10.1161/01.cir.99.18.2389.

Joshi, P., Islam, S., Pais, P., and et al. 2007. Risk Factors for Early Myocardial Infarction in South Asians Compared With Individuals in Other Countries. Jama. 297: 286-294 DOI: 10.1001/jama.297.3.286.

Jha, A. K., Varosy, P. D., Kanaya, A. M., Hunninghake, D. B., Hlatky, M. A., Waters, D. D., Furberg, C. D., and Shlipak, M. G. 2003. Differences in Medical Care and Disease Outcomes among Black and White Women with Heart Disease. Circulation. 108: 1089-1094 DOI: 10.1161/01.cir.0000085994.38132.e5.

Herman, W. H., Ma, Y., Uwaifo, G., Haffner, S., Kahn, S. E., Horton, E. S., Lachin, J. M., Montez, M. G., Brenneman, T., and Barrett-Connor, E. 2007. Differences in A1C by Race and Ethnicity Among Patients with Impaired Glucose Tolerance in the Diabetes Prevention Program. Diabetes Care. 30: 2453-2457 DOI: 10.2337/dc06-2003.

BeLue, R., Francis, L. A., and Colaco, B. 2009. Mental Health Problems and Overweight in a Nationally Representative Sample of Adolescents: Effects of Race and Ethnicity. Pediatrics. 123: 697-702 DOI: 10.1542/peds.2008-0687.

Dunn, R. A., Tan, A. K., and Nayga, R. M. 2012. Obesity Inequality in Malaysia: Decomposing Differences by Gender and Ethnicity Using Quantile Regression. Ethnicity & Health. 17: 493-511 DOI: 10.1080/13557858.2012.661407.

Paffenbarger Jr, R. S., Hyde, R. T., Wing, A. L., Lee, I.-M., Jung, D L., and Kampert, J. B. 1993. The Association of Changes in Physical-activity Level and Other Lifestyle Characteristics with Mortality among Men. New England Journal of Medicine. 328: 538-545 DOI: 10.1056/NEJM199302253280804.

Siscovick, D. S., Weiss, N. S., Fletcher, R. H., and Lasky, T. 1984. The Incidence of Primary Cardiac Arrest During Vigorous Exercise. New England Journal of Medicine. 311: 874-877 DOI: 10.1056/NEJM198410043111402.

Albert, C. M., Mittleman, M. A., Chae, C. U., Lee, I.-M., Hennekens, C. H., and Manson, J. E. 2000. Triggering of Sudden Death from Cardiac Causes by Vigorous Exertion. New England Journal of Medicine. 343: 1355-1361 DOI: 10.1056/NEJM200011093431902.

Mittleman, M. A., Maclure, M., Tofler, G. H., Sherwood, J. B., Goldberg, R. J., and Muller, J. E. 1993. Triggering of Acute Myocardial Infarction by Heavy Physical Exertion--Protection against Triggering by Regular Exertion. New England Journal of Medicine. 329: 1677-1683 DOI: 10.1056/NEJM199312023292301.

Wang, J.-s., Jen, C. J., Kung, H., Lin, L.-J., Hsiue, T.-R., and Chen, H. 1994. Different Effects of Strenuous Exercise and Moderate Exercise on Platelet Function in Men. Circulation. 90: 2877-2885.

Harmon, K. G., Asif, I. M., Maleszewski, J. J., Owens, D. S., Prutkin, J. M., Salerno, J. C., Zigman, M. L., Ellenbogen, R., Rao, A., Ackerman, M. J. 2015. Incidence, Etiology, and Comparative Frequency of Sudden Cardiac Death in NCAA Athletes: A Decade in Review. Circulation. DOI: 10.1161/circulationaha.115.015431.

Zimmerman, F. H., Cameron, A., Fisher, L. D., and Grace, N. 1995. Myocardial Infarction in Young Adults: Angiographic Characterization, Risk Factors and Prognosis (Coronary Artery Surgery Study Registry). Journal of the American College of Cardiology. 26: 654-661 DOI:

Chan, M. Y., Woo, K., Wong, H., Chia, B., Sutandar, A., and Tan, H. 2006. Antecedent Risk Factors and Their Control in Young Patients with a First Myocardial Infarction. Singapore Medical Journal. 47: 27.

Fournier, J., Sanchez, A., Quero, J. 1996. Fernandez‐Cortacero, J., and González‐Barrero, A. Myocardial Infarction in Men Aged 40 Years or Less: A Prospective Clinical‐angiographic Study. Clinical Cardiology. 19: 631-636 DOI: 10.1002/clc.4960190809.

Heller, R. 1992. For INCLEN Multicentre Collaborative Group. Risk Factors for Cardiovascular Disease in the Developing World. A Multicentre Collaborative Study in the International Clinical Epidemiology Network (INCLEN). J Clin Epidemiol. 45: 841-847 DOI: 10.1016/0895-4356(92)90067-W.

Ko, M., Kim, M. T., and Nam, J. J. 2006. Assessing Risk Factors of Coronary Heart Disease and Its Risk Prediction among Korean Adults: the 2001 Korea National Health and Nutrition Examination Survey. International Journal of Cardiology. 110: 184-190 DOI: 10.1016/j.ijcard.2005.07.030.

McDonnell, L. A., Pipe, A. L., Westcott, C., Perron, S., Younger-Lewis, D., Elias, N., Nooyen, J., and Reid, R. D. 2014. Perceived vs Actual Knowledge and Risk of Heart Disease in Women: Findings from a Canadian Survey on Heart Health Awareness, Attitudes, and Lifestyle. Canadian Journal of Cardiology. 30: 827-834 DOI: 10.1016/j.cjca.2014.05.007.



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