Documentos de Académico
Documentos de Profesional
Documentos de Cultura
15,760-765 (1992)
The Cardiovascular Pathology Registry, St. Vincent Hospital and Health Care Center, Nasser, Smith & Pinkerton Cardiology, Inc.;
*Division of Forensic Pathology, Department of Pathology, Indiana University School of Medicine, Indianapolis,Indiana, USA
Summary: The incidence of various types of cardiovascular disease was evaluated in 2007 consecutive forensic
patients. Cardiovascular deaths accounted for 22.8% of the
study patients and atherosclerotic coronary heart disease
was the most common type of cardiac disease (18%).
Among subjects dying of atherosclerotic coronary disease,
sudden death was three times more frequent than acute
myocardial infarction. Expected cardiac findings included
the incidence of severe coronary atherosclerosis (21%),
floppy mitral valves (5%), and congenital bicuspid aortic
valves (1%). Major cardiac findings occurred in 32% and
minor cardiac findings were found in 40%. Only 17% of
hearts were anatomically normal. An unexpected cardiac
necropsy finding included the high frequency of myocardial bridges (23%). Unexpected cardiac findings included
the low incidence of acute myocarditis (0.6%) and common finding of tunneled epicardial coronary arteries
(myocardial bridges) (23%).
Introduction
Cardiovascular disease remains the number one killer in
the United States. More than half of these deaths are sudden,
unexpected; or both24 and thus fall into the realm of forensic pathology. In 1987 we began a systematic evaluation of
consecutive hearts from forensic autopsies to determine various types of cardiac abnormalities. Our first evaluation of
consecutive 470 hearts has been reported previously? The
present study, now encompassing over 2000 consecutive
forensic cardiac evaluations, expands the initial report fivefold. These cardiac observations (expected and unexpected)
provide a database for the frequency with which they may be
found in a group of nonhospitalized decedents.
Methods
Site and Population
This study was based upon forensic autopsies conducted in the Marion County Coroners system derived from an
area including the city of Indianapolis, Indiana, and surrounding townships. This population base is estimated at
1.5 million. Of 21 19 cardiac specimens examined between
1987 and 1991, 112 (5%)were excluded from this analysis because of severe decomposition or skeletonization.
Evaluation of Hearts and Collection of Data
76 1
such as elongated chordae tendineae, interchordal hooding, or redundancy of valve leaflets and endocardial friction lesions were supportive, if present, but not required
for establishing this diagnosis.
Primary aortic dissection or ruptured aortic aneurysm
was diagnosed in the absence of any trauma and no other
potential cardiac cause of death. Complex congenital heart
disease was defined as conditions such as hypoplastic ventricles, valve atresia, primary endocardial fibroelastosis,
and a combination of two or more simple congenital defects such as atrial or ventricular septal defect (e.g., tetralogy of Fallot). A coronary artery ostium was considered in
a high take-ofposition if its ostium arose 5 mm or more
above the aortic sinotubular junction. A conal coronary
artery was defined as an accessory or third coronary vessel
arising in the right sinus of Valsalva and supplying the outflow tract of the right ventricle (i.e., conus). Segments of
epicardial coronary arteries which became covered by
myocardium (intramural segment), then returned to the
epicardial surface after at least 1 mm of depth and distance
were designated as tunneled coronary arteries (myocardial bridges). Hearts were classified as demonstrating
excess epicardial fat (cardiac adiposity) when 100% of
the right ventricular surface and adjacent atrioventricular
sulcus was covered by epicardial fat. Primary neoplastic
lesions seen in this study were all benign papillomas (papillary fibroelastoma).
Results
Demographics
TABLE
I Categories of death
Year
Cardiovascular
Cardiac
Aorta
Traumatic
Other
1987
n = 470 (%)
87
85
2
273
110
(18.4)
(18.0)
(0.4)
(58)
(23)
1988
n = 583 (%)
n = 483 (%)
1990
n = 531 (%)
n = 2007 (%)
126
125
1
319
78
98
95
3
304
81
146
143
3
324
61
457
448
9
1220
330
(24.2)
(24.0)
(0.2)
(61)
(15)
1989
(20.6)
(20.0)
(0.6)
(63)
(17)
(27.5)
(26.9)
(0.6)
(61)
(11)
Total
(22.8)
(22.3)
(0.45)
(61.0)
(16)
762
Year
n = 470 (%)
Cardiac disease
Coronary heart disease
Sudden coronary death
Acute myocardial
infarction
Cardiomyopathy
Acute myocarditis
Rheumatic heart
disease
Degenerative aortic
stenosis
Floppy mitral valve
(sudden death)
Anomalous coronary
artery
Complex congenital
heart disease
Subtotal
Aortic disease
Primary aortic
dissection
Rupture aortic
aneurysm
Subtotal
Total
64 (13.6)
49
15
6 (1.3)
4 (0.8)
Total
1988
n = 523 (%)
1989
n = 483 (%)
1990
n = 531 (%)
n = 2007 (%)
101 (19.3)
72
79 (16.4)
53
119 (22.4)
101
363 (18.1)
275 (13.7)
18
9 (1.7)
4 (0.8)
88 (4.4)
31 (1.5)
13 (0.6)
29
12 (2.3)
2 (0.4)
26
4
3
(0.8)
(0.6)
1 (0.2)
1 (0.2)
1 (0.2)
1 (0.2)
(0.4)
(0.4)
6 (0.3)
5 (1.1)
3 (0.6)
(0.8)
(0.9)
17 (0.8)
1 (0.2)
1 (0.2)
2 (0.1)
3 (0.6)
143 (26.9)
14 (0.7)
448 (22.3)
4 (0.8)
85 (18.0)
5 (1.0)
125 (24.0)
2 (0.4)
1 (0.2)
0
2 (0.4)
87 (18.4)
0
1 (0.2)
126 (24.2)
Causes of Death
Causes of death for the 2007 forensic patients were classified as cardiovascular (heart and aorta); traumatic
(including homicides, suicides, and accidents); and other
noncardiac (noncardiac natural, sudden infant death syndrome, neoplastic, stroke, etc.). Cardiovascular causes of
death constituted 22.8% of the deaths (Tables I, II). The
most common type of cardiac death was coronary heart
disease (18%), followed by cardiomyopathy (1.5%), acute
myocarditis (0.6%), floppy mitral valve (0.8%), anomalous coronary artery (0.1%), and rheumatic heart disease
(0.1%) (Tables I, II). Diseases of the aorta as a cause of
death constituted only an additional 0.45%. Among the
subjects dying from atherosclerotic coronary disease, sudden coronary death was a more frequent mode of death
compared with acute myocardial infarction (14 versus 4%)
(Table 11).
2 (0.4)
95 (20.0)
(0.4)
1 (0.2)
3 (0.6)
146 (27.5)
3 (0.6)
98 (20.6)
8 (0.4)
1 (0.05)
9 (0.45)
457 (22.8)
1
I
(0.6)
2 (0.1)
Tunneled
coronary
artery
4.9
763
Year
Atherosclerotic coronary
heart diseasea
Left main disease
Single vessel
Double vessel
Triple vessel
Acute myocardial
infarction (1) rupture
Healed myocardial
infarction
Left ventricular aneurysm
Ruptured papillary muscle
Sudden coronary death
1987
n=470 (%)
1988
n=523 (%)
1989
n=483 (%)
77 (16.0)
4
3
11
59
15 (3.2)
[OI
124 (23.7)
6
5
14
99
29 (5.5)
Total
1990
n=531 (a)
n = 2007 (%)
103 (21.3)
3
8
16
76
26 (5.4)
111
110 (21.0)
5
9
15
81
18 (3.4)
[I1
414 (20.6)
18
25
56
315
88 (4.4)
131 (0.2)
(9.0)
(0.4)
(0.2)
(14.1)
39 (8.1)
0
0
60 (12.4)
56 (10.5)
1
0
83 (15.6)
172 (8.6)
4 (0.2)
1 (0.05)
261 (13.0)
4 (0.8)
2 (0.4)
0
11 (2.1)
1 (0.2)
0
3 (0.6)
1 (0.2)
0
7 (1.3)
2 (0.4)
0
25 (1.2)
6 (0.3)
0
4 (0.8)
2 (0.4)
3 (0.6)
4 (0.8)
13 (0.6)
3
8
1
7
(0.6)
(1.7)
(0.2)
(1.5)
0
5 (1.0)
0
5 (1.0)
1 (0.2)
8 (1.6)
0
8 (1.6)
0
5 (0.9)
0
5 (0.9)
4
26
1
25
2 (0.4)
0
36 (8.0)
1 (0.2)
0
51 (9.8)
3 (0.6)
0
22 (4.6)
2 (0.4)
1 (0.2)
40 (7.5)
8 (0.4)
1 (0.05)
149 (7.4)
0
1 (0.2)
2 (0.2)
2 (0.2)
30 (6.0)
1 (0.2)
0
44 (9.4)
HI
47
2
1
74
Cardiomyopathyb
Idiopathic dilated
Hypertrophic
Amyloid
Inflammatory
(acute myocarditis)
Valve diseaseC
h4itral stenosis
Aortic stenosis
Rheumatic
Degenerative
Primary (nontraumatic)
aortic dissection
Ruptured aortic aneurysm
Cardiac trauma
Neoplasm
Primary
Metastatic
2 (0.2)
0
1 (0.2)
0
0
(0.6)
(1.3)
(0.05)
(1.25)
by the bicuspid aortic valve (0.8%). Minor acquired cardiac abnormalities including excessive epicardial fat, left
ventricular hypertrophy, and mitral annular calcium were
found in 802 (40%)hearts (Table V) and minor congenital
defects, including conal arteries and probe patent foramen
ovale defects, occurred in 1378 (68%)of hearts (Table V).
Only 339 hearts (17%) were free of the acquired or congenital lesions sought.
Discussion
The major goal of this and our previous study5 was to
focus on cardiac findings in a forensic pathology population. To our knowledge this remains the only study which
sequentially evaluates general gross cardiac findings in
forensic necropsy patients. Previous studies have evaluat-
764
TABLE
IV MaioP congenital cardiac findings
Year
Complex
Floppy mitral valve
Bicuspid aortic valve
Atrial septal defect only
Ventricular septal defect only
Congenital coronary anomaly
Single coronary artery
Right from left sinus
Left from right sinus
Absent left main
(separate origin left
anterior descending
and left circumflex)
Slit-like coronary ostium
a
1987
n = 470 (%)
4
22
3
1
1
2
(0.8)
(5.0)
(0.6)
(0.2)
(0.2)
(0.4)
(0.4)
1988
n = 523 (%)
5
31
6
1
0
2
(1.0)
(5.9)
(1.1)
(0.2)
(0.4)
1989
n=483 (%)
2
27
4
0
0
1
(0.4)
(5.6)
(0.8)
(0.2)
1990
n=531(%)
3
19
3
1
0
2
(0.6)
(3.6)
(0.6)
(0.2)
(0.4)
Total
n = 2007 (%)
14
99
16
3
1
7
(0.7)
(4.9)
(0.8)
(0.1)
(0.05)
(0.3)
1 (0.2)
0
1 (0.2)
0
0
1 (0.2)
0
1 (0.2)
0
1 (0.05)
1 (0.05)
4 (0.20)
1 (0.2)
1 (0.05)
TABLE
V Minor acquired and congenital cardiac findings
Year
Minor acquireda
Cardiac adipoisty
Left ventricular hypertrophy
(>1.5cm wall thickness)
Mitral valve annular calcium
Minor congentialb
Conal right coronary artery
Probe patient foramen ovale
High takeoff coronary ostium
Bicuspid pulmonic valve
Quadracuspid pulmonic valve
Tunneled epicardial coronary
Totals
1987
n=470 (%)
1988
n=523 (%)
1989
n = 483 (%)
1990
n=531(%)
n=2007 (%)
101 (22.0)
61 (13.0)
141 (27.0)
82 (15.7)
128 (26.5)
77 (15.9)
137 (25.8)
91 (17.1)
507 (25.3)
311 (15.5)
18 (4.0)
29 (5.5)
26 (5.4)
21 (4.0)
94
(4.7)
148 (28.3)
101 (19.3)
27 (5.2)
162 (33.5)
113 (23.4)
23 (4.8)
195 (36.7)
129 (24.3)
19 (3.6)
625
429
108
1
1
463
(31.1)
(21.4)
(5.4)
(0.5)
(0.5)
(23.1)
120
86
39
1
1
138
(26.0)
(18.0)
(8.0)
(0.2)
(0.2)
(29.0)
0
0
0
0
122 (23.3)
107 (22.1)
0
0
96 (18.1)
Observations in this study which were expected included: (1) coronary atherosclerosis as the major cardiac disease and leading cardiac cause of death; (2) the necropsy
frequency for floppy mitral valve (5%),17the frequency of
conal coronary arteries (38%)23and congenitally bicuspid
aortic valves (1%), and the low frequency of stenotic mitral valves (0.2%) and congenital coronary artery anomalies (0.3%).23
Unexpected Findings
TWO unexpected cardiac findings in this forensic necropsy study were: (1) a low frequency of fatal acute myocarditis (0.6%), and (2) high frequency of tunneled coronary
arteries (myocardial bridges) (23%). Several studies have
reported an incidence of myocarditis ranging from 7-12%,
particularly in pediatric cases.21124-26Differences in myocarditis definitions and the number of histologic sections
evaluated could explain this difference. Nearly 25% of the
hearts in this study contained a tunneled segment of a
major coronary artery (most commonly the left anterior
descending). This high frequency suggests tunneled coronary arteries are a common entity and mitigates against the
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