Sudden cardiac death during physical exercise: Characteristics of victims and autopsy findings

Figures & data

Table I. Causes of death defined by medico-legal autopsy. Modified from Hookana et al. (19) with the permission of the publisher.

Adjudicated causes of death	Descriptive causes of death from autopsy	Autopsy findings
Coronary artery disease
Acute coronary syndrome	CAD with active plaque, thrombosis, or acute myocardial infarction	Chronic atherosclerotic lesions with occlusive or non-occlusive thrombi, acute myocardial infarction, acute plaque complication in histologic examination of culprit lesions
Chronic ischemic heart disease	CAD with healed scar or fibrosis	Chronic occlusive atherosclerotic lesions, with old myocardial scars or diffuse fibrosis
Anomalous coronary arteries	Anomalous coronary arteries	Anomalies of origination and course, anomalies of intrinsic coronary arterial anatomy, anomalies of coronary termination, anomalous collateral vessels
Valvular heart disease	Valvular heart disease	Aortic valve calcification, mitral valve calcification
Inflammatory heart disease	Inflammatory heart disease	Myocarditis: inflammatory cell infiltrate of the myocardium with necrosis and/or degeneration of the adjacent myocytes
Structurally normal heart	No cardiac abnormalities at autopsy	Macroscopically normal heart, normal microscopic findings, with or without identified genetic abnormality
Non-ischemic cardiomyopathy
DCM	DCM	Left ventricular dilation with inadequate degree of LVH, in later stages pale and flabby myocardium and dilation of both ventricles and atria, unspecific fibrosis, and focal atrophy/hypertrophy of myocytes
Hypertrophic cardiomyopathy	HCM	Concentric LVH, with myocyte disarray accompanied by various degrees of interstitial fibrosis
	HOCM	LVH, with asymmetric septal hypertrophy, myocyte disarray, and various degrees of interstitial fibrosis
Right ventricular dysplasia	ARVD	Right ventricular dilation, atrophy of the right ventricular myocardium with fibro-fatty replacement of myocytes
Other cardiomyopathies	Fibrotic CM	Interstitial, diffuse, or patchy myocardial fibrosis of unknown etiology, such as LVH, myocardial scarring, or other structural abnormalities
	Hypertensive CM	Increased heart weight, LVH, unspecific fibrosis, other organ changes related to hypertension
	Alcoholic CM	No specific macroscopic or microscopic findings, focal replacement fibrosis of the myocardium, in later stages signs of dilated CM, other organ changes related to excessive long-term alcohol consumption
	CM associated with obesity and non-specific CM	Heart weight increased over value predicted for normal body weight, LVH or both left and right ventricular wall hypertrophy, dilation of both atria and ventricles, excessive epicardial fat and fat infiltration of myocardium, obesity

ARVD = arrhythmogenic right ventricular dysplasia; CAD = coronary artery disease; CM = cardiomyopathy; DCM = dilated cardiomyopathy; HCM = hypertrophic cardiomyopathy; HOCM = hypertrophic obstructive cardiomyopathy; LVH = left ventricular hypertrophy.

Table II. Characteristics and autopsy findings of sudden cardiac death victims.

Variable	SCD at physical exercise	SCD at rest	P value
Patient characteristics:
Mean age (years)	62.0 ± 10.6	63.1 ± 12.2	0.14
Body mass index (kg/m^2)	27.4 ± 4.7	27.2 ± 6.6	0.64
Male gender	309/328 (94%)	678/876 (77%)	< 0.001
Prior cardiac disease	134/316 (42%)	350/842 (42%)	0.797
Prior diagnosed AMI	37/297 (12.5%)	71/811 (8.8%)	0.066
Prior diagnosed CAD	72/298 (24%)	150/796 (19%)	0.052
Angina pectoris	33/290 (11%)	76/799 (9.5%)	0.364
Hypertension	88/287 (31%)	309/798 (39%)	< 0.05
Diabetes mellitus	40/297 (13%)	160/816 (20%)	< 0.05
Dyslipidemia	44/290 (15%)	67/806 (8.3%)	< 0.01
Congestive heart failure	16/290 (5.5%)	89/805 (11%)	< 0.01
Medication:
Beta-blocker	54/239 (23%)	189/679 (28%)	0.13
Digoxin	12/239 (5.0%)	53/678 (7.1%)	0.148
Warfarin	21/241 (8.7%)	51/683 (7.5%)	0.535
Diuretics	29/240 (12%)	128/679 (19%)	< 0.05
Acetylsalicylic acid	39/239 (16%)	136/679 (20%)	0.209
Nitroglycerin	46/242 (19%)	151/686 (22%)	0.329
Antipsychotics	12/239 (5.0%)	94/682 (14%)	< 0.001
Antidepressants	9/239 (3.8%)	72/682 (11%)	< 0.01
Autopsy findings:
Ischemic heart disease (CAD)	299/328 (91%)	657/876 (75%)	< 0.001
Non-ischemic CMP:	18/328 (5.5%)	159/876 (18%)	< 0.001
Hypertrophic CMP	3/328 (0.91%)	6/876 (0.68%)	0.680
Myocardial fibrosis without any known etiology	0/328 (0%)	34/876 (3.9%)	< 0.001
Dilated CMP	0/328 (0%)	11/876 (1.3%)	< 0.05
Alcoholic CMP	2/328 (0.61%)	33/876 (3.7%)	0.004
CMP related to obesity	11/327 (3.3%)	59/875 (6.7%)	0.026
Myocarditis	3/328 (0.9%)	8/876 (0.9%)	0.998
Valvular heart disease	8/328 (2.4%)	11/876 (1.3%)	0.142
Other autopsy findings:
Myocardial scarring	194/328 (59%)	370/876 (42%)	< 0.001
Hypertrophied heart	243/327 (74%)	585/876 (67%)	< 0.05

The values are mean ± SD or number of patients (percentage in parenthesis).

AMI = acute myocardial infarction; CAD = coronary artery disease; CMP = cardiomyopathy; SCD = sudden cardiac death.

Table III. Type of exertion related to sudden cardiac death.

Type of exertion	Number of patients	Percentage
Skiing	38	12%
Cycling	36	11%
Snow shoveling	30	9.1%
Jogging and brisk walking	28	8.5%
Logging	25	7.6%
Hunting	20	6.1%
Yard work	18	5.5%
Berry picking	11	3.3%
Fishing	7	2.1%
Dancing	7	2.1%
Ball games	7	2.1%
Running	6	1.8%
Farming	6	1.8%
Swimming	4	1.2%
Intercourse	3	0.9%
Other	83	25%

The most common triggers of exercise-related sudden cardiac death.

Figure 1. Odds ratios of sudden cardiac death related to exercise versus rest for the combinations of various autopsy findings. The victims with different combinations of autopsy findings are compared to those without any of these findings. The number of cases with all three findings was 71. All P values < 0.001.

Hookana E, Junttila MJ, Puurunen V, Tikkanen JT, Kaikkonen KS, Kortelainen M-L, et al. Causes of nonischemic sudden cardiac death in the current era. Heart Rhythm. 2011;8:1570–5.

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