Out-of-hospital sudden death referring to an emergency department

doi:10.1016/0895-4356(96)00114-X

Journal of Clinical Epidemiology

Volume 49, Issue 8, August 1996, Pages 865-868

https://doi.org/10.1016/0895-4356(96)00114-X Get rights and content

Abstract

Over an 11-year period, autopsies were performed on 957 of 1038 nontraumatic deaths in the Emergency Department of the Central Hospital in Ferrara, Italy. Of these 957 cases, 732 (76.5%) met criteria for sudden death.

In 100 (14%) of these cases, the death could be attributed to pulmonary embolism (55 cases), stroke (17), or rupture of aortic aneurysm (28).

Acute myocardial infarction accounted for 403 (55%) of all sudden deaths. Severe coronary artery disease was found in 340 (84%) of these 403 deaths, with plaque fissuring or thrombi in 189 or 151 cases, respectively.

Among the 229 sudden deaths for whom no immediate cause could be determined (31% of the total population), all had evidence of heart disease: 147 individuals had severe coronary artery disease, with plaque fissuring or thrombi found in 72 or 43, respectively. The remaining cases with no immediate cause of death had evidence of a cardiomyopathy (61) or valvular disease (21).

We conclude that acute myocardial infarction accounts for the majority of cases of nontraumatic sudden death in our Emergency Department. Altogether, 84% of these patients had severe coronary artery disease. In approximately one-third of cases for whom no immediate cause of sudden death could be determined, all had evidence of heart disease, and about two-thirds had severe coronary artery disease.

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Cited by (68)

The Lancet Commission to reduce the global burden of sudden cardiac death: a call for multidisciplinary action
2023, The Lancet
Despite major advancements in cardiovascular medicine, sudden cardiac death (SCD) continues to be an enormous medical and societal challenge, claiming millions of lives every year. Efforts to prevent SCD are hampered by imperfect risk prediction and inadequate solutions to specifically address arrhythmogenesis. Although resuscitation strategies have witnessed substantial evolution, there is a need to strengthen the organisation of community interventions and emergency medical systems across varied locations and health-care structures. With all the technological and medical advances of the 21st century, the fact that survival from sudden cardiac arrest (SCA) remains lower than 10% in most parts of the world is unacceptable. Recognising this urgent need, the Lancet Commission on SCD was constituted, bringing together 30 international experts in varied disciplines. Consistent progress in tackling SCD will require a completely revamped approach to SCD prevention, with wide-sweeping policy changes that will empower the development of both governmental and community-based programmes to maximise survival from SCA, and to comprehensively attend to survivors and decedents’ families after the event. International collaborative efforts that maximally leverage and connect the expertise of various research organisations will need to be prioritised to properly address identified gaps. The Commission places substantial emphasis on the need to develop a multidisciplinary strategy that encompasses all aspects of SCD prevention and treatment. The Commission provides a critical assessment of the current scientific efforts in the field, and puts forth key recommendations to challenge, activate, and intensify efforts by both the scientific and global community with new directions, research, and innovation to reduce the burden of SCD worldwide.
Chronologic and Climatic Factors of Acute Aortic Dissection: Study of 1642 Patients in Two Continents
2020, Annals of Thoracic Surgery
Citation Excerpt :
However, the proportion of type A aortic dissection was significantly higher during the full moon phase (73.7%, 286 of 388) compared with that during other moon phases (66.9%, 839 of 1254; P = .012), as shown in Figure 3. With an estimated incidence of 5 to 30 per million per year, AAD and ruptured aortic aneurysm rank in the third position (3.8% of cases) among autopsy-confirmed causes of out-of-hospital sudden death in the general population.13 Even with modern medical, endovascular,14 and surgical therapies, the mortality of AAD is still as high as 19.8% with all treatment options, according to the International Registry of Acute Aortic Dissection.15
The purpose of this study was to examine whether chronologic and climatic factors and lunar phases affect the onset of acute aortic dissection (AAD).
The frequencies of AAD were analyzed with regard to the chronologic and climatic factors and lunar phases on the day when AAD occurred for 1642 patients with AAD from two aortic referral centers in the United States and China.
Mean age of patients was 51.6 ± 13.1 years, and 1260 (76.7%) were men. Dissection was type A in 1125 patients (68.5%) and type B in 517 (31.5%). Early mortality rate was 11.6% (190 of 1642), including 89 aortic ruptures before operation and 101 operative deaths. There was a winter peak in occurrence (33.6%, P < .01) with a relative risk of 1.519. In a week, the frequency was highest on Wednesday (15.5%) and Monday (15.2%), and lowest on Sunday (12.8%). Month-specific incidence was significantly inversely correlated to the mean temperature (rho = −0.650, P = .022) and directly correlated to the atmospheric pressure (rho = 0.706, P = .001). The proportion of type A dissection was significantly higher in the full moon phase compared with type B dissection (73.7% vs 66.9%, P = .012).
Acute aortic dissection exhibits significant chronologic variation in the frequency of occurrence, with a peak in winter and on Wednesdays, and nadir in summer and on Sundays. The incidence is significantly correlated to the mean temperature and atmospheric pressure. The proportion of type A dissection is higher in the full moon phase. These results are important for understanding the mechanisms involved in triggering AAD events and helpful for improving disease prevention and patient care.
Sex and Circadian Periodicity of Cardiovascular Diseases: Are Women Sufficiently Represented in Chronobiological Studies?
2017, Heart Failure Clinics
Citation Excerpt :
The underlying etiopathologic factors are not fully known, because different entities may have SCD as the final clinical outcome. A study on a consecutive series of 732 SCD cases, referring to the emergency department and undergoing necropsy, was performed in Italy a couple of decades ago.55 In 403 of 732 cases (55%), the pathologist identified the final cause of death.
In-hospital mortality due to pulmonary embolism in patients with Alzheimer disease: A sex effect?
2016, American Journal of Emergency Medicine
Emergency evaluation for pulmonary embolism, part 1: Clinical factors that increase risk
2015, Journal of Emergency Medicine
Citation Excerpt :
The all-cause, 30-day mortality after diagnosed PE is about 8% (9–13). Autopsy studies suggest that PE is the second leading cause of sudden, unexpected, nontraumatic death in outpatients (14–16). In most cases, the PE was not diagnosed premortem.
Pulmonary embolism (PE) can be fatal, but profligate testing for PE can harm patients.
With consideration of potential medicolegal implications, this two-part review provides current evidence about the care of patients with suspected and diagnosed PE in the emergency department (ED) setting.
In part 1, we review published evidence to describe the epidemiology, risk factors, and clinical presentation of PE in the ED setting. Older age, surgery requiring endotracheal intubation within the past 30 days, new use of oral contraceptives, and prior unprovoked venous thromboembolism in nonanticoagulated patients are clear risk factors for PE in ED patients. Recent history of unexplained dyspnea, pleuritic chest pain, and hemoptysis increase probability, but the effect of syncope is less clear. Treated and inactive cancer, smoking, obesity, and pregnancy have not been found to increase the probability of PE in symptomatic ED patients. Unexplained dyspnea, tachycardia, and a low pulse oximetry reading increase probability of PE. Finding of wheezing on lung auscultation reduces the probability of PE, and findings that suggest deep venous thrombosis increase the probability of PE.
Understanding of risk factors, historical data, and physical findings that have been found to increase or decrease the probability of PE in symptomatic ED patients can help create rational guidelines for the diagnostic approach to PE.
Outcomes and radiation exposure of emergency department patients with chest pain and shortness of breath and ultralow pretest probability: A multicenter study
2014, Annals of Emergency Medicine
Excessive radiation exposure remains a concern for patients with symptoms suggesting acute coronary syndrome and pulmonary embolism but must be judged in the perspective of pretest probability and outcomes. We quantify and qualify the pretest probability, outcomes, and radiation exposure of adults with both chest pain and dyspnea.
This was a prospective, 4-center, outcomes study. Patients were adults with dyspnea and chest pain, nondiagnostic ECGs, and no obvious diagnosis. Pretest probability for both acute coronary syndrome and pulmonary embolism was assessed with a validated method; ultralow risk was defined as pretest probability less than 2.5% for both acute coronary syndrome and pulmonary embolism. Patients were followed for diagnosis and total medical radiation exposure for 90 days.
Eight hundred forty patients had complete data; 23 (3%) had acute coronary syndrome and 15 (2%) had pulmonary embolism. The cohort received an average of 4.9 mSv radiation to the chest, 48% from computed tomography pulmonary angiography. The pretest probability estimates for acute coronary syndrome and pulmonary embolism were less than 2.5% in 227 patients (27%), of whom 0 of 277 (0%; 95% confidence interval 0% to 1.7%) had acute coronary syndrome or pulmonary embolism and 7 of 227 (3%) had any significant cardiopulmonary diagnosis. The estimated chest radiation exposure per patient in this ultralow-risk group was 3.5 mSv, including 26 (3%) with greater than 5 mSv radiation to the chest and no significant cardiopulmonary diagnosis.
One quarter of patients with chest pain and dyspnea had ultralow risk and no acute coronary syndrome or pulmonary embolism but were exposed to an average of 3.5 mSv radiation to the chest. These data can be used in a clinical guideline to reduce radiation exposure.

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^☆: Supported by grants from the Italian Ministry of University and Scientific and Technological Research (60%).

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Original articleOut-of-hospital sudden death referring to an emergency department☆

Abstract

Am Heart J

Am Heart J

Am J Med

Am J Cardiol

A prospective study of 1152 hospital autopsies. 1. Inaccuracies in death certification

J Pathol

The autopsy as a measure of accuracy of death certificate

N Engl J Med

Ischaemic heart disease

Post mortem histochemical techniques

Sudden cardiac death. I. A decade's experience with out-of-hospital resuscitation. 11. Outcome of resuscitation, management, and future directions

Mod Conc Cardiovasc Dis

Original article
Out-of-hospital sudden death referring to an emergency department☆