Serum concentrations of cardiac troponin T in sudden death

Ischemic heart disease is the most common cause of sudden death of natural causes in most western countries. By autopsy, there may be no gross or histologic evidence of acute myocardial damage unless the patient survived for several hours following the event. Cardiac troponin in serum has become the recommended biochemical marker for myocardial injury in the clinical setting. We performed a prospective study on 102 autopsied subjects at the Central Hospital of Rogaland, Stavanger, Norway. Femoral blood was sampled for subsequent analysis of cardiac troponin T (cTnT). In the subjects with morphologic evidence of recent myocardial injury (n = 34), the mean serum cTnT level was 1.95 microg/L compared with 0.16 microg/L in the subjects with a noncardiac cause of death (n = 35) and 0.61 microg/L in the group with probable sudden cardiac death without morphologic signs of acute myocardial injury (n = 33). The observed differences in mean serum cTnT levels between the groups were statistically significant (P < 0.0001). These data suggest that elevated postmortem serum concentration of cTnT reflects ongoing myocardial damage and may support a diagnosis of cardiac-related death in cases associated with sparse or inconclusive morphologic findings postmortem.     

A rapid postmortem cardiac troponin T assay: laboratory evidence of sudden cardiac death

Postmortem examination may be useful in establishing the cause of sudden unexpected death. In many instances, however, limitations of staffing, budget, and time may force the pathologist to triage cases to external examination rather than autopsy. A rapid assay for cardiac troponin T (cTnT) to document suspected cardiac-related deaths may optimize the use of the time and resources of the autopsy pathologist. Peripheral blood was sampled percutaneously before each of 40 autopsies and placed in the well of the Cardiac T Rapid Assay unit in accordance with the included instructions, and the results were read after 15 minutes. The assay result, decedent age, postmortem interval, and evidence of cardiopulmonary resuscitation were tabulated and subsequently correlated with the cause of death. On final sign-out of each of the autopsies, the cause of death was determined to be cardiac-related (n = 20) versus the cause in non-cardiac control subjects (n = 20). This determination was made while the investigators were blinded to the cTnT assay result. Of the 20 cardiac deaths, 17 (85%) showed positive results for cTnT compared with 6 (30%) false-positive results among the 20 control cases; this result was statistically significant according to the chi-square test. In the over-50 age group, the sensitivity of this assay in detecting cardiac-related death was 91%, with a specificity of 86%. Perimortem cardiopulmonary resuscitation did not appear to result in false-positive results. In the appropriate setting, this rapid assay for cTnT can provide valuable data supportive of a cardiac-related death. This inexpensive test may best be used in triaging sudden deaths in persons over 50 to external examination versus complete autopsy.     

心脏性猝死的机制研究进展

世界范围内心脏病性猝死发病率正呈逐年升高趋势并已成为第一大死亡原因,因此国内外学者在这方进行了广泛而深入的研究。本文综述了心脏病性猝死的病理学、神经体液、电生理特别是其分子生物学发病机制的研究成果。     

Intrapulmonary aquaporin-5 expression as a possible biomarker for discriminating smothering and choking from sudden cardiac death: a pilot study

The diagnosis of mechanical asphyxia as a cause of death, especially smothering and choking lacking evident injury, is one of the most difficult tasks in forensic pathology. The present study investigated the intrapulmonary expressions of aquaporins (AQPs; AQP-1 and AQP-5), as markers of water homeostasis, in forensic autopsy cases (total n=64, within 48 h postmortem) of mechanical asphyxiation due to neck compression (strangulation, n=24), including manual/ligature strangulation (n=12) and atypical hanging (n=12), smothering (n=7) and choking (n=8), compared with sudden cardiac death (n=14) and acute brain injury (n=11). Quantification of mRNA using a Taqman real-time PCR assay system demonstrated suppressed expression of AQP-5, but not AQP-1, in smothering and choking, compared with that in strangulation as well as sudden cardiac death and acute brain injury death. Immunostaining of AQP-5 was weakly detected in a linear pattern in the type I alveolar epithelial cells in smothering and choking cases, while cardiac and brain injury death showed marked positivity, and most strangulation cases had AQP-5-positive granular aggregates and fragments in intra-alveolar spaces. These observations indicate a partial difference in pulmonary molecular pathology among these causes of death, suggesting a procedure for possible discrimination of smothering and choking from sudden cardiac death.     

118例心源性猝死分析

心源性猝死(sudden cardiac death,SCD)在成人猝死的死因中占首位,本文对1998-2005年陕西地区发生的118例SCD案例进行统计分析,结果显示男性是女性的5.9倍,其中冠心病占55.1%,心肌炎占17.8%,心肌病占9.3%,先天性心脏病、瓣膜病、主动脉夹层瘤破裂各占2.5%,其他疾病占4.5%。说明SCD多发于男性,冠心病仍是SCD的主要基础疾病,心肌炎是青少年SCD的主要原因,心肌病是青壮年SCD的危险因素,无结构异常的心脏病也同样严重威胁生命健康。     

Age-dependent morphologic findings of the thyroid in sudden infant death

Age (eight days to 12 months) and degree of colloid depletion or colloid content of the follicles (normal, partially depleted, depleted) were correlated on the basis of 176 thyroid investigations in cases of sudden infant death syndrome (SIDS). In the 176 SIDS cases, a resting thyroid gland with normal colloid content could only be found in 14%, whereas partially depleted follicles were found in 35% and depleted follicles in 51%. 60% of all cases showed a large degree of epithelial desquamation up to collapse of all follicles. A marked capillary hyperemia was found in 48%. 80% of the cases showed a normal colloid content in the first month of life, and colloidfree follicles should not be detected in any case. An increased incidence of thyroid activation was obtained in the total number of cases only from the second month of life. The histomorphological appearance of the thyroid gland thus corresponds to that of healthy infants only in the first month of life. The question as to why there is an evidently raised thyroid activity in the subsequent months of life in SIDS cases is discussed.     

Myocardial sarcoidosis as a rare cause of sudden cardiac death

Two relatively young women died suddenly due to myocardial sarcoidosis. Necropsy in both cases revealed compact infiltration of the ventricular septum by fibrous tissue. Histologic sections elucidated extensive granulomatous degeneration and giant cells of the Langhans' and foreign body type without central necrosis of the granulomas. Both women had been entirely free of symptoms, but in the second case of a 35-year-old, who had been 6 months pregnant, an ultrasound sonography of the heart had documented a suspicious area in the ventricular septum interpreted as a scar. Further investigations had been postponed until delivery. Isolated myocardial sarcoidosis should be taken into account as one possible cause of sudden death, especially in young people.     

A cytologic study of the sediments in pericardial fluid as it relates to a diagnosis of the mechanism of death

We have studied the sediments obtained from the pericardial fluids of 70 cadavers subject to different causes of death. The fluids were taken in the course of corresponding legal autopsies. The samples were organized according to the cause of death and cellular predominance, in the following groups, respectively: hanging, multiple trauma, craniocerebral trauma, other violent deaths, myocardial infarction, pulmonary embolism, and other natural deaths. According to cell type followed these categories: Group 1 (isolated mesothelial cells), group 2 (isolated and plated mesothelial cells), group 3 (inflammatory cells and mesothelial cells, isolated and plated), and group 4 (inflammatory cells and mesothelial cells). The statistical analysis was attained through Pearson's coefficient. We have found a significant statistical relation (P less than or equal to 0.05) between the presence or lack of inflammatory cells and the mechanism of death. In those cases with a short survival period and without cardiac affectation, the presence of inflammatory cells was practically null. Furthermore, differences in the cross-sections of inflammatory cells reflected the duration of the death process, with elements characteristic of acute inflammation revealing acute cardiac process.     

致死性心律失常的法医学研究进展

据文献报道,有很多心源性猝死是由于致死性心律失常所致。在法医学鉴定工作中,心律失常所引起的猝死往往很突然,尸检及镜下病理学检查又缺乏特征性的改变,使得鉴定其死亡机制成为一大难点。因此,寻找一种客观、准确的心律失常鉴定方法,对于致死性心律失常所致心源性猝死的鉴定尤为重要。本文将就上述问题,从致死性心律失常的定义、分类、产生原因、致死机制、形态学所见及死后生化检测指标等方面进行综述,以期为心源性猝死致死原因的法医病理学分析、鉴定提供帮助。     

Arrhythmogenesis and diagnosis of cardiac sarcoidosis. An immunohistochemical study in a sudden cardiac death

We present an uncommon case of sudden cardiac death in a 34-year-old white woman. She was found lifeless at home by her parents. Three months before death she was recovered at the Emergency Room for chest pain, palpitation and loss of consciousness. Subsequent cardiological evaluation with ECG showed sinusal rhythm, QRS deviation to the left, QS aspect, asymmetric and rounded T waves and slight length of QT. During hospitalization she presented some episodes of supraventricular paroxysmal tachycardia and non-sustained ventricular tachycardia. No echocardiography alterations were found. An anti-arrhythmic treatment was prescribed. Autopsy revealed some fibrotic scarring in the myocardium of left ventricle. The histological examination of the heart revealed diffuse and extensive fibrosis with non-caseating sarcoid granulomas. The lungs, kidneys and lymph node also showed the same non-caseating granulomas. The diagnosis of sarcoidosis with massive and extensive cardiac involvement was established as cause of death.     

心源性猝死者窦房结神经突触素定量研究

探索常规检验尚未查清的心源性猝死者的死因。采用 L SAB免疫组织化学染色法 ,对窦房结中突触素阳性物作计算机图像分析 ,定量检测及其检验处理。对照组窦房结中突触素阳性物平均每视野 1.75± 0 .6 7;在猝死组 10例中 ,A组 5例窦房结突触素阳性物平均每视野为 0 .75± 0 .11,与对照组比较有显著差异 (P<0 .0 0 11) ;B组 5例平均每视野为 1.88± 0 .74,与对照组比较无显著差异 (P>0 .4)。窦房结神经组织异常可能是导致心源性猝死的因素之一     

A case of sudden cardiac death in connection with Salmonella typhimurium infection

A case of fatal myocarditis in a 24-year-old otherwise healthy man is described. It was possible to cultivate Salmonella typhimurium from the alimentary tract, the blood, the liver and skeletal muscles. The possibility of a solitary myocarditis with fatal outcome due to Salmonella typhimurium infection is discussed. Such a case seems not to have been mentioned previously in the literature.The problems concerning the statistical registration of such a death are briefly discussed.     

Rupture of a cardiac diverticulum resulting in sudden death

Cardiac diverticula have been documented in approximately 80 patients. In over 70% of cases, this lesion is associated with midline thoracoabdominal defects or other congenital malformations of the heart. The diverticulum is thought to occur early in embryogenesis from an outpouching of the endomyocardium through a weak region in the left ventricular wall, but its exact etiology is uncertain. The case of a 6-year-old white boy who died suddenly while playing is presented. Autopsy revealed a ruptured diverticulum of the left ventricular apex with massive hemopericardium and cardiac tamponade. No other abnormalities were found. The pertinent literature is reviewed.     

Evaluation of cardiac troponin I immunoreaction in autopsy hearts: a possible marker of early myocardial infarction

Postmortem diagnosis of early myocardial infarctions is an ever recurrent problem in pathology. In the present study we determined the troponin I expression in 46 autopsy hearts using an immunohistochemical technique. Troponin I has, as a specific cardiac muscle protein, become a widespread used marker in testing patients with acute chest pain. The hearts were divided into three groups based on the macroscopical findings: definite signs of infarction, possible signs of infarction and no signs of infarction. All 14 cases of definite myocardial infarction showed a well-defined area with loss of troponin I. Twenty-three of 24 cases of possible myocardial infarction also showed a well-defined area with loss of troponin I. None of the eight non-cardiac death controls showed loss of troponin I expression. The results suggest troponin I expression as a sensitive test in diagnosis of early myocardial infarction.     

Evaluation of eosin-fluorescence in the diagnosis of sudden cardiac death

The diagnostic significance of the eosin-fluorescence method was evaluated and compared with the enzymehistochemical β-hydroxybutyrate-dehydrogenase method (β-HBDH) and the degree of hyperchromasia in 568 samples from 24 β-HBDH-negative and β-HBDH-positive sudden cardiac deaths (SCD) and 23 non-cardiac deaths as controls. The effect of autolysis was investigated separately on isolated human hearts at +4°C and +22°C. All samples were examined without any knowledge of clinical or autopsy data. Normal olive-green fluorescence was observed in only five individuals of the control group and two in the β-HBDH-negative one. The frequency of the yellow-fluorescence and hyperchromasia increased from the control subjects towards the β-HBDH-positive-ones. The difference in frequency distribution of fluorescence between the groups was statistically highly significant (P < 0.001). The change in fluorescence did not correlate with the loss of β-HBDH-reaction or the distribution pattern of hyperchromasia. Postmortem autolysis did not change the fluorescence significantly but the 78% wrong positive subjects in the control group render this method too sensitive and unreliable for medicolegal purposes.     

Evaluation of eosin-fluorescence in the diagnosis of sudden cardiac death

The diagnostic significance of the eosin-fluorescence method was evaluated and compared with the enzymehistochemical beta-hydroxybutyrate-dehydrogenase method (beta-HBDH) and the degree of hyperchromasia in 568 samples from 24 bets-HBDH-negative and beta-HBDH-positive sudden cardiac deaths (SCD) and 23 non-cardiac deaths as controls. The effect of autolysis was investigated separately on isolated human hearts at +4 degrees C and +22 degrees C. All samples were examined without any knowledge of clinical or autopsy data. Normal olive-green fluorescence was observed in only five individuals of the control group and two in the beta-HBDH-negative one. The frequency of the yellow-fluorescence and hyperchromasia increased from the control subjects towards the beta-HBDH-positive-ones. The difference in frequency distribution of fluorescence between the groups was statistically highly significant (P less than 0.001). The change in fluorescence did not correlate with the loss of beta-HBDH-reaction or the distribution pattern of hyperchromasia. Postmortem autolysis did not change the fluorescence significantly but the 78% wrong positive subjects in the control group render this method too sensitive and unreliable for medicolegal purposes.     

窦房结中央动脉狭窄与心源性猝死

近年来国内外学者相继报道由单纯窦房结中央动脉狭窄引起的猝死。本文就窦房结中央动脉的解剖、组织学特点、病变特点进行综述,探讨窦房结动脉狭窄引起猝死的机制,以期为相关法医病理学死因鉴定提供理论基础。     

分子生物学检查在猝死综合症患者法医学尸体检验中的应用

猝死综合症用来泛指急死后是用传统检查技术手段未能发现致死病变的情况。由于原因不明,其诊断和病因学的研究均十分困难。猝死综合症的诊断是法医学尸体检验实践中的难题之一。近年来,随着分子生物学技术和遗传学研究的不断深入,对于一些与猝死有关的发现不断报道,有希望用于法医学实践,用于将此类猝死进一步分型,并为进一步的深入研究提供准确的流行病学资料。