Understanding and Preventing Sudden Death

Your Life Matters

Koon Hou Mak

• Publisher: WSPC
• Year: 2015
• eBook ISBN: 9789814641173
• Topic: Medicine
• Subtopic: Cardiology

Sudden death is an uncommon condition. But when it occurs, especially in a young person, the acute loss can generate a substantial amount of grief with a great sense of disbelief. This mysterious and dreadful condition instils much fear and anxiety into the living, and more specifically for family members and friends. Understandably, the apprehension is brought about by the unexpectedness of the event and uncertainty of the consequences. The feeling of uneasiness is largely attributed to the lack of information regarding this condition. However in recent years, several causes of sudden death have been clarified. Treatment modalities have improved and reduced the occurrence of dying suddenly.This book is meant for anyone who wants to know more about sudden death. It aims to diminish its terror by explaining the various conditions that predispose individuals to sudden death and ways which may prevent it from occurring. Contents:

• Reflections on Sudden Death
• Dedication
• About the Author
• Preface by ESM Goh Chok Tong
• Preface
• Forward
• Abbreviations
• Introduction:
  • It Just Did Not Happen Suddenly, or Did it?
• Sudden Unexpected Death Syndromes:
  • Surprise! Happy … Birthday?: Heart Attacks and … Heart Attacks
  • A Peculiar Chamber: Thickened Heart Muscle Walls: Hypertrophic Cardiomyopathy
  • The First Kiss Of Love … and Death: Emotional Ups and Downs, Electrical Longs and Shorts: The Long-QT Syndrome
  • Clues and Red Herrings: The Most Unhearty "Wagyu": Arrhythmogenic Right Ventricular Cardiomyopathy
  • Slipping into Eternal Rest: Death Creeping into Sleep: The Brugada Syndrome
  • ":Ah-Choo!" "… and You are Dead!": Infection and Inflammation of the Heart: Myocarditis
  • "I Have Just had a Baby, Not a Cardiac Arrest!": A Large Weak Heart: Dilated Cardiomyopathy
  • The Big White Killer Wolf: Bypass Tracts and Short-Circuits: the Pre-Excitation Syndrome
  • It's Not Only the Heart: Time Bombs Ticking in the Head
  • The Sporadic Killers: Less Common Causes of Sudden Death
• Can Sudden Death be Prevented?
  • History … Checked … Examination … Checked … Investigation … Checked …: The Role of Routine Medical Examination
  • Keep on Moving: Physical Activity and Exercise
  • Longevity Potions and Elixir of Health: Omega-3 Fatty Acid Supplementation
  • Poisons and Medicines: Drugs that Prevent Sudden Death
  • Empowering the Rescuer: CPR Training and Advent of Automated External Defibrillator
  • Having Your Personal ER Team: Intra-Cardiac Defibrillators
• The Final Post
• References
• Index
• General public (family and friends of the deceased, witnesses and care-givers), GPs, medical students training in cardiology, paramedics and cardiologists. Key Features:
  • No known competing title and written public information on this subject is lacking
  • Author is an eminent cardiologist with previous books communicating to the public
  • This book contains up-to-date information and guidance on the subject

PART I

Introduction

It Just Did Not Happen Suddenly, or Did It?

“Nενικήκαμεν”

“We have won!”

Pheidippides, 490 BCE

Sudden death is supposed to occur suddenly: it is to have taken place unexpectedly and without warning; whereby heart function ceases abruptly resulting in death. The first thing that comes to our mind regarding sudden death is that the cause is a heart attack. While a heart attack (acute myocardial infarction) may result in sudden cardiac death, there are several other causes. Furthermore, the sudden onset is a matter for debate. Traditionally, the individual was previously well but died within an hour of onset of symptom.² When there are no witnesses, death occurring within 24 hours may also be considered sudden. Indeed, about 30% to 40% of cardiac arrest was unwitnessed.³ Other known causes, such as multiple injuries due to a road traffic accident or suicide, should be excluded. But again, the issue of accidents is complicated. Did the driver or person have an acute medical event that caused the unfortunate incident? Or was it the “shock” of the accident that resulted in the death of the victim?

How Common is Sudden Death?

We often read or hear about people dying suddenly. In the United States, there are approximately 295,000 out-of-hospital cardiac arrests yearly.⁴ Of note, sudden death accounted for approximately two-thirds of the total deaths from cardiovascular disease.⁵ However, there was wide regional variation within the country, and the incidence of sudden death ranged from 180,000 to >450,000 yearly.⁶ Such surveys have been conducted in several countries. Overall, the incidence of sudden death in the population ranges from 50 to 100 per 100,000.^3,4,7–9 As expected, the incidence of sudden death increases with age. For men, it was about 100 per 100,000 for 50 years old and 800 per 100,000 for 75 years old.¹⁰ The rate of sudden death is generally lower for women, about 30% of that of men and lags behind by at least 10 years.¹¹ But this trend tends to reverse after the age of 65.¹² Most sudden cardiac arrests occur in the community and less than 5% to 10% survive even when they are attended to by emergency medical services.⁴ Therefore, the occurrence of sudden death in various reports may be influenced by how each case is identified and counted.

Gender Differences

Although the causes of sudden death varies according to age and sex; overall, coronary artery disease is the most common cause, accounting for 80% among men and 45% among women.¹³ In the United Kingdom, coronary artery disease accounted for 59% to 86% of sudden deaths.^14,15 So, sudden death does not only refer to heart attack although individuals with heart attack may die suddenly. In about 5% of them, a cause cannot be determined in some reports.^13,16,17 Similar to men, coronary risk factors contributed to sudden death in women.^18,19 However, about two-thirds of women do not have a known history of heart disease compared to half in men.^3,11,18 Furthermore, they were less likely to have previously known reduced left ventricular function or coronary artery disease.¹⁹ These differences may account, at least in part, for the variation in temporal trends. In the United States, from 1989 to 1998, while the occurrence of sudden death increased by about 21% for women who were 35 to 44 years of age, it fell by 2.8% for men in the same age group.²⁰

Incidence and outcomes following an out-of-hospital cardiac arrest event differed between the two sexes. From 1998 to 2007, the pattern of occurrence cardiac arrest for 15,701 men and 11,179 women was studied in the population of Osaka prefecture.²² For girls whose age is 12 years or younger, the likelihood for an out-of-hospital event was three-quarters that of boys. Between the ages of 13 and 49 years, this risk further reduced to two-fifths. When they are 50 years or older, women were about half as likely as men to suffer from an out-of-hospital cardiac arrest event. Not only that, out-of-hospital events occurred less frequently among female and the chances for good neurological recovery was twice that of male between the ages of 13 and 49 years. The investigators attributed the favourable outcome among women with out-of-hospital cardiac arrest to the protective effect of oestrogens.

No Easy Answers

When considering those who died suddenly without previous illnesses, the causes of unexpected sudden death were different. In the United Kingdom, the proportion of unexplained sudden deaths was estimated to be 3.8% in 1988¹⁴ and 4.1% in the 1990s,¹⁵ despite intensive evaluation by three cardiac pathologists. In a later study involving all coroners in the United Kingdom, no abnormality was detected in the heart for 269 (59%) of 453 individuals who died suddenly during post-mortem examination.²¹ A new name, sudden adult death syndrome, was coined. Since abnormal rhythm was the mechanism of death, it was re-named as sudden arrhythmic death syndrome (SADS). The potentially lethal rhythm disorder is largely due to abnormal proteins on the surfaces of the heart muscle that result in disturbances in electrical discharge.

In Times of Ages Past

Throughout history, sudden death has been recorded. More than 4,000 years ago, it has been found in the archives of ancient Egypt.²³ Ebers Papyrus (c. 1550 BC) recorded, “When thou examines a person with a suffering in his abdomen, he is ill in his arm, in his breasts, and in the stomach-region; and it is told him that it is the uat-illness … then thou sayest: ‘It is Death that has penentrated his mouth and take up its abode.’”²⁴ In China, when “an intermittent pulse” is detected, it is “a predictor of imminent death.”²³ Even Hippocrates recognised that “intense chest pain that radiates to the clavicle (collar bone) and back is a sign of poor prognosis … (and) … obese individuals are more likely to die suddenly …” Perhaps the most famous story of sudden death is based on the origins of the word “Marathon.” After winning an exigent battle between the Persians and the Greeks, Pheidippides, a messenger ran about 26 miles (about 42 kilometres) from Marathon, the site of the fighting, to Athens to break news of the victory. On arrival, he announced “Nενικήκαμεν” (or “Nenikékamen”, which may translate to “We have won”) before collapsing and died (Figure 2). This was the story believed to mark the origin of this arduous event. But it was not so straight-forward.

It was in 492 BCE when Darius I, King of Persia, with a large military force — consisting of a fleet of 600 ships, was to invade Greece. During the journey, the fleet faced attacks and a sudden severe storm which wrecked half its fleet. Although weakened, the Persians attacked Greece initially in 490 BCE with 25,000 men and 600 triremes. King Darius chose the Bay of Marathon to be the place for landing because of a broad plain of a mile wide and six miles long, which would be suitable for the Persian cavalry. On the other hand, the Greeks being democratic, opinions were divided as to how the invading force should be dealt. But time was not on their side. So about 11,000 men from Athens and Platanos were hastily gathered and led by General Miltiades to face the Persians. Soon the Greeks real ised that they were greatly outnumbered, Pheidippides was sent to Sparta to seek assistance. As much as they would like to, the Spartans were celebrating a religious festival and were unable to participate in that war. During the 9-day Karneia, military activites were suspended. So, Pheidippides ran back with the disappointing news in about 48 hours, and the entire trip was estimated to be 150 miles (about 241 kilometres). He then fought the battle valiantly in full armour. This event was thought to have taken place during the months of August or September, right in the heat of summer. After this exhausting battle, Pheidippides ran his final race, from Marathon to Athens (Figure 2).

Figure 2. Le soldat de Marathon (The Soldier of Marathon) by Luc-Olivier Merson, 1869.

Pheidippides giving word of victory after the Battle of Marathon.
Photograph obtained from http://commons.wikimedia.org/wiki/File:Phidippides.webp

Sudden Death in the Uniformed Services

Although death is not an uncommon occurrence during war, soldiers may also die during peacetime. Some of these unfortunate incidents were sudden. The uniformed services tend to keep excellent records of their personnel as part of their routine and accountability. In the United States Armed Forces, there were 6.3 million 18-year-old recruits undergoing intense military training for 8 weeks over a 25-year period.²⁵ There were 277 deaths that were not related to injuries. So, the estimated rate of occurrence of sudden death was 4.4 per 100,000 recruits. Another study was conducted by the United States Armed Forces on mortality trend from 1998 to 2008,²⁶ with a mean annual population of 1.39 ± 0.02 million, which provided additional insight into the causes of sudden death among relatively young adults. Over this period, 14,771 service personnel passed away. After excluding those who died from wars, homicides, accidents and illnesses, records for review ...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• Reflections on Sudden Death
• Dedication
• About the Author
• Preface by ESM Goh Chok Tong
• Preface
• Foreword
• Abbreviations
• Part I Introduction
• Part II Sudden Unexpected Death Syndromes
• Part III Can Sudden Death be Prevented?
• Part IV The Final Post
• References
• Index