Sudden coronary death. Frequency of active coronary lesions, inactive coronary lesions, and myocardial infarction

BACKGROUND: The reported frequency of active coronary lesions (plaque rupture and coronary thrombosis) in sudden death due to coronary artery atherosclerosis (sudden coronary death) has varied from < 20% to > 80% of cases in previous series. In hearts lacking an active coronary lesion, sudden death has usually been attributed to a healed myocardial infarction. The purpose of the present study was to determine the frequency of active and inactive coronary lesions and myocardial infarction in individuals with sudden coronary death. METHODS AND RESULTS: The hearts of persons who died as a result of sudden coronary death underwent perfusion-fixation and postmortem angiography. An active coronary lesion was defined as a disrupted plaque, luminal fibrin/platelet thrombus, or both. We defined an inactive lesion as having a cross-sectional luminal stenosis of > or = 75% with neither plaque disruption nor luminal thrombus. Ninety hearts were examined (from 72 men and 18 women; mean age at the time of death, 51 +/- 10 years). Acute myocardial infarction was present in 19 (21% [acute myocardial infarction only in 9, both acute and healed myocardial infarction in 10]), healed myocardial infarction only in 37 (41%), and no myocardial infarction in 34 (38%). Active coronary lesions were identified in 51 (57%): acute thrombi plus disrupted plaques in 27, acute thrombi only in 21, and disrupted plaques only in 3. In hearts with acute myocardial infarction, active coronary lesions were significantly more prevalent than in hearts with only healed myocardial infarction or hearts lacking an acute or a healed myocardial infarction (89%, 46%, and 50%, respectively; P < .005). Hearts without acute or healed myocardial infarction and without active lesions were similar to hearts with active lesions with respect to heart weight and severity of epicardial coronary disease. CONCLUSIONS: Acute changes in coronary plaque morphology (thrombus, plaque disruption, or both) were found in 57% of cases of sudden coronary death. In hearts with myocardial scars and no acute infarction, active coronary lesions were identified in 46% of cases. Neither myocardial infarction (acute or healed) nor an active coronary lesion was present in 19% of hearts.     

A clinical and pathological study of 46 cases of sudden and unexpected death

A series of 46 autopsied adult cases of sudden and unexpected natural death were investigated. In this study, sudden and unexpected death was defined as any death occurring with 24 hours of onset of symptoms in a person with or without probable cause of death suggested by medical history. The cases included 31 males and 15 females aged 26 to 85 years (mean 66.6 years). Age distribution peaked in seventies. The lesions causing sudden and unexpected death according to the most frequent organ systems were, diseases of the heart (acute myocardial infarction with or without old infarct, 20; old myocardial infarction without acute infarction, 2; dilated cardiomyopathy, 2; sarcoidosis, 1; amyloidosis, 2; and valvular disease, 2), the aorta (ruptured aneurysm, 6; dissecting aneurysm, 2), the respiratory tract (pulmonary embolism, 7; pulmonary hypertension, 1), the alimentary tract (intestinal obstruction, 1), and other diseases (cause unknown, 1). The cardiovascular lesions were found in 78.2% of cases autopsied. The sudden and unexpected death caused by acute myocardial infarction was found in 47.8%, and acute myocardial infarction seemed to play a major role in cardiac sudden death in these series. The respiratory lesions were found in 17.4%. Four of seven cases with pulmonary embolism died in two weeks after surgical operation. The most common underlying disease was post-operative condition.     

The direct and indirect costs of cardiovascular disease in South Africa in 1991

BACKGROUND: In South Africa, cardiovascular disease (CVD) is the leading cause of death among all population groups, other than blacks, among whom it ranks third. CVD therefore has a severe impact on the South African economy. OBJECTIVES: To ascertain the availability and quality of South African data on the cost of CVD and to estimate the impact of CVD on the South African economy during 1991. METHODS: The direct health care costs and the indirect costs related to loss of productivity were estimated. Where no direct or complete detailed South African data were available, projections were made based on reasonable assumptions of data and models developed in other countries; these were applied to the limited available South African data. The major disease outcomes considered for this cost estimation were: expenditure on ischaemic heart disease, cerebrovascular disease (stroke), venous thrombosis and embolism, and peripheral vascular diseases and related conditions. These diseases are responsible for the majority of fatal cases of CVD reported in South Africa. RESULTS: The estimated total cost of CVD in South Africa in 1991 was between R4.135 billion and R5.035 billion. This does not include the cost of rehabilitation and follow-up of CVD patients since the necessary data were not available to estimate it. About three-quarters of the direct health care costs were carried by the private sector. The direct health care costs were estimated to be approximately 42% of the total cost. The rest reflects the indirect cost of earnings foregone as a result of premature morbidity and mortality. CONCLUSION: To determine accurately the total economic burden of CVD on the South African economy, additional data will have to be collected. The estimated economic burden of CVD in South Africa clearly highlights the need for a broad-based population strategy, part of an overall national effort to prevent, diagnose and cost-effectively treat CVD.     

Pathogenesis of acute coronary syndromes

Coronary artery diseases may categorized into asymptomatic disease, angina pectoris, myocardial infarction, chronic heart failure, and sudden coronary death. Unstable angina, acute myocardial infarction, and sudden cardiac death are known as the acute coronary syndromes. Coronary atheroma is unstable in the patients with acute coronary syndromes. Stable plaques will be unstable when dynamic alterations occur. The alterations are plaque rupture, plaque hemorrhage, coronary thrombosis and vasospasm. They act each other. We analysed the histopathology of coronary arteries who died of acute myocardial infarction in 85 cases. It showed that the risk factors of plaque rupture are clusters of form cells, eccentric plaque with soft lipid rich core, and thinning of fibrous cap in atheroma. Most of these cases ruptured at edge of the atheroma.     

Sudden deaths in yearling feedlot cattle

A survey of the causes for fatal diseases of yearling feedlot cattle was conducted on more than 407,000 cattle during a 14-month period. Of the 4,260 (1%) cattle that died during this period, 1,358 (32%) were categorized as cases of "sudden death syndrome." Of the 11 most frequent causes of the syndrome, as determined at necropsy, only 4--bloat, pulmonary aneurysms, riding injury, and hemopericardium--were considered as short-course problems and true causes of sudden death. The largest number of cases of sudden death were attributed to pneumonia (113 animals). Consequently, the sudden death syndrome is a misnomer for many long-course diseases and, in some instances, a mask for neglect because, as clinically used, the name frequently includes cattle that have been sick, often with pneumonia, for several days.     

Intramural coronary artery dysplasia of the ventricular septum and sudden death

We report four cases of sudden unexpected death in three males and one female aged 12 to 31 years. Death occurred during exercise in three of four cases, and there was no history of sudden death or previous cardiac history in any patient. At autopsy, there was marked intramural coronary artery dysplasia of the ventricular septum, accompanied in three of the four cases by myocardial fibrosis. The arterial dysplasia was characterized by severe medial thickening with smooth muscle cell disorganization and marked luminal narrowing. There was no evidence of myofiber disarray or asymmetric septal hypertrophy to suggest hypertrophic cardiomyopathy. Other than an ostium secundum type atrial septal defect in one case, there were no associated cardiac or extracardiac lesions found at complete autopsy of these individuals. We conclude that small vessel disease of intramural coronary arteries of the ventricular septum may be an isolated finding leading to sudden cardiac death in young adults.     

Sudden death of adults in Japan

Epidemiological features, risk factors and preventive methods of sudden death (SD) derived from studies the authors have performed since 1987 together with colleagues in Niigata University School of Medicine were reviewed. When SD was defined as death occurring within 24 hours of the onset of symptoms, the annual incidence was 145/100,000 for people aged 15 years and older in Niigata Prefecture. The incidence increased sharply along with the advance of age, while the proportion of SD to natural death due to circulatory diseases was higher in younger people. Though diseases of the circulatory system made up approximately 90 percent of all causes of death, SD due to ischemic heart disease was less frequent in Japan than in western countries. SD showed various patterns in seasonal and "within-a-day" occurrences according to sex, age and cause of death. The months of the highest SD occurrence differed by occupation and matched the busiest work periods. A decrease in sleeping hours and mental stress experienced during the preceding week were related to the occurrence of both sudden death and non-fatal acute myocardial infarction. People having structural circulatory diseases were shown to be predisposed to SD when stress occurred, because fatal arrhythmia is easily induced by the above factors in such people. Health examinations were shown to have preventive effects, though limited, against SD. Differences in the resuscitated rates in cases where a witness was present and where one was not indicates that educating people about correct resuscitation methods is important to minimizing SD.     

Sudden unexpected cardiac death: methods and results of a national pilot survey

In order to develop a methodology for measuring the occurrence and circumstances of sudden unexpected adult deaths due to cardiac and to unidentified causes throughout England, a stratified random pilot sample of 12 of the 133 coroner's jurisdictions in England was invited to survey prospectively a quota sample of 78 consecutive white Caucasians, aged from 16 to 64 years, with no history of ischaemic heart disease, who were last seen alive within 12 h of being found dead, and for whom a coroner's post-mortem examination found either a cardiac or no identifiable cause of death. Eleven (92%) coroners participated. In a median of 105 days (range 21-169), 65 cases (83% of the quota) were ascertained (54 (83%) males). Of the ascertained cases, registration forms were received on 62 (95%), tissue specimens on 63 (97%), and post-mortem reports on 58 (89%). Death was witnessed in 58%, of which 35% were 'instantaneous'. The median time from symptom onset to death was 40 min. In unwitnessed deaths, the median time since last being seen alive was 90 min. Sixty-eight per cent of all deaths were attended--by a relative in 34%, passer-by (8%), ambulance crew (32%), nurse (11%), doctor (38%), and police (9%). Cardio-pulmonary resuscitation was attempted in 38 of the 42 attended deaths. Sixty-seven per cent were taken ill at home, 12% at work, 12% in a public place, and 10% elsewhere. The certified cause of death was ischaemic heart disease in 89%, in whom coronary thrombosis and/or myocardial damage was absent in 6 cases (9%). In the remainder, the certified cause was hypertensive heart disease (5%), hypertrophic obstructive cardiomyopathy (3%), 'cardiomegaly' (1.5%) and 'sudden cardiac arrhythmia' alone (1.5%). A retrospective audit of coroner's records revealed the median case ascertainment rate was 75%. This approach to surveying sudden unexpected adult death nationally resulted in a high response rate (92%) from coroners, consultant pathologists and their staff, the identification of a large proportion of eligible cases, and complete information in most of the identified cases. In from 2% to 15% of cases, death may have been either purely dysrhythmic or due to a sudden adult death syndrome.     

Morphometric analysis of the kidney lesions in mixed connective tissue disease (MCTD)

We examined histopathological changes of the kidney in patients with mixed connective tissue disease (MCTD) including those of glomeruli, arteries and interstitium by morphometric method. All specimens examined were collected from 25 autopsy cases diagnosed as MCTD according to the criteria for this disease proposed by the MCTD committee sponsored by the Japanese government. Clinical evidence of renal dysfunction such as proteinuria was present in 16 out of 25 cases (64%). Histopathologically, membranous type glomerular lesion was found most frequently (40%), followed by membrano-proliferative (6.7%) and mesangioproliferative types (6.7%). Nine cases had no glomerular lesion. Severe arterial lesion such as necrotizing angiitis was not found in our kidney specimens. However, morphometry revealed a high incidence of intimal thickening in the renal arteries of these patients as compared to control cases, showing this to be one of the most common features of MCTD with clinical importance. This type of arterial lesion, also seen in kidneys in other types of collagen diseases, may suggest an etiology common to them. The severity of the renal interstitial lesion in MCTD was intermediate between that of systemic lupus erythematosus (SLE) and progressive systemic sclerosis (PSS), poly-or dermatomyositis (PM/DM).     

Cardiac disease in intracerebral hematomas

INTRODUCTION AND OBJECTIVE: The Central Nervous System (CNS) plays an essential role in the regulation of the cardiac function. There is strong evidence that many CNS lesions, mainly those of hemorrhagic origin, may induce repolarization abnormalities and enlargement of the QT interval (ECG changes) and several types of arrhythmias. In some cases these changes have been related to sudden death. The imbalance between the sympathetic and parasympathetic systems, favoring the former, seems to be the etiopathogenic factor. MATERIAL AND METHODS: We have carried out a study on thirty-two in-patients suffering from non-severe intracerebral hemorrhage, by means of a Holter ECG examination within the first 72 hours and a second record after two months. We have assessed any significative differences on the ECG findings in relation to the location of the hematoma (left or right hemispheres) and the presence of a personal history of arterial hypertension and/or heart disease. RESULTS: One or more ECG changes were present in 69.2% of the patients and 73% showed one or more rhythm abnormalities. There was a higher incidence of supraventricular arrhythmias associated with the right hemisphere hematomas, with an statistical significance for the atrial extrasystolia. No differences were found between the group with a previous history of hypertension and/or heart disease and the one without these conditions. There were two cases of sudden death, both with left hemisphere hematomas, and in one of them the previous rhythm abnormalities were recorded. CONCLUSIONS: This study corroborates the hypothesis that right hemispheric hematomas induce supraventricular arrhythmias more frequently. The possible association between severe ventricular arrhythmias and sudden death with left-hemisferic hematomas should be studied in a higher number of patients. We recommend monitoring every acute case of intracerebral hematoma when possible.     

The Münster Heart Study (PROCAM): total mortality in middle-aged men is increased at low total and LDL cholesterol concentrations in smokers but not in nonsmokers

BACKGROUND: Some large epidemiological studies have shown an increase in mortality at low levels of total and LDL cholesterol. It has been speculated that low cholesterol levels may play a causative role in this association. To investigate this question, we analyzed all deaths occurring among middle-aged men in the Münster Heart Study (PROCAM), one of the largest prospective epidemiological studies of coronary heart disease risk markers in Europe. METHODS AND RESULTS: In the Münster Heart Study, 10,856 men aged 36 to 65 years at study entry (46.8+/-7.3 years [mean+/-SD]) were followed for 4 to 14 years (7.1+/-2.4 years). During this period, 313 deaths occurred--46 from myocardial infarction, 48 from suspected or definite sudden cardiac death, 14 from cerebrovascular disease, and 10 from other diseases of the circulatory system. There were 121 deaths from cancer and 33 deaths from violent causes (injuries in 16, suicide in 14, and homicide in 3 cases). Death in 29 cases occurred from other causes and was unexplained in 12 cases. Total cholesterol, LDL cholesterol, and the LDL/HDL ratio showed a J-shaped relationship with total mortality. At high total and LDL cholesterol concentrations, increased mortality was due to increased coronary deaths. At low total and LDL cholesterol concentrations, increased mortality was seen in smokers only and was explained by an increase in smoking-related cancer deaths. CONCLUSIONS: The increase in mortality at low levels of total and LDL cholesterol among middle-aged men in the Münster Heart Study is explained by an increase in smoking-related cancer deaths among smokers.     

Prospective blinded study of the relationship between plasma homocysteine and progression of symptomatic peripheral arterial disease

PURPOSE: An elevated plasma homocysteine level is an established risk factor for atherosclerotic coronary heart disease (CHD), cerebrovascular disease (CVD), and lower extremity occlusive disease (LED). An elevated plasma homocysteine level can be reduced by therapy with folate and vitamins B6 and B12. An accurate evaluation of the role of vitamin therapy requires knowledge of the influence of plasma homocysteine levels on the progression of CHD, CVD, and LED. METHODS: The Homocysteine and Progression of Atherosclerosis Study is a blinded prospective study of the influence of homocysteine and of other atherosclerotic risk factors on the progression of disease in patients with symptomatic CVD, LED, or both. This study is set in a university hospital vascular surgery clinic and the General Clinical Research Center. Consecutive patients with stable symptomatic CVD or LED underwent baseline clinical, laboratory, and vascular laboratory testing for homocysteine and other risk factors and were examined every 6 months. The primary endpoints were ankle brachial pressure index, duplex scan-determined carotid stenosis, and death. The secondary endpoints were the clinical progressions of CHD, LED, and CVD. The hypothesis that was tested was whether the progression of symptomatic CVD or LED was more frequent or more rapid in patients with elevated plasma homocysteine levels. plasma homocysteine levels. RESULTS: After a mean follow-up period of 37 months (range, 1 to 78 months) for deaths from all causes (>14 micromol/L; elevated, 18.6%; normal, 9.4%; P = .022), deaths from cardiovascular disease (elevated, 12.5%; normal, 6.3%; P = .05) and the clinical progression of CHD (highest 20% of homocysteine levels, 80%; lowest 20% of homocysteine levels, 39%; P = .007) were significantly more frequent or more rapid by life-table analysis when the homocysteine levels were elevated. Multivariate Cox proportional hazards regression model showed a significant independent and increasing relationship between the plasma homocysteine levels and the time to death (relative risk for highest one third of homocysteine values, 1.6; 95% confidence interval [CI], 1.04 to 2.56; P = 029; and relative risk for highest one fifth of homocysteine values, 3.13; 95% CI, 1.69 to 6.64; P = .0001). After an adjustment for age, smoking, hypertension, diabetes, cholesterol, and the vascular laboratory progression of CVD or LED, each 1.0 micromol/L increase in the plasma homocysteine levels resulted in a 3.6% increase (95% CI, 0.0% to 6.6%; P = .06) in the risk of death (all causes) at 3 years and a 5.6% increase (95% CI, 2.2% to 8.5%; P = .003) in the risk of death from cardiovascular disease. CONCLUSION: We conclude that elevated plasma homocysteine levels are associated significantly with death, with death from cardiovascular disease, and with the progression of CHD in patients with symptomatic CVD or LED. These results strongly mandate clinical trials of homocysteine-lowering vitamin therapy in such patients.     

Interactions between dietary fat type and xylanase supplementation when rye-based diets are fed to broiler chickens 2. Performance, nutrient digestibility and the fat-soluble vitamin status of livers

We analyzed retrospectively the outcome of 169 patients in chronic hemodialysis (CHD), divided into four groups: 1) 24 patients with diabetic nephropathy (age 53.7 +/- 11 years); 2) 19 with polycystic kidney disease (age 55.3 +/- 9 years) 3) 43 patients older than 60 when starting chronic hemodialysis with etiologies different from diabetes and polycystic kidney disease (age 69.2 +/- 5.8 years) and 4) 83 patients younger than 60 with diverse etiologies (age 42.8 +/- 12.4 years). In groups 1, 2 and 3 serum creatinine, arterial hypertension at the beginning, morbility, mortality and its causes were registered. In group 1, the prevalence of severe diabetic retinopathy and cardiovascular disease at the beginning were also analyzed. In all groups survival was determined. Of the diabetics, 92% presented severe diabetic retinopathy and 88% cardiovascular disease. The prevalence of hypertension was 100, 74 and 67% in groups 1, 2 and 3, respectively (p = 0.13). Twelve diabetics died before the first year of treatment; there was no difference in creatinine, age, cardiovascular disease, severe retinopathy and hypertension with those who lived more than one year. The percentage of time in risk hospitalized and the days/patients/year hospitalized were significantly different between group 1 and 3 and group 2 (p < 0.001). Patients were hospitalized for similar causes in groups 1 and 3: the initiation of CHD, cardiovascular and neurological diseases. The main causes of death in groups 1 and 3 were: cardiovascular disease and sudden death at home. Survival was better in group 2 compared with group 1 (p = 0.0014) but was similar between groups 1 and 3 (p = 0.21) even though there was a difference of 15 years between them. The Cox's proportional hazard model identified as risk factors diabetes, age, year of starting chronic hemodialysis and hospitalization episodes, adjusted for covariates. The outcome of diabetic patients in chronic hemodialysis showed high morbidity and mortality and was quite similar to that of elderly patients.     

Ultrastructural changes in cerebral blood vessels following prolonged administration of L-dopa to laboratory animals

Patients with anomalous left coronary artery arising from the pulmonary artery rarely survive to adult life. Those who attain adulthood may present with angina indistinguishable from coronary artery disease and are liable to sudden death. Myocardial infarction, though rare in young adults, may occur and may be due to coronary artery steal. Accurate diagnosis requires coronary arteriography. Two further cases of coronary artery steal in adults with anomalous origin of the left coronary artery from the pulmonary artery are presented. In both patients aortocoronary bypass grafting using a reversed autogenous saphenous vein with closure of the origin of the anomalous left coronary artery was successfully performed. This operation provided complete symptomatic relief and may protect patients against the risk of sudden death.     

Analysis of cause of death in Central Rhine prisons and in police detention centers 1949 to 1990

Using the documents from the Institute of Legal Medicine in Bonn, the deaths (86) in Middle Rhine detention centres and police custody since 1949 were investigated. All the deceased were male (average age 37, range: 18-67 years). As far as deaths from natural causes were concerned, death caused by myocardial infarction was the most frequent. The average age of myocardial infarction victims was 48. In two of these cases Koch's disease of the lung was diagnosed. Death of unnatural causes was the most frequently recorded, accounting for 63% of cases (suicide by hanging of incision injuries = 51%, and death by intoxication = 12.5%). Hanging was the most common means of committing suicide usually being discovered in the morning. Items of clothing and cell windows were the most commonly used objects. Nearly all the suicides were under the influence of alcohol. In 6.8% of cases the drug tests were positive.     

Comparison of sudden and nonsudden coronary deaths in the United States

BACKGROUND: The present study was designed to compare risk factor prevalences in coronary heart disease deaths in persons dying within 1 hour of onset of cardiovascular symptoms (sudden coronary death), those dying without such sudden symptoms (nonsudden coronary death), and those with unknown duration of symptoms before death (other coronary death). METHODS AND RESULTS: Data from the 1986 National Mortality Followback Survey and the US Bureau of the Census were examined to assess death rates for sudden, nonsudden, and other coronary deaths. Multivariate logistic regression methods were used to calculate the odds ratio (OR), compared with nonsudden and other coronary deaths, for sudden coronary death associated with socioeconomic status variables, the person's location at death, and coronary heart disease risk factors. Mortality rates for all coronary deaths increased with age, were higher for men than women, and increased with decreasing years of schooling. The rate of sudden coronary death was highest for Hispanics. In 1986, an estimated 251,000 sudden coronary deaths (95% CI = 238,000 to 263,000) occurred in the United States. Sudden coronary deaths were less likely than nonsudden coronary deaths to occur at home (OR = 0.5, 95% CI = 0.4 to 0.6), but individuals who died of sudden coronary death were more likely to have been current cigarette smokers (OR = 1.3, 95% CI = 1.0 to 1.8). No other modifiable risk factors for coronary heart disease distinguished sudden coronary deaths from nonsudden coronary deaths. CONCLUSIONS: Contrary to the commonly held view, coronary deaths in the home are more likely to be nonsudden than sudden. Cigarette smoking more likely results in sudden than nonsudden coronary death, perhaps because of nicotine-induced ventricular arrhythmias.     

Cloning and bacterial expression of sesquiterpene cyclase, a key branch point enzyme for the synthesis of sesquiterpenoid phytoalexin capsidiol in UV-challenged leaves of Capsicum annuum

The optimal prophylactic strategy for cytomegalovirus (CMV) disease after allogeneic hematopoietic stem cell transplantation has not yet been established. The aim of this study was to analyze our single-center experience with a uniform protocol of CMV antigenemia-guided pre-emptive treatment with ganciclovir (GCV) after allografting. Fifty-two consecutive adult patients, 48 of them transplanted from HLA-identical matched related donors were included. T cell-depleted marrow or peripheral blood were used in 21 cases. After engraftment, weekly blood samples were tested for CMV pp65 antigenemia and viremia (conventional cultures) until day +100. GCV was started if CMV antigenemia and/or CMV viremia were detected. CMV infection (CMV-I) was found in 19 patients (37%). Seven patients suffered from CMV disease (CMV-D), three colitis and four pneumonias. There was one death directly related to CMV-D and three further cases died from refractory GVHD with CMV-D. Only one patient developed CMV pneumonia without any previous positive antigenemia and/or viremia. Multivariate analysis identified grades II-IV acute GVHD (P = 0.02) and peripheral blood stem cell transplantation (P = 0.03) to be risk factors for developing CMV-I. In conclusion, this monitoring protocol allowed early treatment of CMV-I without progression to CMV-D. Pre-emptive therapy had the additional advantage of avoiding GCV administration in most of our allograft recipients.     

Histopathological studies on the myocardial fibrosis and vascular lesion of rheumatic valvular disease

To clarify the types and frequency of myocardial fibrosis and vascular lesions caused by different types of the rheumatic valvular disease, 41 autopsied hearts with rheumatic valvular lesions were examined and the following results were obtained. As to myocardial fibrosis, 1) perivascular fibrosis, caused mainly by perivascular inflammation and partly by myocardial strain, varied in grade according to the types of the valvular disease, i.e., most severe in mitral regurgitation (MR) and combined valvular disease (CVD) and least in mitral stenosis (MS); 2) Aschoff's nodes: 3 typical and 8 atypical cases were found; 3) perimycial fibrosis due to myocardial strain: most severe in MR and CVD and least in MS; and 4) irregular patchy fibrosis, caused mainly by myocarditis and partly by ischemia, was noticed in all types of the valvular disease. As to vascular lesion, 1) angitis was found in 7 cases and most frequently in MR; and 2) thickening of the intima and media was found in all types of valvular disease. Thus, myocardial fibrosis and vascular lesion varied according to the types of valvular disease, and not only hemodynamic changes but also myocardial fibrosis and vascular lesions might determine the prognosis of the valvular disease.     

pH sensitive properties of Tc(V)-DMS: analytical and in vitro cellular studies

Coronary arteries anomalies may be part of complex congenital malformations of the heart or be an isolated defect. In our anatomic collection of congenital heart disease, an isolated anomalous origin of coronary arteries was observed in 27 of 1,200 specimens (2.2%): left coronary artery from pulmonary trunk in five, origin from the wrong aortic sinus in 12 (both right and left coronary artery from the right sinus in four and from the left sinus in seven, left coronary artery from the posterior sinus in one), left circumflex branch from right aortic sinus or from very proximal right coronary artery in three, high takeoff of right coronary artery in three, stenosis of the coronary ostia attributable to valvelike ridge in four. In 16 (59%) patients (12 males and 4 females, age ranging from 2 months to 53 years; median, 14), the final outcome was sudden death; it occurred in all cases of left coronary artery origin from right aortic sinus, in 43% of right coronary artery origin from left aortic sinus, and in 40% of the left coronary artery from the pulmonary trunk. Sudden death was precipitated by effort in eight (50%) and was the first manifestation of the disease in eight (50%); previous symptoms consisted of recurrent syncope in four, palpitations in three, and chest pain in one. Five patients who died suddenly during effort were athletes. In conclusion, (1) more than half of our postmortem cases with anomalous origin of coronary arteries died suddenly, (2) all but two patients with sudden death had anomalous coronary artery origin from the aorta itself, (3) the fatal event was frequently precipitated by effort, (4) palpitations, syncope, and ventricular arrhythmias were the only prodromic symptoms and signs. Recognition during life of these coronary anomalies, by the use of noninvasive procedures, is mandatory to prevent the risk of sudden death and to plan surgical correction if clinically indicated.     

Morphological and biochemical changes in the myocardium after sudden death from ischemic heart disease

The myocardium was examined in 44 persons who had suddenly died of ischemic heart disease, in 37 who had died of injury, and in 28 who had died of alcohol poisoning. Those with ischemic heart disease had foci of necrosis of the muscle fibers, severe disturbances in microcirculation, changes in the activity of certain myocardial enzymes and in the content of lipids in the myocardium. Biochemical changes similar to these in many respects were revealed in individuals who had died of alcohol poisoning, in view of which alcohol poisoning may be a factor conducive to sudden death in ischemic heart disease.