Sudden Cardiac Death in Two Young Adult Males, New Risk Factors for Ischaemic Heart Disease
Roque Gabriel Wiseman Pinto
Shanta S. Kudale
Siddhartha S. Banaulikar
Avinash J. Pujari
Ischemic heart disease (IHD) is a group of diseases that include angina pectoris, myocardial infarction, chronic IHD with heart failure, and sudden cardiac death. IHD is the leading cause of death all over the world. Its incidence in young males is ever increasing with well-deﬁned risk factors. We report two young males, aged 22 years and 18 years with sudden cardiac death, most probably due to an acute myocardial infarction, as seen in post-mortem. Two new risk factors were observed in these patients namely (1) The use of steroids and growth hormones in ﬁtness instructors and body builders (2) Polyarteritis Nodosa
Ischemic heart disease (IHD) also known as Coronary Artery Disease (CAD) continues to be a major public health problem in the industrialised world and it is becoming an increasingly important problem in the developing countries as well, India being no exception. It is the leading cause of death worldwide. Ischemic Heart Disease (IHD) includes a group of cardiac disorders that cause a reduction in the coronary blood ﬂow. These cases are on the rise even in young adults. Males are seen to be aﬀected more in comparison to females.
Sudden cardiac death (SCD) is deﬁned as a sudden, unexpected death due to cardiac causes that occur in a short time period (usually within 1 hour of symptom onset) in a person with known or unknown cardiac disease. SCD can result from innumerable causes such as myocardial infarction, arrhythmias, cardiomyopathy, and structural/valvular heart disease. In this article, the two case reports describe two young adult males who died of SCD and in whom autopsies were performed. Post-mortem ﬁndings and the pathological diagnosis has been described here.
Case Reports :
Case 1 :
A 22-year old male, a Gymnasium instructor and trainer, presented with acute, severe chest pain. He collapsed and died within 30 minutes after admission. A post mortem was performed .
Pathological Findings :
Cardiovascular system revealed moderate cardiomegaly with left ventricular hypertrophy, areas of congestion on anterior and posterior walls of the left ventricle externally, anterior descending branch of the left coronary artery (LCA) showed complete occlusion by a fresh thrombus and an atheromatous plaque (Figure1). The other branches of both coronaries showed atheromatous changes. Respiratory system revealed moderate congestion and edema of both lungs. Central nervous system revealed mild congestion and edema. Liver was enlarged with moderate congestion. Other organs revealed congestion.
The microscopic examination revealed a fresh thrombus superimposed on an atheromatous plaque. (Figure 2) Heart showed congestion on microscopy.
The cause of death was sudden cardiac death as a result of total occlusion of the anterior descending branch of the LCA by a fresh thrombus superimposed on a pre-existing atheromatous plaque.
Young men frequenting gymnasiums who are body builders or professional athletes are known to use steroid hormones and growth hormones and also consume high caloric diets to build up their muscles to improve their strength and endurance levels. Steroids also enhance appetite. Steroid use has been shown to increase atherosclerosis as well as increase the risk of thrombus formation. This is in addition to left ventricular contractility dysfunction that can occur. The use of steroids was clearly a risk factor in this case contributing to the probable myocardial infarction causing SCD.
Case 2 :
An 18-year-old male college student collapsed and died while playing football on the college grounds. An autopsy was performed.
Pathological Findings :
On postmortem examination there was complete occlusion (brownish-white and reddish in color) of the LAD (Left Anterior Descending) branch of the LCA. The left ventricular wall was congested. Microscopic examination: The LAD branch of LCA showed a transmural arteritis of the arterial wall, mixed inﬁltrate of neutrophils, eosinophils, mononuclear cells, and ﬁbrinoid necrosis with a thrombus in the lumen. The arterial wall showed concentric onion-skin ﬁbrosis. These features are diagnostic of Polyarteritis Nodosa (PAN).
PAN is a systemic vasculitis aﬀecting medium sized vessels. Cardiac involvement usually is a coronary arteritis that causes stenosis, aneurysms, dissection, aneurysmal rupture, thrombosis and possible myocardial infarction. In addition, there may occur a myocarditis resulting from the arteritis as well as valvular involvement in some patients.
Ischemic heart disease has several risk factors. These include smoking, hypertension, diabetes mellitus, dyslipidemia, alcoholism, sedentary habits, positive family history, obesity, anemia, anti-psychotic medication, narcotic drug abuse, increased waist to hip ratio, nephrotic syndrome, hypercoagulability, systemic lupus erythematous. In these cases, we describe two new risk factors namely (1) Use of corticosteroids and growth hormone, used by ﬁtness instructors (2) Polyarteritis Nodosa.
Young patients (below 30 years of age) presenting with an acute myocardial infarction have the following clinical features :
Chest pain is the most important presenting symptom. Anterior wall myocardial infarction, usually a single vessel disease, and smoking and a positive family history are common risk factors. Non-atherosclerotic coronary artery disease due to hypercoagulability should be investigated in younger patients. Overall, 4-8 % of the patients with an acute myocardial infarction are less than 40 years of age. There is a paucity of information concerning the clinical features, natural history and prognosis of young patients with an acute myocardial infarction. In young patients besides morbidity there are other concerns like psychological eﬀects, ﬁnancial constraints for the person and family.
- Sricharan K.N., Rajesh S., Rashmi, Meghana H.C., Sanjeev B, Soumya M. Study of Acute Myocardial Infarction in Young Adults : Risk Factors, Presentation and Angiographic Findings. Journal of Clinical and Diagnostic Research, 2012, Vol 6 (2), 257-260.
- Venkateshwarlu N, Gandaiah P, Indira G, Reddy PAG, Sivarajappa P. Acute Myocardial Infarction in young below 30 years of age: Special insight into risk factors. International Journal of Medical and Applied Sciences, 2013, Vol 2, Issue 4, 90-98.
- Vaidya CV, Majumdar DK, A Study of Acute ST elevation MI in young patients from Government teaching hospital. Sudan Med. Moritt. 2015, Vol 10, issue 2, 45-49.