الفهرس 
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Abstract
Summary
Death in young adults when occurred suddenly or unexpectedly has an actual medicolegal aspect, and in some of the most difficult problems in medicolegal cases the cause of death was frequently concealed ”unknown natural disease” and was discovered with surprise at post mortem examination.
The aim of this work was to estimate the incidence of sudden cardiac death among young adult Egyptians admitted to the Egyptian’s Medicolegal Administration in the period from first of January 2010 to end of December 2011, with studying the heart grossly and microscopically, to give an idea about the incidence of young adult deaths due to cardiac diseases in comparison with other groups of different ages and non-cardiac diseases , and to shed light on the prevalence of different cardiac diseases contributing to sudden death among young adult Egyptians.
Up to our knowledge, such study has not been previously reported in Egypt.
All cases of sudden deaths, which were admitted to the Medico-legal Administration in two years 2010 - 2011, were investigated. The age, sex, any available medical history of the deceased and autopsy findings were recorded.
Hearts of sudden deaths were pathologically examined grossly and microscopically, with focusing on its weight, ventricular wall thickness, coronaries, myocardium or any suspicious lesion.
Coronaries were evaluated for presence of any anomaly; the grade of stenosis was assessed according to percentage of occlusion (G0=No Occlusion “<25% occlusion”, GI=Mild “25%-<50%l occlusion”, GII=Moderate “50%-<75% occlusion” or GIII=Severe “>75%l occlusion”), the atherosclerotic lesions were histological typed according to the AHA (type I, II, III, IV, V or VI), and plaques were also evaluated for the presence of inflammation whether in the plaques or in the adventitia.
Myocardium was evaluated for the presence of new ischemic changes (acute “within 12hours”, recent “within 1day-2 weeks” and healing “within 2-10 weeks”) &/or old ischemic changes (distribution of fibrosis was either transmural or non-transmural) and myocarditis (focal or diffuse with determining the main inflammatory cell type).
Sections from coronaries and myocardium were stained with H&E and Masson trichrome stain.
The results of the sudden coronary deaths were statistically analyzed.
The current study included 205 hearts of sudden deaths that represented 3.4% of all autopsies obtained in the Medico-legal Administration in the two years 2010 & 2011. These sudden deaths were classified according to the WHO classification to 190 cardiac (92.2%) and 15 non-cardiac deaths (7.8%). The age of sudden deaths ranged from the 1st to the 8th decade with male predominance.
The majority of sudden cardiac deaths were due to sudden coronary deaths (84.2%). Their age ranged from the 3rd to the 8th decade with male predominance (91.3%), young adults constitute (31.6%) of them and the majority of deaths didn’t have available medical history (70%).
The 160 hearts of sudden coronary deaths were classified to 3 main groups according to the pathology found which caused death:
In the 1st group (48.8%), deaths were due to severe stenosis (associated with type V atherosclerosis), in which the majority showed myocardial ischemia.
In the 2nd group (40%), death was due to presence of type VI atherosclerosis “complicated atheroma”, in which the majority didn’t show myocardial ischemia.
In the 3rd group (11.2%), death was due to presence of MI in association with moderately stenosed and type V coronaries.
In young adults before 40 years old, the majority of deaths were due to type VI atherosclerosis. While after 40 the severely stenosed coronaries and the MI were the main causes.
The heart weight and the LV thickness in hearts with severe stenosis and in hearts with MI were both higher than that in hearts with type VI.
Pathologic evaluation of the 4 main coronaries in the 160 hearts of sudden coronary deaths revealed significant correlation between grades and types of atherosclerosis as well as between plaque IC and adventitial IC with different coronary grades and types of atherosclerosis.
The majority of coronaries showed moderate stenosis (48.2%), followed by severe stenosis (40.9%), and Type V constituted the majority of both.
The majority of coronaries showed advanced atherosclerotic lesions (90.3%) in which, Type V was the most prevalent. The majority of type V and type IV were moderately stenosed, while the majority of coronaries with type VI were severely occluded.
Plaque inflammatory cells were present in most of the coronaries; it was present in the majority of grade III stenosis followed by grade II stenosis and in the majority of type VI followed by type V atherosclerosis. Adventitial inflammatory cells were present in more than half of the coronaries that showed either grade III stenosis or type VI atherosclerosis.
Examination of the myocardium of the 160 hearts of sudden coronary deaths revealed ischemic heart changes in 67.50%. The majority of the newly formed changes showed combinations of more than one new ischemic change and the majority of old ischemic changes showed non-transmural fibrosis alone.
Complicated myocardial infarction in sudden coronary deaths has been found such as adhesive pericarditis in 26 hearts, aneurysmal formation in the left ventricle was present in 12 hearts and mural thrombi in 4 hearts.
Associated valvular diseases in sudden coronary deaths was present such as dystrophic calcific aortic valve and mitral annular calcification in 4 hearts and pathologic calcified mitral and aortic valves were present in 2 hearts with renal failure and renal tumor.
Myocarditis was the cause of death in 5.25% of sudden cardiac deaths in young adults. They were focally distributed and the cellular infiltrate was neutrophilic, lymphocytic or eosinophilic. The majority of hearts were grossly normal.
Old Rheumatic valvular heart disease was the cause of death in 5.25% of sudden cardiac deaths of young adults. Congenital heart disease in 3.15% of sudden cardiac deaths of young adults in which the congenital coronary disease was either bridging or high take off, and the congenital heart disease was a surgically repaired Fallot tetralogy. Rupture aortic aneurysm with hemopericardium in 1.05% of sudden cardiac deaths. The majority of these hearts showed cardiomegaly, ventricular hypertrophy and myocardial ischemic changes. Aortic & Mitral valves were fibrosed in the rheumatic valvular heart diseases while the pulmonary valve was fibrosed in Fallot tetralogy. The lymphoma of the parietal pericardium was the cause of death in 1.05% of sudden cardiac deaths of young adults , in which there was history of prostatic tumor in one case. The heart was normal.