A study to find out correlation between life style, nutritional status, personnel habits, physical development and sudden death due to cardiac origin

Introduction

Sudden death is defined as a natural, unexpected fatal event within one hour of the beginning of symptoms in apparently healthy subject.1 or one whose disease was not so severe enough as to predict such an abrupt outcome.2 Some consider death within 24 hours of onset of events. In the present era of modernization and new inventions, there are changes in life styles, eating habits, increasing comfort at working environment, leading to less physical activity. Due to changes at social, economical and cultural level there are increase stress factors especially in middle economic group make them prone to many cardiovascular complications and sudden deaths in early age.

In natural death, the death due to cardiac disease is the most common cause of an unexpected sudden death in all age groups commonly in people aged 30 or over, while non cardiac conditions such as acute respiratory arrest, choking or asphyxiation, toxicity or poisoning, anaphylaxis, or trauma.3 Coronary artery disease is one of the most common causes of sudden death and it is increasing day by day. It is sometimes called “The Captain of the Men’s death” and it constitutes a significant portion of the deaths attended by clinicians as well as at autopsies observed by Forensic experts in our country. Coronary heart disease (CHD) is the leading cause of death in India as well as worldwide. Previously it was considered a disease of primarily high-income countries but now leads to more deaths and disability in low and middle-income countries, such as India, with death rates that are increasing disproportionately compared to high-income countries. It affects people at younger ages in low and middle income countries, compared to high-income countries, thereby having a greater economic impact on low- and middle income countries.4

Though these deaths are natural, they carry medico-legal importance because these deaths occur in persons who have been apparently healthy, without any diagnosed disease that can be attributed to the cause of death or, the period of illness before the supervening of death is so short that the disease cannot be diagnosed so early.3, 4 Gross and microscopic appearance of an infarct at autopsy depends on the duration of survival of the patient following the events of myocardial infarction.4

Economic burden of CHD in india

India is estimated to have lost 8.7 billion 1998 international dollars in 2005 because of CHD, stroke, and diabetes. These estimates increase to 54 billion 1998 international dollars by 2015. India’s growth of gross domestic product (GDP) is estimated to fall by 1% because of the combined economic impact of CHD, stroke, and diabetes (WHO, 2005). A 2000 estimate of 9.2 million productive years of lives lost in Indian adults secondary to overall CVD contributing to this economic decline. As CHD (and CVD) rates increase, this estimate increases to 17.9 million by 2030 (Leader).5 Effective screening, evaluation, and management strategies for CHD are well-established in high-income countries, but these strategies have not been fully implemented in India. Ischemic heart disease globally is the most common form of heart disease, the cause of myocardial infarction and the most common cause of death.6 Tobacco products are widely consumed as smoking and smokeless tobacco (SLT). The consumption of smokeless tobacco may effects of nicotine and tobacco-specific N-nitrosamines. They generally consume the most commonly available SLT products like local made or refinedgutkha and khaini8-10 times per day. There was a strong correlation of nicotine with reactive oxygen species (ROS), reactive nitrogen species (RNS), cholesterol, and creatinine in exposed smokeless tobacco (gutkha) consumers. These data demonstrate SLT users are at high cardiovascular risk due to nicotine-induced free radicals and oxidative damage.7 Histopathological examination of the heart is very important tool to come to definitive opinion regarding the presence of infarction at autopsy. On gross examination the infarct is not identifiable within the first 12 hours but under the microscopic examination the area of myocardial infarction presents as a circumscribed area of ischemic, coagulative necrosis (cell death).8, 5 Standard antemortem diagnostic criteria:As per the revised WHO criteria in 20009 for the diagnosis of myocardial infarction the following parameters are to be met with:

1. Typical clinical symptoms

2. Pathological Q waves

3. ST elevation or depression or coronary intervention along with

4. Increased serum cardiac Troponin levels

Looking into the magnitude of the involvement of heart in sudden death cases and considering the importance of cause of death both in criminal investigation and to establish the death due to cardiac origin present the study was carried out to find out any correlation between the life style, nutritional status, personnel habits, physical development and sudden death due to cardiac origin.

Figure 1

Comparison between body mass index and age

Materials and Methods

The present study was carried on the deceased which were brought for medico legal postmortem examination by investigating officer on the deceased either brought dead from outside or who died during the treatment within 24 hours of admission having history of chest pain, perspiration, vomiting and unconsciousness or previous history of coronary artery disease. The personal data were collected by interview with the patients relatives or police officer or from the available treatment case papers. To find out the cause of death in these cases, as per the institutional policy, medico-legal postmortem examination was carried. Based on the following criteria the deceased were selected:

Discussion

Most of the sudden death of cardiac origin are due to ischemic changes in myocardium. It results from the lack of adequate blood perfusion to the myocytes, leading to a deficiency of oxygen and nutrients, resulting in abnormal function. In a clinical setting, myocardial ischemia is assessed by an individual’s symptoms and electrocardiographic (ECG).10 studies. The ECG changes may include ST-T segment wave alterations ⁶⁴. Myocardial ischemic manifestations are vague and multiple. Symptoms may include chest pain (angina), epigastric and arm discomfort with exertion or at rest, shortness of breath, nausea, and vomiting.11 However, these symptoms may be subtle and are not easily recognized. Key TJ, Frase GE et al., observed that IHD is more common in Non vegetarian as compared to vegetarian while in our study vegetarians are more affected than non-vegetarian.12 According to study patient having high body mass index have higher survival rate while we observed most of the deceased are either overweight or obese.13

Several authors studied that smokeless tobacco is also harmful as compared to smoking. The effect of tobacco is inform of fibrosis and narrowing of vessels. In our study we also observed that people are using more smokeless tobacco as compared to smoking and resulting in sudden death. Authors has also observed that people consume smokeless tobacco are also on high risk of cardiovascular disease and in our study we also observed that deceased consume SLT are affected more to sudden death of cardiac origin as compared to smoking. 14, 15, 16, 17, 18 Atheroma and calcification is common in the coronary arteries in sudden death cases. In present study it is observed that coronary atheroma present in almost all autopsies. The youngest male of 28 years old show atheroma and calcification in the coronaries. The adult cannot be divided into subjects having and those not having atherosclerosis, the disease could be further classified according to the degree of stenosis in each artery. This concurs with the findings of Strong & McGill. Thrombosis complicating the atheroma and calcification was present in 13 cases in left coronary and in 8 cases in right coronary. In five cases thrombus was found in right coronary and in one case thrombus was found in left coronary in the absence of atheroma and calcification. This supports the suggestion of Gresham and Howard19, 20 that coronary thrombosis can occur in the absence of atherosclerotic plaques.

It is observed that there is a strong correlation between the arterial lesions and ischemic heart disease in both the incidence and severity. The atheroma and stenosis were commonly observed in the hearts that showed ischemic changes. This support the observations by Strong and McGill who opine that this correlation between coronary lesions and fatal ischemic heart disease suggest that the modern epidemic is based primarily on atherosclerotic lesions rather than a terminal episode such a thrombosis, and that the severity of coronary lesions is the determining factor in morbidity and mortality from ischemic heart disease. The above findings were supported in present study that males subjects are more as compared to female and the incidence of myocardial infarction is increasing as the age advances but more in age group 46 – 55 years followed by 56 -65 years. In present study it observed that there was a correlation between myocardial infarction the stenosis in the coronaries. This support the study carried at Maulana Azad Medical Collage, New Delhi.

Summary and Conclusion

A total of 61 sudden death cases were taken up in this study. Among the subjects there were cases of acute myocardial infarction and healed myocardial infarction. Subjects comprised of both males and females, maximum age of the deceased was 93 years and minimum of 28 years. Out of 61 cases studied, the percent of males and females was 81.96 and 18.04% respectively. Comparison was made between males and females. Body weight of the subjects varied between 43 and 93 Kg. there is presence of stenosis, atheroma and calcification in both coronaries and in few cases had thrombus. Subjects with stenosis were further grouped based on their severity of the stenosis.

Source of Funding

None.

Conflict of Interest

None.