Abstract
Anecdotal observations and case discussions with forensic pathologists previously had suggested to us that forensic (medico-legal) cases with a potential cardiac pathology were referred mainly to look for ischaemic heart disease (IHD) deaths. To consider this premise, we undertook a review of all such cases (1999–2014) that were referred to a single cardiac pathologist (SKS).
We identified 124 eligible cases, comprising 101 males (81%, median age 44 years) and 23 females (19%, median age 79 years). The majority of referrals came via the police (95%), with 5% via other routes (pathologists and family). The circumstances of the initial alleged forensic incidents were physical assaults (64%), verbal altercations (2%), deaths in custody (9%), deaths of bystanders (1%) and bodies found in suspicious circumstances (23%).
We found that 49 deaths (39%) were judged unrelated to heart disease (i.e. unremarkable hearts). These were clearly excluded by other findings from the examinations and/or toxicology data. Of these, 36 were deaths due to injury, with another 13 reflecting self-harm, drug overdose or domestic accident.
There were 34 cases (27%) that had significant cardiac pathology, considered to place them at risk of sudden death at any time, regardless of the circumstances. Thus, the cardiac disease was the main pathology, above that of the circumstances prompting case referral. Of these, 27 cases revealed severe IHD. The others showed two cases of bicuspid aortic valve, four cases with inherited heart diseases (two cases of arrythmogenic right ventricular cardiomyopathy, and one case each of hypertrophic cardiomyopathy and long QT syndrome/channelopathy) and one with neoplasia (cystic atrio-ventricular node tumour). The deaths were thus clearly defined as reflecting the cardiac pathology identified.
In eight cases (6%), death was considered not to be heart-related as a consequence of another pathology rather than underlying heart disease. However, of these, six cases had significant IHD but where other non-cardiac pathology was considered to have interacted with the individual’s limited cardiovascular physiological reserve. Surprisingly, two people with no underlying IHD died from acute pancreatitis, but both had a degree of myocarditis.
Lastly, there was a group of 33 cases (26%) with known heart disease, but where the individual was clearly living with this condition in a stable fashion. In this group, the background history was judged of relevance, wherein a possibility of sudden cardiac death was judged to have become a probability, reflecting the nature/severity of the reported crime/circumstance. In short, the circumstances applied to the deaths were the significant factors added to the risk of death. In this group, there were 30 cases with IHD, but also one with combined atrial septal defect and histological cardiac amyloid, one with dilated cardiomyopathy and one drug-related dysrhythmia.
In summary, this brief review shows that many cases of stressful event/s and sudden death have no link to cardiac status. There are also (as suspected) many cases with significant IHD, where death could have occurred at any time and where this will be the/a major defining factor in the cause of death. 1 The fact that other non-IHD occurs at low frequency should prompt consideration of specialist cardiac referral in medico-legal cases. Finally, one must be aware that it is only when the circumstances of the death, the toxicology and other general autopsy examination are complete that the forensic pathologist (managing/overseeing the case) will be able to titrate any cardiac pathology into the cause of death.