Sudden cardiac death causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Zand, M.D.[2]

Overview

Sudden cardiac arrest may be caused by coronary artery abnormality such as coronary atherosclerosis, acute MI, coronary artery embolism, coronary arteritis , hypertrophy of myocardium such as HCM, hypertensive heart disease, primary or secondary pulmonary hypertension , myocardial disease such as ischemic cardiomyopathy, non-ischemic cardiomyopathy, myocarditis ,valvular heart disease such as aortic stenosis, aortic insufficiency, mitral valve prolapse, endocarditis , congenital heart disease such as congenital septal defect with eisenmenger physiology , abnormality in conducting system such as Wolf-Parkinson-White syndrome , electrical instability such as (CPVT, LQTS)

Causes

Sudden cardiac arrest may be caused by :

• Coronary artery abnormality such as coronary atherosclerosis, acute MI, coronary artery embolism, coronary arteritis

• Hypertrophy of myocardium such as HCM, hypertensive heart disease, primary or secondary pulmonary hypertension
• Myocardial disease such as ischemic cardiomyopathy, non-ischemic cardiomyopathy, myocarditis

• Valvular heart disease such as aortic stenosis,aortic insufficiency, mitral valve prolapse, endocarditis

• Congenital heart disease such as congenital septal defect with Eisenmenger physiology
• Abnormality in conducting system such as Wolf-Parkinson-White syndrome
• Electrical instability such as (CPVT, LQTS)

Multiplication table

Differentaitindg diagnosis of sudden cardiac death	Coronary Artery Disease	Ideopathic dilated cardiomyopathy	Hypertrophic cardiomyopathy	Arrhythmogenic right ventricular cardiomyopathy	Valvular Heart Disease	Congenital Heart Disease	Long QT syndrome	WPW syndrome	Ideopathic monomorphic VT	Ideopathic polymorphic VT	Primary VF	Sudden unexpected nocturnal death	Drugs]]
Incidence of SCD	Atherosclirosis: 80%	10%	2-4% per year in adult, 4-6% in children and adolescence	2%	20% of post operative death after valvular replacement			1/1000 patient-year follow- up	Rare
Mechanism	Atherosclerosis in coronary arteries: 3 vessels disease in 40-86% patients with stenosis > 75%, MI < 50%, Qwave MI < 25%, recent coronary thrombosis 15-64% (plaque, fissure, hemorrhage, thrombosis), healed infarct>50% in autopsy or survivors of SCD, Non atherosclerotic changes including coronary emboli, coronary arthritis, coronary dissection in few cases	Myocardial stretch, neuroendocrine factors, electrolyte abnormality, proarrhythmic effect of antiarrhythmic drugs, excessive activation of sympathetic and renin angiotensin system	Arrhythmia, abrupt hemodynamic deterioration, ischemia	Fatty and fibrofaty myocardial infiltration, patchy myocarditis, apoptosis of left ventricle, left ventricular septum (50-67%), right ventricular inflow, outflow tract and apex( triangle of dysplasia)	Arrhythmia, prosthetic valve dysfunction,Coexisting CAD	Tetralogy of fallot, Transposition of the great arteries, Aortic stenosis, Pulmonary vascular obstruction. SCD is late presentation after surgical repair of complex congenital heart disease	Prolongation of repolarization, early after depolarization	In 10% of patients, SCD is first presentation. development of AF rapid conduction to the ventricle through accessory pathway caused VF	Normal heart structure, Originated from RV outflow tract (more common), or LV outflow tract. SCD is rare	Initiation of arrhythmia with coupled premature complex,SCD is more common than monomorphic VT, sporadic or familiar
Risk factors of SCD		Frequent episodes of non sustain VT, syncope	Family history of SCD, recurrent syncope, sustained VT, history of SCA, massive LVH, multiple episodes of non sustained VT		Asymptomatic aotric valve disease is low risk for [[SCD].Risk factors of SCD in MVP: myxomatous degeneration of the valve, coexisting mitral regurgitation, LV dysfunction	Risk factors of SCD in TOF: QRS prolongation, dilated RV	Incidence of cardiac event in LQTS1, LQTS2> LQTS3 Lethality of cardiac event in LQTS3>LQTS1,LQTS2	Predictors of VF: AF with shortest interval between ventricle beats less than 250 msec		Cathecolamine release after stressful emotional or physical event
Arrhythmia	VT, VF (75%), bradycardia, asystole(25%)	Mechanism of VT: bundle branch reentry tachycardia, terminal event: asystole, [[electromechanical dissociation in advanced LV dysfunction	9	ECG in normal sinus rhythm:inverted T waves in V1-V3, complete, incomplete RBBB, epsilone wave ( terminal notch on QRS complex), VT is LBBB contour			Arrhythmia:Torsadepoints, Normal ECG findings: abnormal Twaves contour, Twaves alternance, sinus bradycardia		RV outflow tract VT is LBBB contour, inferior axis, Termination with vagal maneuver such as adenosine. LVOT VT or fasciculated VT is RBBB contour with left axis deviation, originated from left posterior septum, Termination with calcium channel blocker	SCD in the presence of polymorphic VT and normal LV function without torsadepoints, Termination of cathecolaminergic polymorphic VT (CPVT) with betablocker, No response to betablocker in the presence of ideopathic VF or short coupled of torsadepoints

• Causes of acquired Long QT syndrome include the following:

• Antiarrhythmic agents
• Class IA: quinidine, procainamide, N-acetyl procainamide, disopyramide
• Class III: amiodarone, low risk of torsade de points
• Class IV: bepridil,mibefradil
• Antihistamines
• Terfenadine
• Astemizole
• Antimicrobials
• Erythromycin
• Trimethoprim-sulfamethoxazole
• Clarithromycin
• Cotzimoxazole
• Azithromycin
• Ketoconazole
• Pentamidine
• Chloroquine
• Gastrointestinal
• Cisapride
• Liquid protein diets
• Anorexia nervosa
• Lipid-lowering
• Probucol
• Psychotropic agents
• Tricyclic and tetracycline antidepressants
• Haloperidol
• Phenothiazines
• Risperidone
• Selective serotonin reuptake inhibitors
• Other agents
• Organophosphates
• Diuretics (reduced K+, Mg2+)
• Vasopressin (severe bradycardia)
• Chloral hydrate amantadine
• Electrolyte abnormalities
• Hypokalemia
• Hypomagnesemia
• Hypocalcemia

Causes of Sudden Death Including Sudden Cardiac Death by Organ System

Cardiovascular	Amyloid cardiopathy, Congestive heart failure, Ventricular rupture,
Ischemic	Hypoxia, Coronary thrombosis, Coronary vasospasm, Coronary artery aneurysm, Prinzmetal's variant angina ,
Pericardial	Cardiac tamponade,
Myocardial	Asymmetric septal hypertrophy , ST Elevation Myocardial Infarction, Dilated cardiomyopathy, Giant cell myocarditis , Hypertrophic cardiomyopathy, Kugel-Stoloff syndrome , Myocardial infarction, Myocarditis, Rupture of the papillary muscles,
Endocardial/Valvular	Mitral valve prolapse, Valvular aortic stenosis/insufficiency, Mitral valve disruption, Endocarditis, Prosthetic valve dysfunction,
Conduction/Arrhythmia	Arrhythmogenic right ventricular cardiomyopathy, Arrhythmogenic right ventricular dysplasia, Brugada syndrome, Jervell and Lange-Nielsen Syndrome, Prolonged Q-T Interval Syndrome, Multifocal ventricular premature beats , Naxos disease , Romano-Ward syndrome , Sick sinus syndrome, Short QT syndrome , Sinus node disease, Stokes-Adams Syndrome, Sudden Arrhythmia Death Syndrome, Wolf-Parkinson-White syndrome,
Vascular	Acute aortic insufficiency, Acute coronary syndrome, Aortic dissection, Aortic stenosis, Aorto-ventricular tunnel, Arteritis, Coronary artery disease, Coronary arteries - congenital malformation , Ruptured abdominal aortic aneurysm,
Congenital/Developmental	Congenital aortic or pulmonary valve stenosis, Congenital septal defect with eisenmenger physiology, Congenital heart block , Congenital Long QT syndrome, Noncompaction Cardiomyopathy, Sudden Infant Death Syndrome, Uhl anomaly
Chemical / poisoning	Snake bite
Dermatologic	No underlying causes
Drug Side Effect	Agalsidase beta, Articaine, caspofungin acetate, Clozapine, cytomegalovirus immune globulin, Drug allergy, drug overdose, Dornase Alfa, ferumoxytol, Flucytosine, galsulfase, Iodixanol, laronidase, Lincomycin Hydrochloride, Polidocanol, Potassium bicarbonate, pramipexole, prednisolone, Ramucirumab, Calcium gluconate, Dextran, Tiagabine
Ear, Nose, Throat	No underlying causes
Endocrine	Diabetic ketoacidosis - typically from undiagnosed diabetes, Thyrotoxicosis,
Environmental	Hypothermia,
Gastroenterologic	Appendicitis, Gastrointestinal bleeding, Retroperitoneal bleed,
Genetic	Brugada syndrome, 3-methylglutaconic aciduria, type 1, Familial dilated cardiomyopathy , Familial hypertrophic cardiomyopathy 1, Hyperbilirubinemia transient, familial neonatal, Marfan syndrome , Timothy syndrome
Hematologic	No underlying causes
Iatrogenic	Transfusion reaction
Infectious Disease	Flu mainly in the elderly, infants, infirm or chronically ill, Neurocysticercosis , Lyme disease
Musculoskeletal / Ortho	No underlying causes
Neurologic	Apoplexy, Encephalitis, Intracranial hemmorhage, Meningitis, Stroke, Subarachnoid hemorrhage,
Nutritional / Metabolic	3-methylglutaconic aciduria, type 1, Alpha-ketoglutarate dehydrogenase deficiency , Food allergy
Obstetric/Gynecologic	Amniotic fluid syndrome , Childbirth hemorrhage,
Oncologic	Atrial myxoma, familial
Opthalmologic	No underlying causes
Overdose / Toxicity	Opioid overdose , Oxycontin overdose, Pain killer overdose , Sleeping pill overdose
Psychiatric	No underlying causes
Pulmonary	Hypercapnia, Pickwickian Syndrome, Pulmonary embolism, Tension pneumothorax, Status asthmaticus
Renal /Electrolyte	Hypercalcemia, Hypokalemia, Hyperkalemia,
Rheumatology / Immune / Allergy	Amyloidosis, Anaphylaxis, Myasthenia gravis, Sarcoidosis,
Sexual	No underlying causes
Trauma	Commotio cordis, Homicide, Motor Vehicle accident
Urologic	No underlying causes
Miscellaneous	Shock, Asphyxia, Insect bite Sepsis syndrome, Shock

Differentiating sudden cardiac death from non-cardiac causes

Cardiac causes of sudden death

Non cardiac causes of sudden death:

Acute aortic insufficiency Acute coronary syndrome Aortic dissection Aortic stenosis Arrhythmogenic right ventricular dysplasia Brugada syndrome Cardiac tamponade Cardiomyopathy Catecholaminergic polymorphic ventricular tachycardia Commotio cordis Complete heart block Congenital heart disease Congestive heart failure Coronary artery disease Dilated cardiomyopathy Hypertrophic cardiomyopathy Jervell and Lange-Nielsen syndrome Long QT syndrome, both congenital and acquired Lyme disease Mitral valve prolapse Myocarditis Naxos disease Noncompaction Cardiomyopathy Papillary muscle rupture Prolonged Q-T Interval Syndrome Pulmonary embolism Romano-Ward syndrome Ruptured abdominal aortic aneurysm Prosthetic valve dysfunction Short QT syndrome Short QT syndrome type 1 Short QT syndrome type 2 Short QT syndrome type 3 Short QT syndrome type 4 Short QT syndrome type 5 Sick sinus syndrome ST Elevation Myocardial Infarction Stokes-Adams Syndrome Sudden Infant Death Syndrome Timothy syndrome Uhl anomaly Valvular Heart Disease Ventricular rupture Wolf-Parkinson-White syndrome with rapid conduction Commotio cordis-blunt chest trauma Sudden death during extreme physical activity

3-methylglutaconic aciduria, type 1 Alpha-ketoglutarate dehydrogenase deficiency Amniotic fluid syndrome Arterial dissections with lentiginosis Anaphylaxis Aneurysm Apoplexy Appendicitis Asphyxia Birth injury Bleeding excessive Childbirth hemorrhage Diabetic ketoacidosis - typically from undiagnosed diabetes Drug allergy Drug overdose Encephalitis Fetal death Food allergy Gastrointestinal bleeding Homicide Hyperbilirubinemia transient, familial, neonatal Hypercalcemia Hypercapnia Hyperkalemia Hypokalemia Hypoxia Injury Insect bite Intracranial hemmorhage Marfan syndrome Meningitis Meningococcal disease Motor Vehicle accident Myasthenia Gravis Neurocysticercosis Opioid overdose Oxycontin overdose Pain killer overdose Pickwickian Syndrome Poisoning Pulmonary embolism Retroperitoneal bleed Sepsis syndrome Shock Sleep apnea Snake bite Status asthmaticus Stillbirth Stroke Subarachnoid hemorrhage Sudden Infant Death Syndrome Suicide Sleeping pill overdose Toxic/metabolic disturbances Tranquilizer addiction Tension pneumothorax Toxic/metabolic disturbances Thyrotoxicosis Toxic shock syndrome Transfusion reaction Venom