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)

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

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

Diffential diagnosis of sudden cardiac death

Differentiating 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	Polymorphic VT	Ideopathic VF	Sudden unexpected nocturnal death (Lai-Lai, sleep death, Laos Pukkuri
Incidence	80%	10%	1%	2%	1% to 5% in native valves, 0.2%–0.9% in prosthesis	0.04%	0.05%	0.1%	Rare	0.15%	5%	0.001%
Mechanism	Atherosclerosis in coronary arteries: 3 vessels disease in 40-86% patients with stenosis > 75% Acute MI < 50% Qwave MI < 25% Recent coronary thrombosis 15-64% 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 fibrofatty 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|| SCD is late presentation after surgical repair of complex congenital heart disease such as Eisenmenger syndrome,transposition of the great arteries (atrial switch or congenitally corrected), Fontan circulations. || 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 structure of the heart Originated from RV outflow tract (more common) or LV outflow tract SCD is rare|| Initiation of arrhythmia with coupled premature complex Aquired or congenital Long QT interval, Ischemia SCD is more common than monomorphic VT Sporadic or familiar|| Normal structure of the heart Without ICD implantation, high recurrence of VF, cardiac arrest , syncope in 30% of patients|| Unknown
Risk factors of SCD	Plaque, fissure, hemorrhage, thrombosis in coronary arteries || Frequent episodes of nonsustain 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|| || Young male sex southeast asian ethnicity
Arrhythmia	VT, VF (75%) bradycardia, asystole(25%) || Mechanism of VT: Bundle branch reentry tachycardia Terminal event: asystole electromechanical dissociation in advanced LV dysfunction || Ventricular tachycardia, Ventricular fibrillation|| ECG in normal sinus rhythm: T waves inversion in V1-V3, complete Incomplete RBBB Epsilon wave ( terminal notch on QRS complex) VT is LBBB contour|| || Atrial arrhythmias (43%) QRS prolongation (mean 132ms) || Torsadepoints Resting ECG findings: Abnormal Twaves contour T Waves 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 may happen in the presence of polymorphic VT and normal LV function without torsadepoints Termination of cathecolaminergic polymorphic VT (CPVT) with betablocker|| Ealy repolarization abnormality in inferior lateral leads No response to betablocker in the presence of ideopathic VF or short coupled of torsades de points || Ventricular fibrillation