Scope and nature of sudden cardiac death before age 40 in Ontario: A report from the Cardiac Death Advisory Committee of the Office of the Chief Coroner
Introduction
Sudden cardiac death in the young is a tragic and devastating event for families and communities. It is currently not known how best to prevent or limit sudden cardiac death in the younger age group.1, 2, 3, 4, 5 Characterization of the population that suffers sudden cardiac death would assist in understanding the scope and nature of the problem and could potentially inform strategies targeting prevention.6, 7, 8, 9 Ontario is Canada’s most populous province, with an ethnically, culturally, and socioeconomically diverse population of 13 million inhabitants. In this province, coroners are mandated to investigate any and all deaths that are sudden, unexpected, or from nonnatural causes. In 2008, of the 2864 deaths that occurred in the 2–40 age group, 1741 were investigated by the coroner’s office. These death investigations were obliged to answer the following 5 questions: who was the deceased; how, when, and where the death occurred; and by what means the death occurred. Coroners in Ontario have the legal right to perform an autopsy to assist in their investigation of the death and have access to additional services such as general and specialist pathologists and toxicology screening. Individual coroners also have the support of the Office of the Chief Coroner of Ontario (OCCO) for assistance and collaboration on complicated cases. The OCCO maintains a centralized, comprehensive database and death investigation files on all deaths investigated in Ontario. We sought to understand sudden cardiac death in persons aged 2–40 years by using this comprehensive provincial registry to enable accurate determination of incidence and cause of sudden cardiac death.
Section snippets
Data collection
This epidemiologic study incorporated a retrospective cohort design. Cases of potential relevance were identified from the comprehensive database of the OCCO, which contains data on all cases reported to and investigated by coroners in Ontario. All files contained a coroner’s report (the Coroner’s Investigation Statement Form 3), and an autopsy report (Report of Post Mortem Examination) if an autopsy was conducted. Other information, such as police reports and reports from other investigating
Results
In 2008, there were 174 cases adjudicated to have sudden cardiac death from an estimated population of 6,602,680 persons aged 2–40 years.11 Based on this information, the incidence of sudden cardiac death in the overall population was 2.6/100,000 person-years. The incidence of sudden cardiac death increased with age, from 0.7/100,000 person-years in those aged 2–18 years to 2.4/100,000 person-years in those aged 19–29 years to 5.3/100,000 person-years in those aged 30–40 years. The majority of
Discussion
In the current study, we have identified an increased risk of sudden cardiac death with age, which primarily affects men at rest with unrecognized heart disease. Before the age of 30 years, deaths are predominantly related to unrecognized cardiomyopathic processes and primary arrhythmia syndromes leading to sudden unexpected death, which increase in incidence in adolescence and early adulthood. Death occurs predominantly at rest and in the home. The strength of the current study is the
Conclusions
Sudden cardiac death in young persons increases with age and is more common in men. In adults, death typically occurs in the home at rest in a person with unrecognized underlying heart disease or a primary arrhythmia syndrome. In children and adolescents, death is more likely to be associated with physical activity, though not typically during competitive sports. Prevention strategies should consider targeting identification of unrecognized structural heart disease and primary arrhythmia
Disclaimer
All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
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Dr Krahn is a career investigator of the Heart and Stroke Foundation of Ontario (CI6498). The study was supported by the Office of the Chief Coroner of Ontario and the Heart and Stroke Foundation of Ontario (T6730).