Autopsy & forensics

Types of injuries

Sudden cardiac death

Topic Completed: 1 January 2016

Minor changes: 8 November 2021

Copyright: 2015-2021,, Inc.

PubMed Search: Sudden cardiac death [title]

R. Amita, M.D.
Page views in 2020: 3,837
Page views in 2021 to date: 3,776
Cite this page: Amita R. Sudden cardiac death. website. Accessed December 8th, 2021.
Definition / general
  • Determination of cause of death in natural deaths, particularly when the death occurred suddenly, unexpectedly or in the young, is an important part of the forensic pathology service
  • Ventricular fibrillation
  • Coronary arteries: occlusion (atherosclerosis, thrombosis, embolus), structural abnormalities of the epicardial arteries, coronary artery dissection or aneurysm
  • Hypertensive heart disease
  • Cardiomyopathies: hypertrophic cardiomyopathy, dilated cardiomyopathy (genetic, myocarditis, toxic, peripartum, idiopathic), restrictive cardiomyopathy (idiopathic, amyloidosis, sarcoidosis, radiation fibrosis, metastasis, deposition disease/inborn errors of metabolism)
  • Other cardiomyopathies: arrhythmogenic right ventricular dysplasia, arrhythmogenic left ventricular dysplasia, left ventricular non-compaction, restrictive conditions (endomyocardial fibrosis, Loeffler endomyocarditis, and endocardial fibroelastosis)
  • Inflammatory: myocarditis, pericarditis (bacterial, viral, Dressler syndrome)
  • Valvular: congenital abnormalities (bicuspid valve), rheumatic heart disease
  • Functional abnormalities: long QT syndrome (LQTS), short QT syndrome (SQTS), catecholaminergic polymorphic ventricular tachycardia (CPVT), Brugada syndrome, Asian sudden unexplained nocturnal death syndrome (SUNDS)
  • Acute myocardial infarction, cardiac tamponade, cardiac outflow obstruction (aortic stenosis, valvular prosthesis thrombosis, atrial myxoma), and congenital heart disease are also heart conditions that can lead to instantaneous / sudden death
Gross description
  • Record weight of the heart
  • Assess myocardial hypertrophy using standard tables
  • An enlarged, globoid or flabby heart indicates structural abnormalities such as hypertrophic or dilated cardiomyopathy, whereas a normal sized but overly stiff heart is seen in restrictive cardiomyopathy
  • Note the origin and distribution of the coronary arteries
  • Acute angle takeoff of a coronary artery or other abnormalities of the coronary ostia may be the only finding in a sudden death
  • Look for nonatherosclerotic coronary artery abnormalities such as location of the left main coronary artery between the aortic and pulmonary artery roots, origin from the pulmonary trunk, tunneled coronary arteries, coronary artery dissection and rupture

  • Section the coronary artery at 2 - 3 mm intervals to identify any significant stenosis or thrombotic occlusion
  • Acute thrombotic occlusion of a coronary artery may be very focal or may not be identified, even in cases of instantaneous death
  • Record the degree of luminal stenosis; in general, stenosis greater than 75% is more likely to be significant
    • However, death can be attributed to coronary artery disease (CAD) with less stenosis if other signs of chronic myocardial ischemia are apparent (left ventricular hypertrophy [LVH], fibrosis, previous infarct)

  • Sudden cardiac death can occur with:
    • Coronary artery occlusion: atherosclerotic plaque, thrombus, platelet aggregates, embolus
    • Coronary artery aneurysm / rupture: associated with Kawasaki disease, vasculitis, connective tissue disease
    • Coronary artery dissection: often young females, multifocal, and associated with increased eosinophils
    • Arteritis: Multiple vasculitides, rheumatic conditions, connective tissue disorders and drugs (eg, cocaine)
    • Coronary artery spasm
    • Congenital anomalies of coronary vessels: abnormal origin and course, osteal malformations, hypoplasia, coronary artery tunneling

  • The heart can be opened by the inflow - outflow method
  • Note the color and consistency of the myocardium
    • Areas of hyperemia and softening can be associated with recent infarcts, and firm, tan-white areas are associated with healed infarcts
  • Measure the thickness of the right and left ventricles and interventricular septum at that level
  • Myocardial hypertrophy can arise from a number of causes, both congenital and acquired
  • Left ventricular hypertrophy is a risk factor for sudden cardiac death, regardless of etiology
Gross images

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Massive hemopericardium

Microscopic (histologic) description
  • If the myocardial fibers appear disorganized
    • A "herringbone" pattern is frequently observed in hypertrophic cardiomyopathy
  • Disorganization with deep fissuring of the endocardium of the left ventricular cavity is suggestive of left ventricular noncompaction (LVNC)
Microscopic (histologic) images

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Acute myocardial infarction

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Coagulative necrosis

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