title: Sudden cardiac death with stress and restraint: The association with sudden adult death syndrome, cardiomyopathy and coronary artery disease.
abstract: OBJECTIVE
  The aim of this study was to report on sudden cardiac death (SCD) during or immediately after a stressful event in a predominately young cohort.
  
  
  METHODS
  This study used retrospective non-case-controlled analysis. A total of 110 cases of SCD in relation to a stressful event such as altercation (45%), physical restraint (31%) in police custody (10%), exams/school/job stress (7.27%), receiving bad news (4%), or a car accident without injuries (2.73%) were retrospectively investigated. The majority of the subjects experiencing SCD were male (80.91%). The mean age was 36 ± 16 years (range 5-82 years). Twenty-three cases (20.91%) were psychiatric patients on antipsychotic medication.
  
  
  RESULTS
  Fifty-three per cent of cases died with a negative autopsy and a morphologically normal heart, indicating sudden adult death which is linked to cardiac channelopathies predisposing to stress-induced SCD. Cardiomyopathy was found in 16 (14.5%) patients and coronary artery pathology in 19 (17%) patients, with atherosclerosis predominating in older patients.
  
  
  CONCLUSIONS
  This study highlights SCD during psychological stress, mostly in young males where the sudden death occurred in the absence of structural heart disease. This may reflect the proarrhythmic potential of high catecholamines on the structurally normal heart in those genetically predisposed because of cardiac channelopathy. Structural cardiomyopathies and coronary artery disease also feature prominently. Cases of SCD associated with altercation and restraint receive mass media attention especially when police/other governmental bodies are involved. This study highlights the rare but important risk of SCD associated with psychological stress and restraint in morphologically normal hearts and the importance of an expert cardiac opinion where prolonged criminal investigations and medico-legal issues often ensue.
authors: Medical School, Aristotle University of Thessaloniki, Greece.
authors: Lydia
authors: L
authors: Krexi
authors: CRY Centre for Cardiovascular Pathology, St Georges Medical School, UK.
authors: Roxani
authors: R
authors: Georgiou
authors: Medical School, Aristotle University of Thessaloniki, Greece.
authors: Dimitra
authors: D
authors: Krexi
authors: CRY Centre for Cardiovascular Pathology, St Georges Medical School, UK m.sheppard@sgul.ac.uk.
authors: Mary N
authors: MN
authors: Sheppard
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D009202:Cardiomyopathies / Q000473:pathology; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D003324:Coronary Artery Disease; D016757:Death, Sudden, Cardiac / Q000209:etiology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013315:Stress, Psychological; D006113:United Kingdom / Q000453:epidemiology; D055815:Young Adult
keywords: forensic medicine; forensic pathology; forensic psychiatry; multiple death investigations