Guidelines for Forensic Assessment of

Natural Unexpected Cardiovascular

Death
Kyung-Moo Yang1, Sang-Yong Lee2, Yoon-Shin Kim1, Joong-Seok Seo1, Yoon Seong Lee3 and Jeong-Wook Seo4
orensic Medicine Division, National Institute of Scientific Investigation, Seoul; 2Clinic of Forensic Medicine,
Pusan National University; Departments of 3Forensic Medicine and 4Pathology, Seoul National University,
Korea

Pembimbing:
Dr.dr.H.Taufik Suryadi
Sp.F

Abstract
Sudden unexpected deaths due to cardiovascular diseases make up almost half of
all natural deaths. Practical guidelines are needed for forensic autopsy practice in
cases of natural unexpected deaths due to ischemic heart disease or other
cardiovascular diseases in Korea. An evaluation of the clinical history is the first
step, including the collection of all available information on the subject. As a
standard autopsy procedure, every subsystem of the heart and vessels should be
thoroughly studied including the coronary arteries, the myocardium, the cardiac
valves, and the conducting system. In addition, histological, toxicological,
biochemical and molecular analysis need to be applied to the detection of
myocardial infarction from the medico-legal point of view. Also important is the
assessment of risk factors for natural unexpected cardiac death (NUCD) in order to
establish a cause effect relationship. There are three groups of ischemic conditions
of heart leading to NUCD, those being acute myocardial infarction, atherosclerotic
heart disease and critical coronary atherosclerosis. Additionally, there are practical
concerns on formulating the report. Pathologists may use sudden cardiac death or
NUCD as a main diagnosis when there is no alternative diagnosis, though they
would do better to comment on conditions contributing to the death. Finally,
pathologists should be encouraged to suspect unexplained causes of death in
order to find clearer answers.

INTRODUCTION
Natural deaths continue to represent a large
portion of the forensic cases, being more
common than unnatural deaths. Sudden
unexpected deaths due to cardiovascular
diseases occupy almost a half (51.8%) of those
natural death and more than 80% of
cardiovascular deaths are associated with
coronary atherosclerosis.

 Guidelines

required in the routine autopsy

practice for the adequate assessment of sudden
cardiac death (SCD) include not only a protocol
for heart examination, histological sampling,
toxicology and molecular investigation but also
for formulating the report.

 From the viewpoint of the forensic pathologist, it

is important to prove a natural death instead of
an unnatural one. Also important is determining
whether the death was unexpected, as the
death may in fact not have been a sudden event
but a gradual deterioration of cardiac function.

EVALUATION ON THE CLINICAL HISTORY

Six groups of information, proposed by Association for
European Cardiovascular Pathology, should be collected.

Basic personal data

Circumstances of death
Medical history
Medication use
Family history of cardiac diseases
Previous test results

UNEXPECTED DEATH

Natural Unexpected
Death

Natural
Unexpected
Cardiovascular Death
- Neural Arrhytmia
-Mechanical
Infarct
Congestive Failure

Natural Unexpected
Nervous
Death
Neural
Reflex,
seizure
-Mechanical
herniation infarct

Un-natural
Death
-Suicide
-Accident
-Criminal

Natural Unexpected
Respiratory
Death
- Neural apnea
-Mechanical
embolism asphyxia

 As for the symptoms and signs before death, symptoms

possibly related cardiac problem were present in 60% of
cases reviewed, these being syncope/presyncope, chest
pain,
palpitations
or
dyspnea.
Among
them
syncope/presyncope was the most common (30%).
Nonspecific symptoms such as fatigue, influenza,
headache.

History of abnormal ECG should be checked carefully

because major or minor ECG abnormalities were present in
82% of the victims of sudden death Common changes were
T-wave abnormalities (35%), ST segment changes (32%)
and conduction defects (20%).

MORPHOLOGICAL FINDINGS AT

FORENSIC AUTOPSY

Atherosclerotic narrowing of coronary arteries is

the most common and important finding in
sudden unexpected deaths due to ischemic
heart disease at forensic autopsies.

Myocardial scar
Dissection of coronary arteries
Secondary lesion of atherosclerotic plaque
Acute plaque disruption/thrombosis

FORENSIC PATHOLOGY REPORTING

AND FORMULATION OF A
DIAGNOSIS AND THE SUMMARY
We propose three groups of ischemic conditions of heart leading
to sudden unexpected death.
1) Acute myocardial infarction is the most definitive diagnosis as
a cause of sudden death regardless of the presence of old
myocardial infarct or other cardiac lesions.
2) Atherosclerotic heart disease, the second category, has a
definitive ischemic lesion and coronary arterial lesion and it is
highly probable that this combination caused this particular death.
3) The third group, critical coronary atherosclerosis, describes a
definitive lesion in coronary artery but its relation to death is
uncertain because the myocardial ischemia is not proven at this
time.

 Deaths that remain unexplained after careful

macroscopic,
microscopic
and
laboratory
investigation should be recorded and searched for
further analysis. Some of them are classified as
sudden arrhythmic death syndrome. We strongly
suspect that the numbers of these unexplained
deaths have been underestimated in the past.
Some may have genetic cause known or
unknown.

THANK YOU