Sudden Cardiac Death
Sudden cardiac death is defined as an unexpected death due to cardiac causes occurring within a short time (generally within one hour) of the onset of symptoms.
The most common diagnosis in these cases is coronary atherosclerotic heart disease, which is present in 80% of cardiac cases. Coronary atherosclerotic heart disease is when the arteries in the heart become hardened, often due to the build-up of cholesterol.
What causes sudden cardiac death?
In pathological studies of sudden cardiac death, 75% of autopsies found that the patient had a recent coronary thrombotic lesion (blockage) with underlying atherosclerosis. The remainder had high grade atherosclerotic stenosis (narrowing of the arteries) but no recent myocardial changes.
Myocardial infarction is the medical term for a heart attack, so this means that they did not show evidence of a recent heart attack. However, in many of those cases the myocardium showed scarring from previously healed myocardial infarctions.
The immediate cause of death is malignant arrhythmia (when the heart stops contracting) caused by myocardial ischaemia (when the blood flow to the heart is reduced, making it deficient in oxygen).
Ventricular tachycardia (rapid heartbeat) degenerating to ventricular fibrillation (quivering of the heart) and later asystole appears to be the most common pathological cascade involved in fatal arrhythmias. Triggers to cardiac arrest are predominantly ischaemia (a lack of oxygen) but also include haemodynamic fluctuations, neuro-cardiovascular and environmental factors.
The post mortem findings will verify the most likely trigger of sudden cardiac death. If there is no evidence of recent myocardial infarction or occlusion of a major artery, the immediate cause of death is probably ventricular fibrillation.
Cardiac chest pain
Coronary heart disease is associated with chest pain. There is a high prevalence of chest pain within the UK population. In around 20% to 40% of patients, the underlying cause turns out to be non-cardiac (not relating to the heart). Among those presenting to their General Practitioner with chest pain, only 17% go on to be diagnosed with ischaemic heart disease.
Classical cardiac chest pain is usually of a constricting quality, radiating to either both arms or neck and jaw. It comes on with exercise or emotion and is made better by stopping the exercise. The difficulty for doctors in primary care and A&E departments is to differentiate trivial chest pain from serious cardiac or other causes.
Nevertheless, even when patients present with atypical chest pain, doctors should maintain a high index of suspicion for coronary heart disease. There is a combination of factors that should make doctors particularly concerned about the possibility of coronary heart disease, such as: high blood pressure, over the age of 50, and high levels of fat in the blood (hyperlipidaemia).
There are also clinical symptoms associated with coronary heart disease, including breathlessness, clamminess, sweating and nausea.
Investigations for cardiac chest pain
If someone is complaining of symptoms consistent with coronary heart disease, he/she should be immediately admitted to hospital for emergency investigations. There must be an echocardiogram (ECG) and a blood test to check the troponin levels. A person with a damaged heart muscle will have elevated troponin levels.
The patient must be kept in hospital for a period of observation. During this time, a series of ECGs and blood tests must be carried out. This will show whether or not there is underlying evidence of myocardial damage. If so, the next step is to investigate the origin of the chest pain, according to the NICE Guidelines titled 'Chest Pain of Recent Origin (2010)'.
The publication has a table which helps medical practitioners calculate the patient's likelihood of having coronary heart disease. A course of treatment is then recommended. For example, a patient who has a 30% to 60% likelihood of coronary heart disease should be offered functional imaging as a first-line diagnosis investigation.
The type of functional imaging used to detect and quantify myocardial ischaemia could include stress ECG, stress echocardiography or radionuclide scanning. Radionuclide scanning is the preferred option in the NICE guidelines.
Treatment
If the radionuclide scan is positive, medical practitioners must decide upon a suitable course of treatment. A cardiologist may choose to treat the patient conservatively with drug medication, such as beta-blockers, statins, aspirins and ACE inhibitors. Alternatively, if there is significant myocardial ischaemia, the cardiologist may choose to proceed straight to surgery, either performing a bypass or inserting a stent.
What happens if treatment is not given?
Both conservative treatment and surgical treatment will help to prevent sudden cardiac death in patients with coronary heart disease.
The natural progression and regression of coronary atherosclerosis is highly unpredictable. It varies from patient to patient and has been altered markedly by the introduction of statin therapy. The idea that coronary atherosclerosis is a linear process leading to a gradual inevitability of progressive arterial stenosis does not fit clinical observations.
When coronary atherosclerotic plaque significantly impedes adequate blood supply to the heart muscle, the symptoms of angina occur. It is generally agreed that coronary atherosclerosis that involves at least 50% of the diameter stenosis is sufficient to reduce maximal blood flow during exercise/stress to produce angina symptoms.
Therefore with either conservative treatment or surgical revascularisation, it is likely that the patient will be successfully treated and will avoid fatal complications of cardiac sudden death.
Negligent medical care
If there are failings in medical care, it can lead to a patient suffering complications that would otherwise have been avoided. Most notably, medical practitioners must obtain sufficient information, as this will ensures that cardiac chest pain is not mistaken for non-cardiac chest pain. An ECG is a diagnostically limited test, so a doctor must take a proper history and record the relevant risk factors for coronary heart syndrome.
This action will guarantee that a patient's cardiac condition is identified and appropriate intervention carried out. If there is a failure to do this and a patient subsequently suffers problems, such as sudden cardiac death or a stroke, there could be a case of medical negligence.
For more information on making a claim for poor medical care, please get in touch with us at Glynns Solicitors.
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