Q J Med 2003; 96: 269-279
© 2003 Association of Physicians
Sudden, unexpected cardiac or unexplained death in England: a national survey
From 1 Clinical Epidemiology, The Royal Brompton and Harefield Campus, National Heart & Lung Institute, Imperial College School of Medicine, University of London, 2 St George's Hospital Medical School, University of London, and 3 Department of Medical Statistics & Evaluation, Royal Postgraduate Medical School, University of London, London, UK
Received 25 November 2002 Accepted for publication 21 January 2003.
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Summary |
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 Top Summary IntroductionMethodsResultsDiscussionAppendix A: Categories of...Appendix B: Participating...Appendix C: Participating...References |
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Background: Post-mortem examinations of adults who were apparently healthy but died suddenly and unexpectedly sometimes reveal no morphological abnormalities to explain their deaths. The frequency of such unexplained deaths in relation to other causes of sudden cardiac death is not known.
Aim: To estimate the frequency of sudden unexpected cardiac or unexplained death in England.
Design: Prospective survey using a stratified random sample of 83 of the 132 H.M. Coroner's jurisdictions in England.
Methods: Consecutive White Caucasians, aged 16–64 years, with no medical history of cardiac disease, seen alive within 12 h of death, on whom autopsy found either a cardiac or no identifiable cause of death, were included. The coroner's officer sent a copy of the post-mortem report and a completed case registration form to the investigators, with tissue samples.
Results: Sixty-seven (81%) coroners participated, each maintaining prospective surveillance for 4 months. Of 692 ascertained cases, case registration forms were received for 650 (94%), post-mortem reports for 682 (99%), blood samples for 569 (82%), myocardial slices for 517 (75%) and whole hearts for 47 (7%). In cases with myocardial tissue, death was ascribed to ischaemic heart disease in 465 (82.4%). In 43.1% the ischaemia was acute, in 19.1% there was myocardial scarring but no acute ischaemia, and 20.2% had coronary atheroma only. Death was due to left ventricular hypertrophy in 32 (5.7%), to other cardiac causes in 30 (5.3%) and in 23 (4.1%) there was no clear cause. Those with cardiac causes were 81% male, median ages 55.9 (male) and 56.6 (female) years. The 23 unexplained deaths were 57% female, median ages 40.5 (male) and 54.9 (female) years. The estimated annual frequency of sudden unexpected death due to cardiac or unidentified causes, in English adults of employment age, was 11/100 000 (3481 annual deaths).
Discussion: In 4.1% of sudden unexpected deaths under 65 years, no cause was found. Until it becomes accepted practice to identify these cases by a name, such as Sudden Adult Death Syndrome (SADS), it will not be possible to study their aetiology systematically.
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Introduction |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix A: Categories of...Appendix B: Participating...Appendix C: Participating...References |
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There are occasions when post-mortem examination of an apparently previously healthy adult who has died suddenly and unexpectedly reveals no morphological abnormalities to explain their death. Whether such occasions are extreme rarities, or represent the tip of a larger iceberg, remains uncertain. In England, when the deceased was not under medical care prior to death, or the deceased's medical practitioner does not know the cause of death, or when death could be due to unnatural causes, the death must be reported to Her Majesty's Coroner, who investigates the cause. Coroner's cases are included in the mortality statistics published by certified cause by the Office of Population Censuses and Surveys,1 but for the deaths attributed to ischaemic heart disease, no distinction is drawn between those with and without an ante-mortem history of the disease. Thus neither the UK national frequency of sudden unexpected cardiac death, nor of those sudden unexpected adult deaths in which the cause is difficult or impossible to identify, are known. Whether the latter should be classified as the adult equivalent of the sudden infant death syndrome has been raised.2
The aim of the present survey was to measure prospectively throughout England the occurrence and circumstances of consecutive sudden unexpected adult deaths due to cardiac or to unidentified causes, and to collect prospectively post-mortem reports and tissue samples from such cases, ascertained by a stratified random sample of Coroners' jurisdictions. This paper describes the survey's principal results.
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Methods |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix A: Categories of...Appendix B: Participating...Appendix C: Participating...References |
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The methodology developed in a pilot study has been published.3 A summary, which includes modifications to the pilot methodology, follows.
Case definition
Sudden unexpected adult death cases were defined as: (i) white Caucasians; (ii) between the ages of 16 and 64 years (inclusive); (iii) with no medical history of heart disease; (iv) who were last seen alive within 12 h of being found dead, and (v) for whom a death certificate could not be issued without a coroner's post-mortem, at which either a cardiac or no identifiable cause of death was found. A history of hypertension alone (i.e. in the absence of any other signs or symptoms of heart disease) did not exclude subjects from the survey.
Sampling frame and sample size
The sampling frame was a list of the 132 coroner's districts of jurisdiction in England, ranked primarily geographically and secondarily by 1992 annual caseload (which ranged from 70 to 4956 cases). The list was divided into four groups of 33 jurisdictions, each group being comparably distributed both geographically and in terms of coroner's workload. The four groups were randomly ordered; the first group of jurisdictions started surveillance on 25 October 1993 and the third group on 27 March 1995. The fourth group of coroners was not required. Each jurisdiction maintained prospective surveillance for cases (as defined above) for a four-month period. Altogether, 83 coroners were invited to participate in the survey and 67 (81%) did so. The total period of surveillance across England was about two years.
Surveillance and case ascertainment
Each coroner and/or their officer completed a check-list (the Death Record Form) on each deceased referred for post-mortem examination, to maintain surveillance for the deceased's race, age, past medical history and when last seen alive (the first four of the above inclusion criteria), so as to advise the coroner's pathologist whether the deceased was eligible for the survey. If the coroner's pathologist then found either a cardiac or no identifiable cause of death (the fifth inclusion criterion), tissue specimens were collected from the case. For the deceased who met all five inclusion criteria, the coroner's officer sent a copy of the post-mortem report and a completed Case Registration Form to the investigators. Fifty-seven jurisdictions used Death Record Forms as their means of prospective self-audit of case ascertainment.3 The remainder set up their own case surveillance mechanisms.
Data and tissue collection
Information requested on the Case Registration Form included the deceased's name and date of birth, the time and circumstances of death, and their general practitioner's name and address. Coroner's officers attached a copy of their own report of the circumstances of death to the Case Registration Form. The following tissue specimens were requested.
Myocardium
A transverse myocardial slice (1 cm thickness) through both ventricles at mid-septal level (or equivalent in piecemeal form) was fixed in a formalin-based fixative for 48 h. Excess formalin was poured off, and the slice was placed in a container.
Blood
Ten millilitres of blood were placed in a plain blood bottle and 2 ml in a fluoride bottle. Each specimen container was labelled and despatched to the investigators.
Case registration forms, specimen containers, stamped addressed envelopes and packaging had been provided in advance by the investigators.
In those cases in whom macroscopic inspection of the transverse myocardial slice revealed no evidence of infarction or ischaemia and in whom neither significant coronary disease nor any other identifiable cause of death was found at post mortem, the whole heart (rather than just the myocardial slice) was sent to the investigators for examination, and the blood underwent central toxicological screening by the investigators. (Prior toxicological screening by the coroner had excluded cases of suspected substance abuse.)
Histology reporting and coding of causes of death
Whole hearts and myocardial slices were all examined macroscopically and histologically in a standard manner, by the study's own consultant cardiac histopathologists. On each case on whom tissue was available, the coroner's post-mortem report, the coroner's officer's report and the investigators' own histological and toxicological findings were reviewed by a panel (MJD, MNS and TJB), who classified the cause of death into one of 27 possible categories (Appendix A). Cases for whom no tissue was available were classified in a similar manner, but without the benefit of study's own independent histological reports.
Death registration and investigator's report to coroner
The investigators reported their pathological findings directly to the coroner. Coroners did not have to delay registration of deaths; they were able to indicate to the Registrar that the results of histological examination were to follow.
Denominator population
The denominator population in which cases arose was the sum of the catchment populations of the participating jurisdictions. These were estimated by using the Office of Population Censuses and Surveys 1994 age-specific mid-year population estimate for English counties and metropolitan areas and, for those counties with more than one coroner, weighting each county's age-specific population between jurisdictions by coroners' annual caseload.
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Results |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix A: Categories of...Appendix B: Participating...Appendix C: Participating...References |
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Coroner participation and case registration
Sixty-seven jurisdictions (81% of those invited) participated in the survey. A total of 10 724 Death Record Forms were returned to the investigators from the 57 jurisdictions that used them. From all 67 jurisdictions, 1029 sudden cardiac or unexplained deaths were registered, 1003 of which met the first four inclusion criteria of the case definition. In 278 of these deaths a definite non-cardiac cause of death was found at post-mortem examination. On a further 33 deaths, there was insufficient information available for diagnostic classification. This left a total of 692 true cases.
Completeness of data and tissue collection
Of the 692 true cases, case registration forms were received for 650 (94%), post-mortem reports for 682 (99%), blood samples for 569 (82%), myocardial slices for 517 (75%), whole hearts for 47 (7%), and no tissue for 128 (18%). For 528 (76%), a complete dataset (post-mortem report, case registration form and tissue) was received (Table 1
).
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Classification of causes of death
The causes of death to which cases were categorized by the panel are summarized in Table 2. Of the 564 (81.5%) cases on whom myocardial tissue was available, 465 (82.4%) were classified as having died due to some manifestation of coronary disease, 32 (5.7%) to left ventricular hypertrophy, 30 (5.3%) to other cardiac causes, and in 23 (4.1%) there was no clear cause. Three other cases (0.5%) also had no clear cause; however, one of these had Down's syndrome, and in the other two prescribed drugs were detected in the blood at non-toxic levels. Eleven other subjects (2%) had an ante-mortem history of epilepsy (4 cases) or of previous alcohol abuse (7 cases). Their deaths had been attributed to cardiac disease (1 epilepsy, 3 alcohol abuse) or to no clear cause (3 epilepsy, 4 alcohol abuse), and are tabulated separately. Details of the other 30 cases with other cardiac causes of death are given in Table 2 (also given in Table 2 is the classification of cases on whom myocardial tissue was not available).
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Age and gender distributions
The 527 cases with myocardial tissue for whom a cardiac cause of death was found were predominantly male (81%), with the genders having similar age distributions: male and female median (range) ages were 55.9 (19.5–64.9) and 56.6 (24.4–64.9) years, respectively. By contrast, in the 23 unexplained deaths, not only were females more frequent (57%), but also age at death differed between genders: male and female medians (range) being 40.5 (16.0–64.9) and 54.9 (25–62.3) years, respectively.
Occurrence rates
Based on the estimated age-specific catchment populations of the participating coroner's jurisdictions (total 15 348 301 people), the frequency of sudden unexpected death due to cardiac causes was estimated to be 10.5 per 100 000 per annum and to unexplained causes 0.5 per 100 000 per annum, in English adults of employment age. If the 128 cases for whom no tissue was received are included in the numerator, the estimate due to cardiac causes rises from 10.5 to 13 per 100 000 p.a.
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Discussion |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix A: Categories of...Appendix B: Participating...Appendix C: Participating...References |
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This national survey has demonstrated that, despite an expert histopathological examination, there remains a proportion of sudden unexpected adult deaths in whom no definite cause of death can be found. The proportion unexplained in this national survey (4.1%) is consistent with that (4.7%) measured in a Wandsworth survey reported in 1988,4 although there are some differences in case definition between the two studies.
The frequencies of sudden unexplained death in Thailand5,6 and in Singapore7 have been surveyed, and a retrospective study of the occurrence and causes of sudden unexpected non-traumatic death in a Minnesota county8 has also been reported. In addition, the rate of occurrence of sudden cardiac death, and its triggers, have been studied in subjects with previously diagnosed cardiac disease in North America9–12 and Europe,13–16 and in subjects both with and without previously diagnosed cardiac disease in the UK.4,17–20
Our survey has provided an estimate of the national rate of sudden unexpected cardiac adult death (10.5 per 100 000 per annum). The rate of sudden unexpected adult deaths measured by this survey to be due to ischaemic heart disease (9.1 per 100 000 per annum) is 20% of the entire national ischaemic heart disease death rate, in the same age group. These occurrence rates would be equivalent to a total of 3338 cardiac, and of 143 unexplained, sudden and unexpected deaths, in adults of employment age throughout England each year.
These cardiac deaths have implications for the early detection and management of cardiac disease. The unexplained deaths raise two issues. The first, and immediate, issue is how best to counsel the relatives of such victims and investigate the surviving family members for cardiac disease. The second, and longer term, issue is how to develop a strategy for investigating the aetiology of such tragedies, thereby hopefully leading to their prevention. English coroners, who must be qualified solicitors or barristers (and may also be medically qualified), were instituted 800 years ago, and in legal antiquity are second in the Realm only to the Lord Chancellor. The verdict of a Coroner's Court has not been challenged, even by the House of Lords. It is most unlikely that any sudden unexpected cardiac or unexplained death occurring in England during the period of this survey would not have been reported to the Coroner. Nevertheless, our occurrence rate estimates (both of cardiac and of unexplained death) are liable to be conservative. While all cases are likely to have been referred to coroners, some may have escaped the surveillance mechanism within some jurisdictions.
In the pilot survey performed to develop the present methodology, an independent retrospective audit of completeness of case ascertainment detected a median true ascertainment rate of 75%.3 Accordingly, the Death Record Form was introduced into the main survey's methodology, to provide a concurrent self-audit mechanism to minimize underascertainment due to incomplete surveillance. The ten jurisdictions which did not use this self-audit mechanism ascertained a total of 56 cases with myocardial tissue (only 10% of the total of 564). While the 10 jurisdictions are 15% of the total of 67 participating, the aggregate of their estimated catchment populations was 2 899 205 (19% of the total). Thus it is not unreasonable to assume incomplete surveillance within these 10 jurisdictions. If occurrence rates in 19% of the population have been underestimated by 25%, then our overall estimates should be increased by 6%. Even in the 57 jurisdictions using the self-audit mechanism, there is no guarantee that ascertainment was 100%. However, it is safe to conclude that our figures are not over-estimates of sudden unexpected adult cardiac and unexplained death rates.
The proportion of cases in whom there was no clear cause of death is likely to be a conservative estimate, not only because of incomplete surveillance in some jurisdictions, but also because allocation to this category has been strict. All such cases were apparently healthy, with no reported co-morbidity prior to their sudden unexpected death, and had a negative toxicological screen for prescribed or illicit drugs. If a sudden adult death syndrome exists, then from time to time it is liable to occur in individuals who have a past history of alcohol abuse or of diseases such as epilepsy or Down's syndrome, or who may be taking prescribed medication. Nevertheless, the ten individuals who fell into one of these groups (epilepsy, alcohol, prescribed drugs detectable on toxicological screen, Down's syndrome), and who had no clear cause of death, have been classified separately from the 23 unexplained cases in whom there was no co-morbidity. While the proportion of cases due to unidentified causes is certainly not less than 4.1%, this proportion might be greater if some of the unexplained cases with co-morbidity were in fact truly unexplained. Whatever the truth of the matter, a similar apparent excess of sudden unexpected adult death in epileptics and in alcoholics was detected in the Wandsworth survey.4 However, it is not possible to estimate their rates, as both surveys made no attempt to make complete ascertainment of such cases with co-morbidity.
In cases in whom coronary atheroma was the only finding, the question arises as to whether it was incidental.21,22 While coronary atheroma is ubiquitous in Western populations from an early age, a distinction needs to be drawn between its presence and ischaemic heart disease as the cause of death; the latter requires support from other evidence: high-grade stenosis, thrombosis or old or recent infarction.13,23 In the present survey, coronary thrombosis may have gone undetected in a proportion of the cases in whom coronary atheroma only was found.
In England, the frequency of coroner's post mortem cases with no morphological abnormality (or with only co-incidental coronary atheroma) is unknown, because there has been no agreed nomenclature for categorizing and recording them.2 Some coroners have accepted a diagnosis of ‘natural death—cause unascertained’; others have not. A pathologist may be tempted to ascribe death erroneously to ischaemic heart disease or to minor conduction system abnormalities.24 A category of ‘sudden adult death syndrome’ is proposed for those victims who were previously well and whose heart is morphologically normal at necropsy.2
In the present survey, unexplained cases had different age and gender distributions to those due to cardiac causes. This may in part simply indicate that it is easier in older subjects to find some pathological cardiac abnormality to which to ascribe death (but whether such abnormality was causal or coincidental remains open to discussion). Nevertheless, the differing age and sex distributions are consistent with the idea that the unexplained cases are a separate entity to those with recognized cardiac causes.
The unexplained cases found in this survey are in fact likely to have causes, which at present cannot be identified. However, until it is accepted practice to identify such cases and label them as such (rather than attribute them to a currently recognized cardiac cause of death without good evidence), it will not be possible to study them systematically and thus identify their cause(s). These sudden unexplained natural deaths should be registered as sudden adult death syndrome.
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Appendix A: Categories of causes of death |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix A: Categories of...Appendix B: Participating...Appendix C: Participating...References |
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Coronary disease
Acute ischaemia or infarction, with prior myocardial scarring
Acute ischaemia or infarction, without prior myocardial scarring
Acute ischaemic haemopericardium, with prior myocardial scarring
Acute ischaemic haemopericardium, without prior myocardial scarring
Prior myocardial scarring, without acute ischaemia or infarction
Atheromatous coronary artery disease only, without acute ischaemia or infarction, prior myocardial scarring, or LVH
Left ventricular hypertrophy (LVH)
LVH with no history of hypertension or ischaemic heart disease
LVH with history of hypertension, but no ischaemic heart disease
LVH with coronary atheroma, but without acute ichaemia or prior myocardial scarring
LVH with aortic stenosis, and no ischaemic heart disease
LVH with both aortic stenosis and hypertension, but no ischaemic heart disease
Other cardiac
Idiopathic myocardial fibrosis syndrome
Hypertrophic cardiomyopathy
Dilated cardiomyopathy
Right ventricular dysplasia
Myocarditis
Mitochondrial myopathy
Sarcoidosis
Right atrial pathology
Anomalous coronary artery
Floppy mitral valve
Aortic stenosis with coronary artery disease, but without acute ischaemia or prior myocardial scarring
Aortic stenosis without coronary artery disease or LVH Endocarditis
Primary tumour
Metastatic tumour
No cause found
Associated conditions
Epilepsy
Alcoholism
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Appendix B: Participating coroners and their jurisdictions |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix A: Categories of...Appendix B: Participating...Appendix C: Participating...References |
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Appendix C: Participating coroners' pathologists |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix A: Categories of...Appendix B: Participating...Appendix C: Participating...References |
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Dr R.A. Jones, Dr M.A. Nurbhai & Dr C. Ritchie, Middlesborough General Hospital
Dr J. Hoffman & Dr K. Karczenski, North Tees General Hospital, Stockton
Dr J.H. McCarthy & Dr K.P. Pollard, South Tyneside District Hospital, South Sheilds
Dr J.P. Sunter, Dr M.J. Egan & Dr P.A. Cross, Queen Elizabeth Hospital, Gateshead
Dr M.R.B. Wetherall, Dr H.R. Cochrane, Dr J.H. McElroy & Dr K.V. Prasad, Sunderland District General Hospital
Dr A.W. Popple, Dr F.I. Young & Dr E.D. Long, Cumberland Infirmary, Carlisle
Dr D. Smith & Dr R.G. Ghazala, West Cumberland Hospital, Whitehaven
Dr D.A. Smith & Dr G.U.A. Igboaka, Wansbeck District General Hospital, Ashington, Northumberland
Dr J.W. Lowe, Dr B. Naylor, Dr D. Gouldesbrough, Dr P.A. Batman, Bradford Royal Infirmary
Dr G.D.H. Thomas & Dr K. Shorrock, Royal Halifax Infirmary
Dr H.H. Ali & Dr M. Cassidy, Huddersfield Royal Infirmary
Dr L.A. Fenton & Dr P. Gudgeon, Dewsbury & District Hospital, West Yorkshire
Professor M.A. Greene, Dr J.C. Clark & Dr C.M. Milroy, Dept of Forensic Pathology, University of Sheffield
Prof J.C.E. Underwood, Dr T. McCulloch & Dr S.S. Cross, Royal Hallamshire Hospital, Sheffield
Dr J.R. Shortland, Northern General Hospital, Sheffield
Dr J.A. Coup, Barnsley District General Hospital
Dr A.W. MacDonald, Hull Royal Infirmary
Dr J.R. Read, Dr P.A. Burgess & Dr H.P.R. Bury, Castle Hill Hospital, Cottingham, North Humberside
Dr G. Kurien & Dr C. Hunt, Scunthorpe General Hospital
Dr C. Gray, Harrogate General Hospital
Dr A.T. Edwards & Dr A. Gledhill, Harrogate District Hospital
Dr J.J. O'Dowd & Dr R.D. Pyrah, Airdale General Hospital, Keighley
Dr I.N. Reid, York District Hospital
Dr J.B. Kershaw & Dr W.M. Peters, Grimsby District General Hospital
Dr D.C. Henderson & Dr K.V. Prasad, Friarage Hospital, Northallerton
Dr A.M. Jackson, Scarborough Hospital
Dr J. Burns, Dr J.R. Gosney, Dr C.P. Johnson, Dr T.R. Helliwell, Dr J. Nash, Dr B. Green & Dr R. Dixon, Royal Liverpool University Hospital
Dr W. Taylor, Dr C.T. Burrow, Dr T.E. Giles, Dr J.D.H. Sheard & Dr M.T. Haqqani, Fazakerley Hospital, Liverpool
Dr W.E. Kenyon & Dr M.W. Myskow, Broad Green Hospital, Liverpool
Dr M.S. Al-Jafari, Walton Hospital, Liverpool
Professor A.J. Freemont, Manchester Royal Infirmary
Dr N.Y. Habouri, Withington Hospital, Manchester
Dr D.M.H. De Kretser, North Manchester General Hospital Dr P.S. Hastleton, Dr E. Sim, Dr H.M. Doran & Dr P.W. Bishop, Wythenshawe Hospital, Manchester
Dr G.R. Armstrong, Dr D.A. Agbamu, Dr R.J. Byers, Dr R.S. Reeve & Dr A.W. Jones, Hope Hospital, Salford, Greater Manchester
Dr J.M. Torry & Dr I. Gupta, Leigh Infirmary, Greater Manchester
Dr M.B. Reid & Dr N.E. New, Royal Albert Edward Infirmary, Wigan
Dr S. Wells, Dr G. Morphopoulos & Dr D.L. Bisset, Bolton General Hospital
Dr R.J. Farrand, The Royal Infirmary, Bolton
Dr D.M. Vickers, Dr A.J. Yates & Dr R.J. Hale, Stepping Hill Hospital, Stockport
Dr D.L. Bee & Dr A.S. Day, Tameside General Hospital, Ashton-under-Lyme
Dr B.N.A. Hamid & Dr M.Y. Sheikh, Trafford General Hospital, Manchester
Dr M.W. Atkinson & Dr I. Seddon, The Royal Oldham Hospital
Dr R. Menon & Dr M.G. Bradgate, Birch Hill Hospital, Rochdale
Dr M.E. Herd, Dr S. Dutt, Dr G. Garrett, Dr A.J. Yates, Dr W. Lawer & Dr S.S. Hom-Choudhury, Fairfield General Hospital, Bury
Dr A.J. Howat, Dr E. Tapp, Dr C.M. Nicholson & Dr P.G. Lynch, Royal Preston Hospital
Dr V. Tagore, Ormskirk & District General Hospital
Dr H.D. Zakhor, Arrowe Park Hospital, Wirral
Dr W.D. Salman & Dr A.A.F. AI-Dawoud, Burnley General Hospital
Dr H.M. Myat, Rossendale General Hospital, Lancashire
Dr Quereshi, Nelson Mortuary, Pendle, Lancashire
Dr J.A. Morris, Dr D.H. Orrell, Dr M. Stewart & Dr R.W. Blewitt, Westmoreland General Hospital, Kendal & Royal Lancaster Infirmary
Dr K.S. Vasudev, Dr M.C.J. Sissons & Dr J. Edwards, Victoria Hospital, Blackpool
Dr D. Semeraro, Dr C.S. Holgate, Dr I.P. Hopper & Dr J. Cocker, Derby Royal Infirmary
Dr J.V. Clark, Dr A.J. Molyneux & Dr S.B. Coghill, Northampton General Hospital
Dr B.E. Gostelow, Dr J.A.H. Uraiby, Dr L.E. Pirie & Dr S.R. Milkins, Kettering General Hospital
Dr P.B. Gray, Dr S. Rogers & Dr S.S. Cross, Chesterfield & North Derbyshire Royal Hospital
Dr D.C. Bouch, Dr K.P. West & Dr C.H. Kendall, Leicester Royal Infirmary
Dr S.M. Shah & Dr D.C.S. Durrant, Pilgrim Hospital, Boston
Dr D.M. Clark, Grantham & Kesteven General Hospital
Dr T.A. French & Dr C.R. Knappett, Central Pathology Laboratory, Stoke-on-Trent
Dr C. Musgrove, Dr J.C. Broome & Dr M. Stephens, North Staffordshire Royal Infirmary, Stoke-on Trent
Dr P. Kitara-Okot, City General Hospital, Stoke-On-Trent
Dr J.L. Christie, Dr O.P.R. Stores, Dr T. Hollingworth & Dr S. Ghosh, Russells Hall Hospital, Dudley, West Midlands
Dr K.W.M. Scott, The Royal Hospital, Wolverhampton
Dr K.J. Holley, Dr E.J. Vella & Dr K.M. Newbold, South Warwickshire Hospital, Warwick
Dr J.F. Nottingham, Hospital of St Cross, Rugby, Warwickshire
Dr N.M.S. Bajallan, George Eliot Hospital, Nuneaton
Dr T.G. Ashworth, Dr K. Chen & Dr T. Guha, Walsgrave Hospital NHS Trust, Coventry
Dr J.C. Macartney, Dr L. Brown & Dr G.H. Eeles, Alexandra Hospital, Redditch
Dr G.M. Kondratowicz, Kidderminster General Hospital
Dr J. Simon & W.J. Fuggle, Sandwell District General Hospital, West Bromwich
Dr P.E. Nicholls, Dr P.W. Leedham, Dr R.A. Fraser, Dr T.J. Jones, Royal Shrewsbury Hospital and Princess Royal Hospital, Wellington, Telford
Dr J.S. Dinnen & Dr F. McGinty, County Hospital, Hereford
Dr D.G.D. Wight, Dr J. Arno, Dr N. Coleman, Dr I. van Lijnschoten, Dr A.M. Goddard & Dr S. Thiru, Addenbroke's Hospital, Cambridge
Dr S. Stewart, Papworth Hospital, Cambridge
Dr T.H.W. Barker, Dr R.N. Lonsdale, Dr R.Y. Ball, Dr B.G. McCann & Dr P.F. Roberts, Norfolk & Norwich Hospital
Dr R.G.G. Rowe, Dr P.A. Judd, Dr J.E. Trowell & Dr J.M. Orrell, Ipswich Hospital
Dr D.A. Harrison, Dr M.J. Wilkinson & Dr N.J. Ball, James Paget Hospital, Great Yarmouth
Dr H.K. Al-Rufiae & Dr T. Biedrzcki, West Suffolk Hospital, Bury St Edmonds
Dr M.D. Harris, Dr A.L. Whitehead & Professor G.A. Gresham, Hinchingbrooke Hospital, Huntingdon
Dr D. Eakins & Dr R.A. Eames, Queen Elizabeth Hospital, Kings Lynn
Dr M. Lesna, Dr D.M. Parham, Dr S.S. Quereshi & Dr A. Connoly, Royal Bournemouth Hospital
Dr D.S. Nicholas & Dr J.H.P. Alexander, Poole General Hospital
Professor P.P. Antony, Royal Devon & Exeter Hospital (Wonford)
Dr T.J. Clarke, Dr R.H.W. Simpson & Dr D.S. Arora, Area Department of Pathology, Exeter
Dr W.L.H. Scarrat, Dr AJ Sherwood & Dr D.M. Lee, Derriford Hospital, Plymouth
Dr A.M. Anscombe, Dr M.C.F. Jenkins & Dr L. Machin, Dorset County Hospital, Dorchester
Dr L. Daborn, West Dorset Hospital, Dorchester
Dr R.W. Pitcher, Dr R.J. Marshall & Dr Y. Sivathondan, Royal Cornwall Hospital (Treliske), Truro
Dr N.A. Shepherd, Dr B.W. Colding & Dr J.S. Uff, Gloucester Royal Hospital
Dr J.P. Sheffield, Yeovil District Hospital
Dr E.W. Hall, Dr C.B. Hobbs, Dr T.I.F. MacLeod & Dr J.V. Lever, Royal United Hospitals, Bath
Dr N. Gubbay, Cheltenham General Hospital
Dr B.M. Hill, Dr D.E. Fish, Dr A.J. Rainey & Dr M. Ameen, East Surrey Hospital, Redhill
Dr R.W. Ainsworth, Dr N.G. Ryley & Dr M.G. Cook, Royal Surrey County Hospital, Guilford
Dr M. Hall & Dr N.A. Ratcliffe, St Peter's Hospital, Chertsey, Surrey
Dr B. Bramble & Dr S. Ibrahim, Ashford Hospital, Middlesex
Dr J.B. Stewart, Dr T.J. Matthews & Dr L.N. Temple, Epsom General Hospital
Professor D.A.L. Bowen, Charing Cross Hospital, London
Dr D. Shove, Finchley Public Mortuary, London
Dr R.C. Chapman & Dr V. Djurovic, Guy's Hospital, London
Dr M.R. Crompton, St George's Hospital Medical School, London
Dr J.L. Dyson, Dr W. Thurrell & Dr D.C. Brown, Wittington Hospital, London
Dr J.E. McLaughlin & Dr A.J. Maddox, Royal Free Hospital, London
Professor N. Woolf, Middlesex Hospital, London
Dr M.J. Heath, Dr P.A. Lannas & Dr D.A. Rouse, The London Medicolegal Centre
Dr I.E. West & Dr F. Patel, Guy's Hospital, London
Dr G.N. Soosay, King George Hospital, Ilford, Essex
Dr N.J.E. Marley, Dr D.A. McCormick & Dr R. Buchanan, St. Mary's Hospital, Portsmouth
Dr R. Coddington & Dr J.D. Buchanan, Haslar Royal Naval Hospital, Gosport
Dr M.J. Jeffrey, Dr J.J. Mikel, Dr D. Madziwa, Dr T. Beer & Dr M.I.J. Andrews, Queen Alexandra Hospital, Portsmouth
Dr P.J. Gallagher, Dr A. Hitchcock, Dr D. Ellison, Dr J.M. Theaker, Dr W.R. Roche, Dr A. Bateman, Dr G. Culora & Professor D.H. Wright, Southampton General Hospital
Dr G.H. Millward-Sadler, Dr A.D. Ramsey & Dr C.E.H. DuBoulay, Lymington Hospital, Hampshire
Dr D.B. Rimmer & Dr A.J. Blackshaw, Bedford Hospital (South Wing)
Dr D.A.S. Lawrence, Dr M. Nayagam & Dr J. Dove, Luton & Dunstable Hospital
Dr P.R. Millard, John Radcliffe Hospital, Oxford
Dr N.J. Mahy & Dr G. Greywood, Horton General Hospital, Banbury
Dr M.J. Turner & Dr Y. Chia, Wycombe General Hospital, High Wycombe, Buckinghamshire
Dr E.M. Husband & Dr J.M. Finch, Basingstoke District Hospital
Dr C.E.T. Smith & Dr J.S. Haldane, Frimley Park Hospital
Dr N. Greenwood, Dr L.H. Kissen & Dr R. Joshi, St. Mary's Hospital, Newport, Isle of Wight
Dr R.G.M. Letcher, Dr K.J. Agarwal & Dr J. McKenzie, St. Margaret's Hospital, Epping
Dr A. Fattah & Dr M.S.S. Al-Izzi, Queen Elizabeth II Hospital, Welwyn Garden City
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Acknowledgments |
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We are grateful to the coroners (listed in Appendix B) and coroner's pathologists (Appendix C) for their participation. We also thank the Clinical Epidemiology and Histopathology Staff at the National Heart and Lung Institute and Royal Brompton & National Heart Hospital: S. Lawlor, R. Florio, N.R. McLennan, J.E. Ingham, P.F. Daniel and R. Valay. This survey was funded by the British Heart Foundation.
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Notes |
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Address correspondence to Dr T.J. Bowker, Cardiovascular Medicine, National Heart & Lung Institute at Charing Cross Campus, Imperial College, London. e-mail: bowkert{at}bhf.org.uk.
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TopSummaryIntroductionMethodsResultsDiscussionAppendix A: Categories of...Appendix B: Participating...Appendix C: Participating...References |
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