Neurological Sudden Death Is Not Rare

Anthony L. Komaroff, MD reviewing Kim AS et al. Neurology 2016 Sep 16.

During 2 years, 5% of so-called sudden cardiac deaths actually were neurological sudden deaths.

Many cases of sudden death do not result in autopsy and are assumed to be of cardiac origin. A
San Francisco team obtained detailed information (including autopsies) at the time of death in
335 cases categorized as “sudden cardiac death” by the medical examiner that occurred during
25 months in 2011 through 2013.

Eighteen cases (5.4%) were judged to be sudden neurological deaths caused by intracranial
hemorrhage (8), epilepsy (6), aneurysmal subarachnoid hemorrhage (2), acute ischemic stroke
(1), and aspiration in a patient with Huntington disease (1). Patients with histories of stroke or
transient ischemic attack were not at significantly greater risk for neurological death than were
other patients (although the study was underpowered to access this factor). Use of antithrombotic
medication was a clear risk factor (odds ratio, 3.9). Of the 15 deaths in patients with epilepsy,
40% were caused by epilepsy, and the rest were caused by cardiac or other causes. Sudden
neurological deaths were the second most common noncardiac cause of death, after drug
overdose.

Comment

Sudden death usually is assumed to be of cardiac origin and is only infrequently pursued with
autopsy examination. But this study suggests that cases of neurological death sometimes can be
misclassified as cardiac deaths. Some deaths in large cardiovascular trials might have been
similarly misclassified.

Atrial Fibrillation Is Associated with Adverse

Cardiovascular Outcomes Beyond Stroke
Paul S. Mueller, MD, MPH, FACP reviewing Odutayo A et al. BMJ 2016 Sep 06.

In a large meta-analysis, patients with AF had excess risk for heart failure, CV-related death,
chronic kidney disease, and ischemic heart disease.

The mainstays of managing patients with atrial fibrillation (AF) include rate control and
anticoagulation to prevent stroke; however, AF also is associated with other adverse
cardiovascular (CV) outcomes. In this meta-analysis of 104 cohort studies, U.K. researchers
examined associations between AF and risks for various adverse CV events, kidney disease, and
early mortality in 9.7 million patients (590,000 with AF).

During median follow-up of 3 to 6 years, AF was associated with significantly higher risks for
peripheral artery disease, all-cause death, ischemic heart disease, chronic kidney disease, sudden
cardiac death, major adverse CV events, CV-related death, stroke, and heart failure (relative risks
ranging from 1.3 for peripheral artery disease to 5.0 for heart failure). Results were consistent
across patient subgroups (e.g., categorized by age or history of ischemic heart disease or stroke)
and across various study characteristics (e.g., study population, study location, follow-up
duration).

Comment

In this meta-analysis, AF was associated with higher risk for a wide range of adverse nonstroke
outcomes. However, these associations do not establish causality; as the authors note, AF could
be acting as a marker for an underlying predisposition to adverse CV and kidney outcomes.
Hence, clinicians should assess risks for these other adverse outcomes when they consider
interventions beyond rate control and stroke prevention in patients with AF.