I am a consultant cardiologist with more than 15 years experience.
I have a wide experience in all aspects of cardiology, particularly ischaemic heart disease (angina, heart attacks), interventional cardiology (balloon angioplasty / stents), heart rhythm disorders and pacemakers.
I have produced medico-legal reports on behalf of Claimant and Defendant for the courts for 10 years.
Nuffield Hospital, Haxby Road, York, North Yorkshire YO31 8TA
Mob: 07713 627418
Email 2: firstname.lastname@example.org
Dr Pye’s recent article as featured in Your Expert Witness magazine:
Sudden Cardiac Death (SCD) / Sudden Arrhythmic Death (SAD)
Sudden cardiac death (SCD) refers to the sudden cessation of cardiac activity with hemodynamic collapse, typically due to sustained ventricular tachycardia/ventricular fibrillation (VT/VF). These events mostly occur in patients with structural heart disease (that may not have been previously diagnosed), particularly coronary heart disease – either in setting of an acute myocardial infarction (heart attack) or due to VF related to an old scarred heart from previous heart attacks, cardiomyopathy or heart surgery.
Death certificate data suggest that SCD accounts for approximately 15 percent of the total mortality in the United States and other industrialised countries.
In absolute terms, the estimated number of sudden cardiac deaths in the United States in 1999 was approximately 450,000 . The magnitude of the influence of underlying cardiac disease on the risk of SCD is illustrated by the following observations:
• The risk of SCD is increased six- to ten-fold in the presence
of clinically recognized heart disease, and two- to four-fold in the
presence of coronary heart disease (CHD) risk factors.
• SCD is the mechanism of death in over 60 percent of patients
with known heart disease. In addition, SCD is the initial clinical
manifestation of CHD in approximately 15 percent.
Etiology – SCD usually occurs in people with some form of underlying structural heart disease, most notably CHD.
Coronary heart disease – As much as 70 percent of SCD have been attributed to CHD. Among patients with CHD, SCD can occur both during an acute coronary syndrome (ACS) and in the setting of chronic, otherwise stable CHD (often such patients have had prior myocardial damage and scar that serves as a substrate for SCD).
Other structural heart disease – Other forms of structural heart disease, both acquired and hereditary, account for approximately 10 percent of cases of out-of-hospital SCD. Examples of such disorders include the following:
• Heart failure and cardiomyopathy
• Left ventricular hypertrophy due to hypertension
• Hypertrophic cardiomyopathy
• Arrhythmogenic right ventricular cardiomyopathy
• Congenital coronary artery anomalies
Absence of structural heart disease – approximately 10 to 12 percent of cases of SCD among subjects under age 45 occur in the absence of structural heart disease.
• Brugada syndrome – (maybe noted in patients with abnormal
• Idiopathic VF
• Congenital or acquired long QT syndrome (maybe noted in
patients with abnormal resting ECG)
• Arrhythmogenic right ventricular cardiomyopathy (maybe noted
in patients with abnormal resting ECG)
• Familial polymorphic ventricular tachycardia, also called
‘catecholaminergic polymorphic VT.’
• Familial SCD of uncertain cause.
• Wolff-Parkinson-White syndrome. Cardiomyopathy (maybe
noted in patients with abnormal resting ECG)
• Acute triggers – In addition to the presence of the above
underlying disorders, superimposed triggers for SCD appear
to play a major role in the pathogenesis of this disorder.
These include ischemia, electrolyte disturbances (particularly
hypokalemia and hypomagnesemia), the proarrhythmic effect of
some antiarrhythmic drugs, autonomic nervous system activation,
and psychosocial factors such as acute stress
• In addition, SCD can result from commotio cordis in which VF is
precipitated by direct trauma over precordium
In Medico legal context the most common area of dispute is whether there was a breach of duty – ie missing a diagnosis of an underlying treatable cause of SCD. This most often arises if a patient had been referred (or not referred) for investigation of a syncopal event (blackout) – and an underlying serious cause was missed. There are certain red flag markers in general practice that should heighten need for more specialist urgent investigation (NICE guidelines suggest being seen within 2 weeks) – ie any history of coronary heart disease or structural heart disease ie cardiomyopathy, syncope on exertion, abnormal findings on exam ie heart murmur or abnormal resting 12 lead ecg.
In patients with known structural heart disease were appropriate risk markers of sudden cardiac death identified and was Internal Cardioverter Defibrillator (ICD) therapy considered?
SCD is obviously an extremely tragic event in every family no matter the age of the victim – emotions often run high – often there is no warning and there is no blame to be attached to anyone – the event could not have been predicted or forseen – it is in only in a few cases can there realistically be claimed to have been a breach of duty.
• For further information visit www.sadsuk.org