Evaluation of deaths BY cardiovascular diseases in forensic autopsy cases in Antalya between 2015-2019

Cardiovascular diseases cause a large number of deaths every year globally. In addition, the most common cause of sudden and unexpected deaths is cardiovascular diseases. In this study, it is aimed to evaluate the frequency of deaths due to cardiovascular diseases in the forensic autopsiesand defining the macroscopic and microscopic changes that occur in the heart and brain in different causes of cardiovascular deaths and evaluate the difficulties that the forensic practitioner may encounter during the autopsy procedure of these deaths. In this study, the forensic /medicolegal autopsy cases whose autopsies were performed in the Morgue Department of the Antalya Barnch of Forensic Medicine Institute, between January 1st, 2015 and December 31st, 2019. Deaths due to cardiovascular diseases were evaluated in terms of gender, age, height, weight, BMI, causes of death, places of death, and autopsy findings. A total of 1045 (22.3%) cases that met the study criteria were identified. It was found that 176 (16.8%) of these cases were female and 869 (83.2%) were male. The median age of the cases was found to be 58 years (median age 59.5 years for women and 58 years for men). Seventy-one-point-five percent of the cases were aged ≥50 years (n=748). Twenty percent (n=206) of the adult population had a BMI in the normal and healthy classification (BMI<25), 51.2% (n=527) were in the overweight classification (25≤BMI<30), 28.8% (n=297) were in obese classification (BMI≥30). It was determined that women were found to be in the healthy and obese classifications at a significantly higher rate, while men were found to be more frequently in the overweight classification. The places in where the health status of the cases were most frequently detoriated were houses (n=417, 39.9%), hotel rooms (n=220, 21.1%) and open spaces (n=195, 18.7%), respectively. There was no witness in the deaths of 418 (40.0%) cases. It was determined that the highest number of deaths occurred in September (10.8%), August (10.4%) and November (10.1%), respectively. In our study, the most common causes of death were found to be ischemic heart diseases (n=719, 68.8%), left ventricular hypertrophy (n=105, 10%), and aortic dissection (n=58, 5.5%), respectively. It was observed that deaths due to ischemic heart diseases were significantly more common in men and deaths due to cerebrovascular diseases, aortic dissection and pulmonary thromboembolism were significantly more common in women. In 735 cases that met the criteria for sudden cardiac death, the three most common causes of death were also ischemic heart diseases (n=503, 68.4%), left ventricular hypertrophy (n=78, 10.6%) and aortic dissection (n=41, 5.6%). Apart from these, no finding was found in 32 cases who met the criteria for sudden cardiac death. It was calculated that the median value of brain weights in adult cases was 1192 g, and this value was 1210 g in men and 1089 g in women. It was found statistically significant that the brain weight was higher in men than in women. It was observed that brain weight decreased as age increased in the adult population, and this relationship was found to be statistically significant. It was determined that weight and brain weight increased together in the whole population and this coexisting increase was also statistically significant. The cause of tamponade in 49 (55.1%) of 89 cases was aortic dissection, followed by ventricular rupture as a result of acute myocardial infarction in 36 (40.4%) cases, ruptured aortic aneurysm in 4 (4.5%) cases. The median heart weight of adult subjects in the study population was 516 g (n=1029, IQR=189, Q1=424, Q3=613, mean=534.9, min=214, max=1303). It was determined that the heart weight in men was significantly higher than in women. When the percentage of heart weight to body weight was compared between the genders, no statistically significant difference was found. Therefore, it was concluded that the gender difference in heart weights was due to the difference in body sizes between men and women. It was determined that the age and heart weights of adult cases increased together, this correlation was statistically significant. Age and heart weight to body weight ratio also increased together, and this coexisting increase was statistically significant. It was observed that heart weight and body weight increased together, and this relationship was statistically significant, as well. Various degrees of atherosclerosis were detected in the coronary arteries in 81.9% (n=856) of the cases. Atherosclerotic plaque that caused severe stenosis within the lumen was detected in the part of the left main coronary artery before the circumflex artery separation in 107 cases (10.2%), in the left anterior descending branch of the left coronary artery in 436 cases (41.7%), in the circumflex branch in 289 cases (27.7%), in the right coronary artery in 303 cases. (29%). It was determined that the degree of narrowing in the lumen of all three coronary arteries and the age of the patients increased together, and this relationship between them was found to be statistically significant. Thrombus was found in the coronary arteries in 78 cases (7.5%). Microscopic findings of previous myocardial infarction were found in the myocardial sections in 569 cases (54.4%), and macroscopic findings of previous myocardial infarction were found in 524 cases (%50,1). Myocardial interstitial fibrosis was found in 59.7% (n=429) of deaths due to ischemic heart disease and 65.2% (n=144) of deaths due to other causes. Histopathological findings of acute myocardial infarction were observed in 122 cases (11.7%) in total population. In our study, the median values for aortic, pulmonary, mitral, and tricuspid valve circumferences were 7.7 cm, 8.6 cm, 10.5 cm, and 13 cm, respectively. For each valve, it was found that the valve circumference in males was significantly higher than in females. CPR was performed in 631 (60.4%) of all cases, while 414 cases (39.6%) died before any medical intervention were applied. Tests have shown that patients whose health status were detoriated at home were recieved CPR significantly less frequently than those that were detoriated in hotels, open spaces, prisons, and other closed spaces. According to the results of our study, in deaths due to cardiovascular diseases, significant differences were found between the causes of death and gender . In cases of sudden cardiac death, in order to detect the causes of death ındisputable, a detailed systematic autopsy protocol should be applied carefully, in all sudden death cases and histopathological and toxicological examinations should be performed. Despite detailed autopsy and histopathological examinations, some heart diseases that cause sudden death may still not be detected. In order to support the diagnosis of the cause of death and to exclude other causes in a more precise and unobjectionable way, and to carry out scientific research in a more detailed and reliable manner, while preparing autopsy reports, information on the past medical documents, disease reports and comorbidities of the deceased should be obtained very quickly. It should be sent with the examination and/or autopsy request letter. In addition, it is recommended that determining the minimum procedures and protocols to be applied in forensic autopsies in our country and establishing a guide by authorized associations and/or institutions would be appropriate to ensure standardization.