J Forensic Sci, May 2014, Vol. 59, No. 3 doi: 10.1111/1556-4029.12371 Available online at: onlinelibrary.wiley.com


Basappa S. Hugar,1 M.D., D.N.B.; Harish S. Shetty,1 M.D., D.F.M.; Girish Chandra P. Yajaman,1 M.D.; and Anitha S. Rao,1 M.B.B.S.

Death Due to Coronary Artery Insufficiency Following Blunt Trauma to the Chest

ABSTRACT: There have been numerous reports of sudden cardiac death following blunt trauma to the chest, but there is lack of such refer-

ences in forensic literature. It is the court of law which makes decision about trauma precipitating natural events. The forensic pathologist is scientifically trained in the medical field and would be in a better position to give clear picture about the victim’s general status at the time of death, exact nature and severity of the illness he is suffering from if any. He can also assess the nature and severity of injuries sustained, and thus, his opinion as to the possible role played by the traumatic event in bringing about the death is valuable. This paper will discuss the mechanism of cardiac injury or possible cardiac injury and sudden death of an apparently healthy 36-year-old male following blunt chest trauma sustained during alleged assault by his neighbor.

KEYWORDS: forensic science, forensic pathology, sudden death, blunt chest trauma, coronary artery insufficiency, coronary artery disease

Forensic pathologist’s role is pivotal in dealing with the cases of sudden deaths which are precipitated by the traumatic event. Trauma could be physical or mental. The physical trauma need not always be direct; it can be indirect as well. The indirect trauma in the form of contra-coup injury can be observed at a site away from impact. It is a difficult task for the forensic pathologist to opine as to whether the trauma precipitated the death in an individual who is already suffering from natural disease and the autopsy revealing the underlying pathological condition of organ/s. The trauma sustained would not have been sufficient to cause death in its normal course, but would have precipitated the existing pathology resulting in death. To avoid humiliation in the court of law, it is advisable to take due precautions at autopsy and while furnishing the opinion in such cases. Even though the significant pathology is noted grossly at autopsy, the relevant organs have to be subjected for histopathological examination to have documentation and which will have more evidentiary value in the court of law, and routine toxicology screen has to be carried out to rule out the remote possibility of any toxic element playing role in bringing about the death. This paper will discuss cardiac injury or possible cardiac injury and death of an apparently healthy 36-year-old male who collapsed and died after sustaining blunt trauma to the chest during alleged assault by his neighbor. Before furnishing the opinion in such cases, the circumstances have to be thoroughly analyzed; apart from making note of nature and severity of the pathology, due consideration should be given to any evidence of the physical trauma at the site of

1 Department of Forensic Medicine, MS Ramaiah Medical College, MSRIT Post, MSR Nagar, Bangalore 560054, India. Received 20 Sept. 2012; and in revised form 28 Jan. 2013; accepted 16 Feb. 2013.


alleged blow and underneath structure or because of transmitted forces due to blow. In the United States, close to one million cases a year of cardiac injury after blunt chest trauma are reported (1). The following injuries can occur: cardiac contusion, rupture of ventricular wall, septum, valves, papillary muscles, or the chordae tendinae (2,3). Some patients exhibit nonlethal arrhythmias, whereas others present in cardiac arrest from ventricular fibrillation caused by cardiac concussion (commotio cordis) (4,5). Even patients with few or no visible signs of chest wall damage, 55% will have some myocardial dysfunction (6). Pathogenesis in all other patients involves any of the following: rupture of the vessel itself, thrombosis from direct trauma, vasospasm, dislodgement and embolization of fibrous plaques, or pseudoaneurysm formation after dissection of the intima (7). The time elapsed between the traumatic event and the onset of symptoms of a fatal event and the death has to be considered while opining. Some patient may ignore the chest discomfort because of major pain elsewhere. Others will develop chest pain hours to days after the trauma, and the connection between the injury and the chest pain is ignored (8–10). Sometimes, it is not until the patient experiences hemodynamic compromise, or the pain persists despite treatment for other presumed causes, that myocardial ischemia is considered (11). Most cases occur in younger, active people who do not have clinical coronary artery disease (CAD). Nevertheless, atheromatous changes can begin early in life, and the plaques do not need to be of a clinically significant size to disrupt the coronary blood flow. A small region of a plaque may break open when it is subjected to shearing forces or blunt trauma. The natural elasticity of arterial wall (due to presence of elastic tissue in tunica media) of coronaries in healthy heart allows it to temper without any adverse effect when the mechanical forces are liberated by a blow over the sternum. An atherosclerotic artery becomes more © 2014 American Academy of Forensic Sciences


like a rigid tube as it loses its elastic properties. Mechanical energy applied to this type of vessel causes deformity and causes rupture of the arterial wall and plaque followed by thrombus formation and occlusion of the coronary vessel (8). Case Report On 14 August, 2011 at around 3.30 pm, a fight broke out between the victim (36 years old male) and his neighbor regarding him stamping on a rangoli (decorative designs made on floor) in front of the house. The neighbor manhandled him and allegedly stomped on his chest. After the fight, the deceased left to visit his uncle with a couple of friends while he developed chest pain and vomiting at around 5.30 pm. He was taken to the nearby hospital where the doctors declared him to be brought dead, and the police registered case under 302 IPC and referred to us for postmortem examination. Autopsy was conducted on the next day. Examination revealed postmortem staining over the back of the body, rigor mortis present all over. No demonstrable external injuries. There were no injuries over the corresponding site of the alleged stomping. Heart weighed 350 g with left ventricular thickness being 1.2 cm and right measured 0.6 cm. Left anterior descending artery showed a plaque causing thickening of the wall and occlusion of the lumen of 70–80% (Fig. 1). The lumen showed a thrombus. Left circumflex coronary artery and right coronary artery were patent. The lungs were edematous. All the other internal organs were intact. Histopathology report confirmed the same. Blood and viscera were sent for chemical analysis, and no toxic group of drugs or metals were detected. The cause of death was provisionally opined to be due to “coronary artery insufficiency as a result of coronary artery disease” upon receiving the histopathology report and chemical analysis report. Results and Discussion The relationship between trauma and disease poses a problem in interpretation in cases where death has occurred following trauma in an individual who was previously diseased or developed the disease after sustaining injury. The outcome of such cases is significant, particularly in criminal cases. The legally

FIG. 1––Photomicrograph of the LAD coronary artery demonstrating thrombus superimposed upon the atheromatous plaque.




pertinent questions that might arise are as follows: whether the trauma was exclusively responsible for the death, whether it contributed to the death or it influenced in the fatal outcome, and whether trauma could be excluded from the cause of death. In India, there is no time limit specified for legal battle if a victim dies after an assault. A variety of cardiac injuries resulting from blunt chest trauma have been reported, such as cardiac arrhythmia, septal damage, valve damage, myocardial contusion, cardiac rupture, coronary artery damage, and myocardial infarction. However, coronary damage resulting in MI is a rare complication of blunt trauma (12). Coronary artery disease is not an acute illness. Therefore, it should have been present for several months/years. Only in cases where there is direct blow on the chest that can be demonstrated to have caused damage to the heart and precipitated a worse coronary condition by either dislodging an atheromatous plaque or causing subintimal hemorrhage, can it be proved that trauma caused death from a myocardial lesion. Where coronary disease is severe, it may be claimed by the defense that death from the underlying disease could have occurred at any time, and therefore, trauma was an incidental case. A close association in time must be present between trauma and death for the association between them to be given serious consideration. The presence of myocardial infarction that occurred soon after the incident has to be proved (13). Animal studies have confirmed that blunt chest trauma can result in coronary occlusion in a plaque-free coronary artery by causing intimal tears with subsequent thrombus formation or spontaneous thrombus formation without an associated tear. The most frequently injured vessels are the left anterior descending coronary artery (76%) and the right coronary artery (12%) (14). Not only the actual injury, but even the emotional upset that occurs during an assault can precipitate an acute myocardial infarction. Such a threat might increase the blood pressure to a point where it causes rupture of an atheromatous plaque or subintimal hemorrhage resulting in coronary artery blocked. The hormonal mechanism of endocrinal response to “fear, fight, and flight” situations should also be borne in mind (13). In trauma, the myocardium is primarily at risk for damage from direct contusions and less commonly from interruption in coronary blood supply. Proximity of the LAD to the anterior chest wall makes it the most susceptible vessel to be injured from blunt trauma to the chest (15,16). The right coronary artery (RCA) is second (1,11,17,18). Nevertheless, atheromatous changes can begin early in life, and the plaques do not need to be of a clinically significant size to disrupt the coronary blood flow. A small region of a plaque may break open when it is subjected to shearing forces or blunt trauma. An atherosclerotic artery becomes more like a rigid tube as it loses its elastic properties. Mechanical energy applied to this type of vessel may cause deformity and rupture of the arterial wall and plaque followed by thrombus formation and occlusion of the coronary vessel (8). The diagnosis of commotio cordis is used only if structural damage to the sternum, ribs, and heart is absent (5,19). In one of the cases, it was observed that there was bruising of the anterior chest with recent bilateral rib fractures without displacement. The heart was enlarged and dilated with an area of recent bruising in the wall of the right atrium. No lethal injuries were identified. A focal area of atherosclerosis was found in the left anterior descending coronary artery causing 50% stenosis. In author’s view, underlying cardiac disease in that case was not sufficient to cause death alone and



might therefore would have predisposed to death from commotio/contusio cordis (20). In the present case, the deceased did not have the history suggestive of cardiac illness, and when the investigating officer sought further clarifications as to the precipitation by the alleged physical trauma (stomping) and the mental stress due to the fight, it was noted that the symptoms have started soon after (i.e., 2 h) the alleged traumatic incident and the individual succumbed to death. It is unlikely to be a case of commotio/contusio cordis as there was significant pathology noted in the form of a plaque causing thickening of the wall and occlusion of the LAD arterial lumen of 70–80% (Fig. 1). The lumen also showed a thrombus. Hence, it was thought that the trauma could have played a role in the thrombus formation (Fig. 1) in the pre-existing coronary artery disease and thus precipitating the death. It was interesting to know that the trauma was not sufficient to leave any evidence of injury on the chest (alleged site). The final opinion was furnished as coronary artery insufficiency as a result of coronary artery disease; however, the death could have been precipitated by the traumatic event. Conclusion The possibility of coronary disruption should be considered in any patient complaining of chest pain following blunt trauma to the chest. It is the prime duty of the forensic pathologist to put forward the facts of the case to the best of his knowledge and ability providing his evidence-based opinion. Crime scene investigation and type of event may help the forensic pathologist to solve the problem. References 1. Shapiro MJ, Wittgen C, Flynn MS, Zuckerman DA, Durham RM, Mazuski JE. Right coronary artery occlusion secondary to blunt trauma. Clin Cardiol 1994;17:157–9. 2. Banzo I, Montero A, Uriarte I, Vallina N, Hernandez A, Guede C, et al. Coronary artery occlusion and myocardial infarction, a seldom encountered complication of blunt chest trauma. Clin Nucl Med 1999;24(2):94–6. 3. Masuda T, Akiyama H, Kurosawa T, Ohwada T. Long-term follow-up of coronary artery dissection due to blunt chest trauma with spontaneous healing in a young woman. Intensive Care Med 1996;22:450–2. 4. Lateef F. Commotio cordis: an underappreciated cause of sudden death in athletes. Sports Med 2000;30(4):301–8. 5. Maron BJ, Gohman TE, Kyle SB, Estes NA 3rd, Link MS. Clinical profile and spectrum of commotio cordis. JAMA 2002;287(9):1142–6.

6. Sutherland GR, Driedger AA, Holliday RL, Cheung HW, Sibbald WJ. Frequency of myocardial injury after blunt chest trauma as evaluated by radionuclide angiography. Am J Cardiol 1983;52:1099–103. 7. Chun JH, Lee SC, Gwon HC, Lee SH, Hong KP, Seo JD, et al. Left main coronary artery dissection after blunt chest trauma presented as acute anterior myocardial infarction: assessment by intravascular ultrasound: a case report. J Korean Med Sci 1998;13(3):325–7. 8. Garcia Gallego F, Sotillo Marti J, Perz Blascon P. Myocardial infarction and subtotal obstruction of the anterior descending coronary artery caused by trauma in a football player. Int J Cardiol 1986;12:109–12. 9. Charbonnier B, Desveaux B, Cosnay P, Fauchier JP, Raynaud P, Brochier M. Traumatic myocardial infarction. Apropos of 2 cases. Arch Mal Coeur Vaiss 1984;77(3):273–82. 10. Dixon AE, Shulman S. Sudden death during sports activities. N Engl J Med 1995;333(6):1784–5. 11. Salmi A, Blank M, Slomski C. Left anterior descending artery occlusion after blunt chest trauma. J Trauma 1996;40(5):832–4. 12. Lai CH, Ma T, Chang TC, Chang MH, Chou P, Jong GP. A case of blunt chest trauma induced acute myocardial infarction involving two vessels. Int Heart J 2006;47:639–43. 13. Dogra TD, Rudra A. Lyon’s medical jurisprudence & toxicology, 11th edn. Delhi, India: Delhi Law House, 2005;821–8. 14. Moore JE. Acute apical myocardial infarction after blunt chest trauma incurred during a basketball game. J Am Board Fam Pract 2001;14 (3):219–23. 15. Unterberg C, Buchwald A, Wiegand V. Traumatic thrombosis of the left main coronary artery and myocardial infarction caused by blunt chest trauma. Clin Cardiol 1989;12:672–4. 16. Fu M, Wu CJ, Hsieh MJ. Coronary dissection and myocardial infarction following blunt chest trauma. J Formos Med Assoc 1999;98(2):136–40. 17. Marcum JL, Booth DC, Sapin PM. Acute myocardial infarction caused by blunt chest trauma: successful treatment by direct coronary angioplasty. Am Heart J 1996;132(6):1275–7. 18. Kawahito K, Hasegawa T, Misawa Y, Fuse K. Right coronary artery dissection and acute infarction due to blunt trauma: report of a case. Surg Today 1998;28(9):971–3. 19. Link MS, Maron BJ, VanderBrink BA, VanderBrink BA, Takeuchi M, Pandian NG, et al. Impact directly over the cardiac silhouette is necessary to produce ventricular fibrillation in an experimental model of commotio cordis. J Am Coll Cardiol 2001;37:649–54. 20. Marshall DT, Gilbert JD, Byard RW. The spectrum of findings in cases of sudden death due to blunt cardiac trauma—‘commotio cordis’. Am J Forensic Med Pathol 2008;29(1):1–4. Additional information and reprint requests: Basappa S. Hugar, M.D., D.N.B. Associate Professor Department of Forensic Medicine MS Ramaiah Medical College MSRIT Post, MSR Nagar Bangalore 560054 India E-mail: [email protected]

Death due to coronary artery insufficiency following blunt trauma to the chest.

There have been numerous reports of sudden cardiac death following blunt trauma to the chest, but there is lack of such references in forensic literat...
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