CASE REPORT

PATHOLOGY/BIOLOGY

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 InsufficiencyFollowing 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 isscientifically 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 ofdeath, exact nature and severity of the illness he is suffering from if any. He can also assess the nature and severity of injuries sustained, andthus, his opinion as to the possible role played by the traumatic event in bringing about the death is valuable. This paper will discuss the mech-anism of cardiac injury or possible cardiac injury and sudden death of an apparently healthy 36-year-old male following blunt chest trauma sus-tained 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 casesof sudden deaths which are precipitated by the traumatic event.Trauma could be physical or mental. The physical trauma neednot always be direct; it can be indirect as well. The indirecttrauma in the form of contra-coup injury can be observed at asite away from impact. It is a difficult task for the forensicpathologist to opine as to whether the trauma precipitated thedeath in an individual who is already suffering from natural dis-ease and the autopsy revealing the underlying pathological con-dition of organ/s. The trauma sustained would not have beensufficient to cause death in its normal course, but would haveprecipitated the existing pathology resulting in death. To avoidhumiliation in the court of law, it is advisable to take due pre-cautions at autopsy and while furnishing the opinion in suchcases. Even though the significant pathology is noted grossly atautopsy, the relevant organs have to be subjected for histopatho-logical examination to have documentation and which will havemore evidentiary value in the court of law, and routine toxicol-ogy screen has to be carried out to rule out the remote possibil-ity of any toxic element playing role in bringing about the death.This paper will discuss cardiac injury or possible cardiac injuryand death of an apparently healthy 36-year-old male who col-lapsed and died after sustaining blunt trauma to the chest duringalleged assault by his neighbor.Before furnishing the opinion in such cases, the circumstances

have to be thoroughly analyzed; apart from making note of nat-ure and severity of the pathology, due consideration should begiven to any evidence of the physical trauma at the site of

alleged blow and underneath structure or because of transmittedforces due to blow.In the United States, close to one million cases a year of car-

diac injury after blunt chest trauma are reported (1). The follow-ing injuries can occur: cardiac contusion, rupture of ventricularwall, septum, valves, papillary muscles, or the chordae tendinae(2,3). Some patients exhibit nonlethal arrhythmias, whereas oth-ers present in cardiac arrest from ventricular fibrillation causedby cardiac concussion (commotio cordis) (4,5).Even patients with few or no visible signs of chest wall dam-

age, 55% will have some myocardial dysfunction (6). Pathogene-sis in all other patients involves any of the following: rupture ofthe vessel itself, thrombosis from direct trauma, vasospasm, dis-lodgement and embolization of fibrous plaques, or pseudoaneu-rysm 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 consideredwhile opining. Some patient may ignore the chest discomfortbecause of major pain elsewhere. Others will develop chest painhours to days after the trauma, and the connection between theinjury and the chest pain is ignored (8–10).Sometimes, it is not until the patient experiences hemodynam-

ic compromise, or the pain persists despite treatment for otherpresumed causes, that myocardial ischemia is considered (11).Most cases occur in younger, active people who do not have

clinical coronary artery disease (CAD). Nevertheless, atheroma-tous changes can begin early in life, and the plaques do not needto be of a clinically significant size to disrupt the coronary bloodflow. A small region of a plaque may break open when it is sub-jected to shearing forces or blunt trauma. The natural elasticityof arterial wall (due to presence of elastic tissue in tunica media)of coronaries in healthy heart allows it to temper without anyadverse effect when the mechanical forces are liberated by ablow over the sternum. An atherosclerotic artery becomes more

1Department of Forensic Medicine, MS Ramaiah Medical College, MSRITPost, MSR Nagar, Bangalore 560054, India.

Received 20 Sept. 2012; and in revised form 28 Jan. 2013; accepted 16Feb. 2013.

830 © 2014 American Academy of Forensic Sciences

J Forensic Sci, May 2014, Vol. 59, No. 3doi: 10.1111/1556-4029.12371

Available online at: onlinelibrary.wiley.com

like a rigid tube as it loses its elastic properties. Mechanicalenergy applied to this type of vessel causes deformity and causesrupture of the arterial wall and plaque followed by thrombus for-mation and occlusion of the coronary vessel (8).

Case Report

On 14 August, 2011 at around 3.30 pm, a fight broke outbetween the victim (36 years old male) and his neighbor regard-ing him stamping on a rangoli (decorative designs made onfloor) in front of the house. The neighbor manhandled him andallegedly stomped on his chest. After the fight, the deceased leftto visit his uncle with a couple of friends while he developedchest pain and vomiting at around 5.30 pm. He was taken to thenearby hospital where the doctors declared him to be broughtdead, and the police registered case under 302 IPC and referredto us for postmortem examination. Autopsy was conducted onthe next day. Examination revealed postmortem staining over theback of the body, rigor mortis present all over. No demonstrableexternal injuries. There were no injuries over the correspondingsite of the alleged stomping. Heart weighed 350 g with left ven-tricular thickness being 1.2 cm and right measured 0.6 cm. Leftanterior descending artery showed a plaque causing thickeningof the wall and occlusion of the lumen of 70–80% (Fig. 1). Thelumen showed a thrombus. Left circumflex coronary artery andright coronary artery were patent. The lungs were edematous.All the other internal organs were intact. Histopathology reportconfirmed the same. Blood and viscera were sent for chemicalanalysis, and no toxic group of drugs or metals were detected.The cause of death was provisionally opined to be due to “coro-nary artery insufficiency as a result of coronary artery disease”upon receiving the histopathology report and chemical analysisreport.

Results and Discussion

The relationship between trauma and disease poses a problemin interpretation in cases where death has occurred followingtrauma in an individual who was previously diseased or devel-oped the disease after sustaining injury. The outcome of suchcases is significant, particularly in criminal cases. The legally

pertinent questions that might arise are as follows: whether thetrauma was exclusively responsible for the death, whether it con-tributed to the death or it influenced in the fatal outcome, andwhether trauma could be excluded from the cause of death. InIndia, there is no time limit specified for legal battle if a victimdies 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, coronaryartery damage, and myocardial infarction. However, coronarydamage 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 caseswhere there is direct blow on the chest that can be demonstratedto have caused damage to the heart and precipitated a worse cor-onary condition by either dislodging an atheromatous plaque orcausing subintimal hemorrhage, can it be proved that traumacaused death from a myocardial lesion. Where coronary diseaseis severe, it may be claimed by the defense that death from theunderlying disease could have occurred at any time, and there-fore, trauma was an incidental case. A close association in timemust be present between trauma and death for the associationbetween them to be given serious consideration. The presence ofmyocardial infarction that occurred soon after the incident has tobe proved (13).Animal studies have confirmed that blunt chest trauma can

result in coronary occlusion in a plaque-free coronary artery bycausing intimal tears with subsequent thrombus formation orspontaneous thrombus formation without an associated tear. Themost frequently injured vessels are the left anterior descendingcoronary 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 myocardialinfarction. Such a threat might increase the blood pressure to apoint where it causes rupture of an atheromatous plaque or sub-intimal hemorrhage resulting in coronary artery blocked. Thehormonal mechanism of endocrinal response to “fear, fight, andflight” situations should also be borne in mind (13). In trauma,the myocardium is primarily at risk for damage from direct con-tusions and less commonly from interruption in coronary bloodsupply. Proximity of the LAD to the anterior chest wall makes itthe most susceptible vessel to be injured from blunt trauma tothe 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 sizeto disrupt the coronary blood flow. A small region of a plaquemay break open when it is subjected to shearing forces or blunttrauma. An atherosclerotic artery becomes more like a rigid tubeas it loses its elastic properties. Mechanical energy applied tothis type of vessel may cause deformity and rupture of the arte-rial wall and plaque followed by thrombus formation and occlu-sion of the coronary vessel (8). The diagnosis of commotiocordis is used only if structural damage to the sternum, ribs, andheart is absent (5,19). In one of the cases, it was observed thatthere was bruising of the anterior chest with recent bilateral ribfractures without displacement. The heart was enlarged anddilated with an area of recent bruising in the wall of the rightatrium. No lethal injuries were identified. A focal area of athero-sclerosis was found in the left anterior descending coronaryartery causing 50% stenosis. In author’s view, underlying cardiacdisease in that case was not sufficient to cause death alone and

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

HUGAR ET AL. . DEATH DUE TO CORONARY ARTERY INSUFFICIENCY 831

might therefore would have predisposed to death from commo-tio/contusio cordis (20).In the present case, the deceased did not have the history sug-

gestive of cardiac illness, and when the investigating officersought further clarifications as to the precipitation by the allegedphysical trauma (stomping) and the mental stress due to thefight, it was noted that the symptoms have started soon after(i.e., 2 h) the alleged traumatic incident and the individual suc-cumbed to death. It is unlikely to be a case of commotio/contu-sio cordis as there was significant pathology noted in the formof a plaque causing thickening of the wall and occlusion of theLAD arterial lumen of 70–80% (Fig. 1). The lumen also showeda thrombus. Hence, it was thought that the trauma could haveplayed a role in the thrombus formation (Fig. 1) in the pre-exist-ing coronary artery disease and thus precipitating the death. Itwas interesting to know that the trauma was not sufficient toleave any evidence of injury on the chest (alleged site). The finalopinion was furnished as coronary artery insufficiency as a resultof coronary artery disease; however, the death could have beenprecipitated by the traumatic event.

Conclusion

The possibility of coronary disruption should be considered inany patient complaining of chest pain following blunt trauma tothe chest. It is the prime duty of the forensic pathologist to putforward the facts of the case to the best of his knowledge andability providing his evidence-based opinion. Crime scene inves-tigation and type of event may help the forensic pathologist tosolve the problem.

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Additional information and reprint requests:Basappa S. Hugar, M.D., D.N.B.Associate ProfessorDepartment of Forensic MedicineMS Ramaiah Medical CollegeMSRIT Post, MSR NagarBangalore 560054IndiaE-mail: basavaraj_hugar2007@rediffmail.com

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