Likely Cause of Death: Sudden Cardiac Death Due to Coronary Artery Disease
The most likely cause of death in this 64-year-old woman is sudden cardiac death (SCD) secondary to underlying coronary artery disease, with hematemesis representing either a coincidental gastrointestinal event or a terminal manifestation of cardiovascular collapse. 1, 2
Primary Diagnosis: Sudden Cardiac Death
This case meets the established criteria for sudden cardiac death:
Death occurred within hours of symptom onset (found unresponsive 4 hours after hematemesis), which aligns with the definition of SCD as "natural death due to cardiac causes, heralded by abrupt loss of consciousness within one hour of the onset of acute symptoms" 1, 2
Unresponsive to resuscitation efforts including CPR and 5 rounds of epinephrine, consistent with ventricular fibrillation (the first recorded rhythm in 75-80% of sudden cardiovascular collapse cases) 1, 2
Strong family history of hypercholesterolemia and heart disease significantly increases her risk, as familial hypercholesterolemia is associated with a standardized mortality ratio of 386 for coronary heart disease death, with the highest excess mortality in younger adults 3
Underlying Etiology: Coronary Artery Disease
In patients over 65 years with known cardiovascular risk factors, coronary artery disease accounts for the overwhelming majority of sudden cardiac deaths. 2
The evidence supporting CAD as the underlying cause includes:
Autopsy studies demonstrate that approximately 2/3 of sudden non-traumatic deaths in middle-aged and elderly subjects are cardiac in origin, with CAD being the predominant cause 1, 2
Family history of hypercholesterolemia creates substantial atherosclerotic burden over decades; by age 50, approximately 80% of males with familial hypercholesterolemia suffer from ischemic heart disease 4
The phenotype fits heterozygous familial hypercholesterolemia, which affects approximately 1 in 200 people and leads to lifelong exposure to elevated LDL cholesterol, accelerating coronary atherosclerosis 5, 6
The Hematemesis Component
The vomiting of blood before bed requires consideration but does not change the primary diagnosis:
Hematemesis could represent a terminal event related to cardiovascular collapse with aspiration of blood from pulmonary edema or stress-related gastric bleeding during acute cardiac ischemia 1
Alternatively, it may have been a coincidental gastrointestinal bleed that precipitated hemodynamic instability in a patient with severe underlying CAD, triggering fatal arrhythmia 7
The 1-day history of cough could represent early pulmonary edema from acute heart failure preceding the terminal event 1
Proper Death Certificate Documentation
Following ACC/AHA and ESC guidelines for death certification:
- Immediate cause of death: Sudden Cardiac Death 2
- Underlying cause of death: Coronary Artery Disease 2
- Contributing factors: Familial Hypercholesterolemia 2, 3
This documentation approach is critical because reliance on death certificate diagnoses results in about 5% underestimation of true coronary heart disease rates, whereas their use as surrogate for SCD yields 16% overestimation. 1
Critical Clinical Pitfalls to Avoid
Do not attribute death primarily to gastrointestinal hemorrhage without autopsy confirmation of massive blood loss; the rapid progression to cardiac arrest despite resuscitation efforts points to primary cardiac etiology 1, 2
Do not list "heart failure" as the underlying cause, as this affects the quality of vital statistics; instead, list the underlying disease process (CAD) 2
Recognize that the "perfect storm" of SCD involves interaction of vulnerable substrate (genetic predisposition from familial hypercholesterolemia) with acute triggering factors (possible hemodynamic stress from GI bleeding) 7