c

Title: myocardial infarction

c

A body of adult male with medium build that fits the descriptions of its appearance and
age presented with congested face and seminal discharge. Internal examination revealed
patchy fibrosis at the wall of the myocardium and atheroma of the coronary artery.
—


 c

a.c (ackground of case

Myocardial infarction (MI) is the irreversible necrosis of heart muscle secondary to

prolonged ischemia. This usually results from an imbalance of oxygen supply and
demand. The appearance of cardiac enzymes in the circulation generally indicates
myocardial necrosis. Cause of myocardial infarction ±atherosclerosis is more common
among men than women. The higher prevalence of atherosclerosis in men is thought to
be due to the protective effects of the female sex hormones. This sex effect is absent after
menopause in women. The incidence of coronary heart disease among women parallels
that of men, but women demonstrate an approximately 10-year chronological delay in the
onset of clinical manifestations.

Cardiovascular diseases cause 12 million deaths throughout the world each year,
according to the third monitoring report of the World Health Organization, 1991-93.
They cause half of all deaths in several developed countries and are one of the main
causes of death in many developing countries; they are the major cause of death in adults
everywhere.c

b.c ational and significance of choosing the case

Myocardial infarction is one of the most common cause of death in the world with most
of the cases are referred to the autopsy table. Therefore, it is important for one to have
extensive knowledge about its presentation and features of the deceased have.
  c

The event occurs at a golf course in Kajang Mewah during a golf tournament


cc c

a.c 9atient biography

Name initials : Mr. KO

Age : 48 y/o
Sex : Male
eligion : Christian
Civil status : Married
ace : Chinese
Occupation : Managing Executive

b.c History of event

The deceased was healthy a day prior to the event with no signs and symptoms of any
diseases. He was cheerful and happy in the fact that he was going to play in golf
tournament with colleagues from the same company of his work.

He was having breakfast with his wife at the day of event, 2-3 hours prior to the event.
He received a pick-up call from his colleagues that just arrived from Terengganu and
asked for him to fetch them from Kuala Lumpur International Airport and to join with the
rest for breakfast before the start of the tournament.

After breakfast, he drives with two of his friend to the golf course at Kajang Mewah golf
course ±approximately 0700, and then rushed back to Seri Kembangan to fetch his family
members. He was a bit late for the registration which is at 0800 thus drive straight to the
golf courses without any proper warming up. The horn was sound as the signal for start
of the tournament. His friend, 9hillip start the game by tee-off followed the deceased
approximately 0810. The tee-off was not smoothly done by the deceased.
 ñpon the 4th shot taken by 9hillip, the deceased was suddenly fall off and knocked by the
golf-buggy. The deceased was collapsed ±his saliva drooling with frothy appearance, the
heart pulse was slow and collapsing. The deceased is then taken by the manager of the
event to the nearest clinic in Kajang Mewah which is about 10 minutes from the venue.

However, the deceased was lost consciousness upon arriving to the clinic. He was then
checked by the general practitioner of the clinic and was confirmed death.

¬
 c  
 c

ñpon examination, it reveals that the body was belong to an adult male with medium
built, with complete rigor mortis and complete post-mortem hypostasis. The deceased
was fully dressed in polo T-shirt and khakis pant and leather belting. The deceased was
Chinese with yellowish skin colour. His height was 159 cm with weight of 58 kg. His
hair was black with short haircut. There was no facial hair. The eye was black, with
dilated pupil. The mouth was foamy, but the deceased was not on denture.

The deceased face was congested; the temperature of the body was following the room
temperature. The face appears congested especially at the area surrounding the neck and
the upper part of the thorax. The hypostasis was collected at lower part of the body
mostly ±as following the gravity and there was no definite contact pallor.

Examination of the finger revealed that there is no change of coloration or disfigurement.

Examination of lower limbs also revealed the same thing but there was evidence of prior
fall ±consistent to the story with the evidence of bruising at area of knee and patella.

Examination of the genital revealed there is evidence of seminal discharge at the glans-
penis ±evidence of myocardial infarction. The penis was not circumcised ±the skin was
retractable.
—
 c  
 c

The internal examination starts with the opening of the thorax through a Y-incision
through the midclavicular line and down to the suprapubic fossa without cutting the
umbilical into two. The thoracic cavity is the opened by cutting through the ribs and the
heart was then revealed.

ñpon the examination, it revealed that the patient¶s heart was enlarged and covered with
fatty tissues ±indication of atherosclerosis. The heart is then taken out weigh to determine
the weight without its fatty distribution. The dissection of the heart revealed a patchy
fibrosis present at the wall of the heart. There were pale areas at the myocardium
especially at area surrounding the valve. These findings were evidence of chronic
myocardial infarction as well as new myocardial infarction that believe to be occurring
during the golf tournament.

Then, the coronary heart circulation was then dissected for examination. It revealed that
there was in fact atheroma of coronary artery. The area affected was the left anterior
descending artery ±correlates with the infarction occurring at the wall of left atrium.

Examination of the brain was not done due to the findings were consistent with findings
from external examination ±seminal discharge is indication for myocardial infarction.

c c

c

A body of adult male with medium build that fits the descriptions of its appearance and
age presented with congested face and seminal discharge. Internal examination revealed
patchy fibrosis at the wall of the myocardium and atheroma of the coronary artery.


 cc 


The cause of death was myocardial infarction

The deceased was presented with congested face and upper region of the thorax as
evidence of blood pooling in the heart. There was also seminal discharge at the glans-
penis ±indication of myocardial infarction resulted from vasovagal reflexes that
consistence with the cause of death.

Internal examination revealed that deceased have enlarged heart covered with fatty
tissues. It also appears that there was multiple fibrosis present at the wall of the heart. The
area was pale and there were also mixture of old and new patches at the myocardium.
The inspection and dissection of the coronary artery has revealed presence of atheroma of
coronary artery consistent with the area of infarction ±left anterior descending artery.c
V  cc 
c

The deceased was having a mixture of chronic and new myocardial infarction ±believed
raised from his lifestyle ±informed by his wife that the deceased never had a heart
examination or mandatory 40 years old examination. There was evidence of coronary
obstruction from the internal examination. The obstruction cause insufficient supply of
oxygen to the heart muscle which leads to myocardial infarction. The myocardial
infarction occurring at the golf tournament believed to be the cause of death whereas it
renders the heart ineffective any longer.

V cc 
c

c Natural death


 c

Coronary artery atherosclerosis is the principal cause of coronary artery disease (CAD)
and is the single largest killer of both men and women in the ñnited States. A major
recent advance has been a refined understanding of the nature of atherosclerotic plaque
and the phenomenon of plaque rupture, which is the predominant cause of acute coronary
syndrome (ACS) and acute myocardial infarction (AMI). Cardiologists now know that, in
many cases (perhaps more than half), the plaque that ruptures and results in the clinical
syndromes of ACS and AMI is less than 50% occlusive. These so-called vulnerable
plaques, as compared with stable plaques, consist of a large lipid core, inflammatory
cells, and thin fibrous caps that are subjected to greater biomechanical stress, thus leading
to rupture that perpetuates thrombosis and ACS.

In this case, the deceased was indeed died from myocardial infarction that resulted from
atherosclerosis ±there was evidence of atheroma at coronary artery, obstructing the flow
of oxygen to the heart muscle which then leads to myocardial infarction.
 Severely obstructive coronary atheromas do not usually cause ACS and MI. In fact, most
of the atheromas that cause ACS are less than 50% occlusive as demonstrated by
coronary arteriography. Atheromas (plaques) with smaller obstruction experience greater
wall tension, which changes in direct proportion to their radii.1

The earliest pathologic lesion of atherosclerosis is the fatty streak. The fatty streak is
observed in the aorta and coronary arteries of most individuals by age 20 years. The fatty
streak is the result of focal accumulation of serum lipoproteins within the intima of the
vessel wall. Microscopy reveals lipid-laden macrophages, T lymphocytes, and smooth
muscle cells in varying proportions.2

The deceased had fatty streaks all over the enlarged heart ±a definitive evidence of
unhealthy lifestyle during the lifetime. The deceased, according to the wife was very fond
to fatty food and chicken skin and fats. He also have never been to health check-up
regarding to the condition and in the impression of there is nothing wrong with himself.
Thus, the heart was remained unchecked until eventually cause him his life.

Atherosclerosis is more common among men than women. The higher prevalence of
atherosclerosis in men is thought to be due to the protective effects of the female sex
hormones. This sex effect is absent after menopause in women. The incidence of
coronary heart disease among women parallels that of men, but women demonstrate an
approximately 10-year chronological delay in the onset of clinical manifestations.3

 
 c

Coronary artery disease probably will not cause immediate death. However, death from
coronary artery disease is likely to be caused by complication of it, such as myocardial
infarction.c c

c
    c

1.c oss , Fuster V. The pathogenesis of atherosclerosis. In: Fuster V, oss , Topol EJ,
eds. Atherosclerosis and Coronary Artery Disease. 9hiladelphia, 9a: Lippincott-
aven; 1996:441-62.
2.c oss . Atherosclerosis--an inflammatory disease. N Engl J Med. Jan
14 1999;340(2):115-26.
3.c Lloyd-Jones D, Adams , Carnethon M, De Simone G, Ferguson T(, Flegal K, et
al. Heart disease and stroke statistics--2009 update: a report from the American Heart
Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. Jan
27 2009;119(3):e21-181.