Histopathological Profile of the Heart in Sudden Death: Forensic Perspectives on Cardiac and Noncardiac Mechanisms

Sudden death is an unexpected natural fatal event that may arise from both cardiac and noncardiac causes. Differentiating true primary cardiac pathology from incidental or secondary myocardial changes remains a major challenge in forensic evaluation, particularly in clearly noncardiac sudden deaths.

The aim of this study was to assess histopathological changes in the heart in cases of sudden death of cardiac and noncardiac origin and to compare the distribution of these findings across different certified causes of death. Additionally, the study aimed to evaluate the frequency and potential forensic relevance of these cardiac alterations.

A retrospective cross-sectional analysis was conducted on 78 medico-legal autopsy cases of sudden death examined at the Department of Forensic Medicine in Bosnia and Herzegovina (2016-2025). Paraffin-embedded cardiac tissue was evaluated histologically by three independent pathologists, while cases involving unnatural causes of death or significant autolysis were excluded.

Cardiac-origin deaths accounted for 76.9% of cases and were more common in males. Individuals who died from cardiac causes were significantly older than those with noncardiac causes (58.7 ± 19.2 vs. 45.7 ± 16.8 years; P = 0.012). Cardiac-origin deaths predominated in middle-aged and older adults, whereas noncardiac sudden deaths occurred more frequently in younger individuals. Myocardial infarction and scar tissue were significantly associated with cardiac-origin deaths (P = 0.017 and P = 0.038). Hypertrophy and dispersed fibrosis increased progressively with age.

Cardiac sudden deaths were more frequent and mainly associated with chronic myocardial changes rather than acute ischemia. Middle-aged individuals were the most vulnerable group, highlighting the need for improved cardiovascular risk assessment and prevention.