Sudden cardiac death (SCD) may occur in various circumstances, including physical exercise and sexual intercourse. A forensic study found that 0.2% of natural deaths that underwent autopsy were associated with sexual activity and predominantly involved middle-aged men.1 Using data from a large specialist cardiac pathology unit, we aimed to assess the proportion of SCDs associated with sexual activity and to describe the characteristics of this cohort and underlying causes of death.
We reviewed a database of SCD cases that were referred to the center for cardiac pathology at St George’s University of London between January 1, 1994, and August 31, 2020. Ethical and research governance approval for this study was granted through the Integrated Research Application System (10/H0724/38). We followed the American Journal of Ophthalmology reporting guideline.
Before referral, all SCD cases underwent a detailed autopsy, including a toxicological screening, to exclude noncardiac causes. Sudden cardiac death was defined as death occurring within 12 hours of apparent well-being. Clinical information was obtained from referring coroners, who were asked to complete a detailed questionnaire. All cases underwent macroscopic and histological evaluation of the heart by expert cardiac pathologists. A minimum of 10 blocks of tissue were taken for histological analysis, as reported in a previous study.2 Results are expressed as mean (SD) for continuous variables or as number of cases (%) for categorical variables. MedCalc, version 17.4 (MedCalc Software Ltd), was used for the statistical analysis.
Of the total 6847 SCD cases we reviewed, death occurred during or within 1 hour after sexual intercourse in 17 (0.2%). The mean (SD) age at death was 38 (18) years, and most of the decedents (11 of 17 [65%]) were male individuals. One individual had a premorbid diagnosis of mitral valve prolapse, which was attributed as the cause of death, and 1 individual was diagnosed with hypertension and died of aortic dissection. In 2 individuals, extensive cardiac investigations did not lead to a definite diagnosis of cardiac disease (Table 1).
A structurally normal heart at autopsy that was suggestive of sudden arrhythmic death syndrome was found in 9 individuals (53%), followed by aortic dissection in 2 individuals (12%). One death was attributed to each of the following causes: arrhythmogenic cardiomyopathy, hypertrophic cardiomyopathy, ischemic heart disease, idiopathic fibrosis, idiopathic left ventricular hypertrophy (defined by raised heart weight and wall thickness in the absence of secondary causes and of myocardial disarray3), and mitral valve prolapse (Table 2). Sudden cardiac death that occurred during sex accounted for a low proportion of decedents even when causes of death were analyzed (sudden arrhythmic death syndrome: 9 of 3426 [0.2%]; arrhythmogenic cardiomyopathy: 2 of 274 [0.7%]; hypertrophic cardiomyopathy: 1 of 265 [0.3%]; aortic dissection: 2 of 97 [2%]; ischemic heart disease: 1 of 573 [0.1%]; idiopathic fibrosis: 1 of 165 [0.6%]; idiopathic left ventricular hypertrophy: 1 of 251 [0.3%]; mitral valve prolapse: 1 of 84 [1%]).
Younger individuals (aged <50 years) with cardiac conditions, such as cardiomyopathies and channelopathies, may be concerned about their risk for sudden death during sexual intercourse because of the catecholaminergic surge that accompanies this activity. Previous studies reported the occurrence of sudden cardiac arrest mainly in middle-aged men.4,5 In the present cohort, we found that the proportion of female decedents was substantially higher than in previous studies. This difference was likely associated with the difference in age bracket given that we included individuals with a mean age at death of 38 years and the other reports included older male individuals among whom a higher prevalence of coronary artery disease was expected. The most common autopsy finding was sudden arrhythmic death syndrome, suggesting that primary electrical disease may be associated with a rare incidence of sudden death during sexual intercourse.
This study has some limitations. First, we examined only SCD cases, and those who survived sudden cardiac arrests were not included in the study cohort. Second, the center focused on SCDs, and therefore other causes of death were excluded or not referred to the center by local pathologists.
Sexual activity was involved in 0.2% of all SCDs in a large cohort of decedents who underwent comprehensive autopsy. Sudden arrhythmic death syndrome and cardiomyopathies were predominant underlying causes, reflecting the age of the cohort of decedents that we assessed. We believe these findings provide some reassurance that engaging in sexual activity is relatively safe in patients with a cardiac condition, especially in younger (aged <50 years) individuals.
Accepted for Publication: November 12, 2021.
Published Online: January 12, 2022. doi:10.1001/jamacardio.2021.5532
Corresponding Author: Mary N. Sheppard, MBBCH, BAO, BSc, MD, Cardiovascular Clinical Academic Group, St George’s University of London, Cardiovascular Sciences, Cranmer Terrace, London SW17 0RE, United Kingdom (email@example.com).
Author Contributions: Drs Finocchiaro and Sheppard had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Prof Sharma and Dr Sheppard contributed equally as senior authors.
Concept and design: Finocchiaro, Westaby, Papadakis, Sheppard.
Acquisition, analysis, or interpretation of data: Finocchiaro, Behr, Westaby, Sharma, Sheppard.
Drafting of the manuscript: Finocchiaro, Westaby, Sharma, Sheppard.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Finocchiaro.
Administrative, technical, or material support: Westaby.
Supervision: Sharma, Sheppard.
Conflict of Interest Disclosures: Drs Westaby and Papadakis reported receiving grants from Cardiac Risk in the Young during the conduct of the study. No other disclosures were reported.
Funding/Support: This study was funded in part by CRY. Dr Finocchiaro was funded in part by CRY.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
et al; Association for European Cardiovascular Pathology. Guidelines for autopsy investigation of sudden cardiac death: 2017 update from the Association for European Cardiovascular Pathology. Virchows Arch
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