Response by Verdecchia et al to Letter Regarding Article "Sudden Cardiac Death in Hypertensive Patients".

In Response: We thank doctors Westaby and Sheppard for their interest in our study1 and their thoughtful comments. We agree that a postmortem examination may be useful in patients with sudden cardiac death (SCD) to clarify the cause of death. However, we think that indications for autopsy were not so stringent in our study. According to Guidelines, autopsy is currently recommended for the routine evaluation of subjects, typically aged <40 years, who die suddenly without a previous diagnosis of clinical conditions that could be reasonably implicated in the cause of unexpected SCD.2 In addition, postmortem examinations should be performed at a specialized cardiac pathology center to limit the overdiagnosis of cardiomyopathy.3 Although such facility is lacking in our area, none of our cases was aged <40 years at the time of the event. Actually, the youngest was 46 and the oldest 99 years old. Besides, for event adjudication, we adopted the definition for SCD set forth by the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards.4 In 23 of 33 patients, the death was unobserved, patients had been seen alive more than 60 minutes before discovery and no attempt was made by relatives or friends to resuscitate them. Other 8 patients showed a rapid witnessed collapse and were resuscitated, either at home or in the emergency room, but did not regain normal vital functions. Other 2 patients were hospitalized at the time of their SCD in a small rural hospital because of clinically stable heart failure (N=1) or arterial occlusive disease (N=1). Both were resuscitated but without success. Notably, none of our SCD cases had evidence of conditions leading to diagnosis of undetermined cause of death. Furthermore, none of the cases had prior terminal conditions, such as an advanced malignancy or end-stage chronic obstructive lung disease. We may have underestimated the incidence of SCD because rare single patients might have experienced a spontaneous aborted SCD, which could have been unnoticed. In summary, we agree that the lack of postmortem examination may be viewed as a limitation of our study, which is shared by comparable population studies on SCD.5 Paolo Verdecchia Fondazione Umbra Cuore e Ipertensione-ONLUS and Struttura Complessa di Cardiologia, Hospital S. Maria della Misericordia Perugia, Italy