Discrepancies in initial death certificate diagnoses in sudden unexpected out-of-hospital deaths: the role of cardiovascular autopsy

Background: The accuracy of death certificates issued for out-of-hospital sudden deaths has been questioned. Methods: We retrospectively studied a series of consecutive autopsies performed at two community hospitals. Results: Fifty-four autopsies in which the deaths were sudden and that occurred outside the hospital were retained for study. The indication for autopsy was largely driven by the wishes of family or physician who was uncertain about the diagnosis. The overall discrepancy rate was 52%. The death certificate diagnosis, rendered before autopsy, was coronary artery disease in 44/54 autopsies (81%). At autopsy, coronary artery disease was the cause of death in 26 cases (48%), cardiomyopathy in 10 (18%), ruptured aneurysm in 8 (15%), pulmonary embolism in 7 (13%), and valve disease in 3 (6%). The diagnosis of coronary artery disease on the death certificate was accurate only 50% of the time. The discrepancy rate was lowest in patients with a history of cardiovascular disease (33%) and was 60% in patients with no prior medical history. The accuracy rate of death certificates was under one third in cases of cardiomyopathy, valve disease, ruptured aneurysm, pulmonary embolism, and valve disease. Conclusions: We conclude that in a highly selected group of sudden deaths, in which there was often a question about cause of death, the rate of initial death certificate accuracy is only one half. Furthermore, coronary artery disease as the cause of death is less than 50%, far less than initial death certificate diagnoses would indicate. (C) 2008 Elsevier Inc. All rights reserved.