【作者】 张慧；

【导师】 郑旭东； 闫红涛；

【作者基本信息】 郑州大学 ， 法医学， 2018， 硕士

【摘要】 背景与目的:冠心病(coronary atherosclerotic heart disease,CHD)是人类的一种常见病、多发病,冠心病猝死(sudden coronary death,SCD)是人类最常见的猝死类型。冠心病猝死属自然死亡,可发生于各种诱因情况下,如争执厮打过程中、劳动过程中、医疗过程中、体育运动过程中、饮酒过程中,甚至睡眠中等等。但因其死亡迅速(往往从发病到死亡不足1小时,有时在几十秒钟内死亡,后者称为即时死),且发病前有半数患者无先兆症状或症状轻微易被忽略,死亡显得出乎意料,常常被怀疑是外伤致死、劳累致死、医疗事故致死或中毒致死等非正常死亡情况,从而引发死因争议。解决死因争议是法医病理学检验的一项重要任务。在司法鉴定实践中因冠心病猝死引发的死因争议案例占有相当比重,为进一步探明其病理变化特点及发病规律,本课题从某某大学司法鉴定中心2007年-2017年受理的各类法医病理学检验案例中筛选出369例冠心病猝死案例进行分析研究,并将其中因争执厮打a诱发的冠心病猝死案例共计192例与安静状态下冠心病猝死案例共计123例进行比较研究,旨在为冠心病猝死的预防及法医学鉴定提供有益参考。材料:从某某大学司法鉴定中心2007年1月至2017年12月受理的2000余例法医病理学检验案例中筛选出冠心病猝死案例369例进行研究,其中男326例,女43例。纳入标准:具有完整尸体解剖资料及尸检照片证实是冠心病猝死;有法医病理学鉴定意见书确定为冠心病猝死;有原始案情记录及病历资料排除由于暴力、毒物、自杀等其他死因;有心脏等大体标本、病理蜡块及H.E.切片进行二次核实。排除标准:凡不符合冠心病猝死或存在死因竞争的案例均予以排除。方法:统计369例冠心病猝死案例的性别、年龄、职业、时间、诱因、心脑脾肾等各脏器大体情况及病变特点,各主要冠状动脉粥样硬化斑块分布情况、狭窄程度及并发症等。应用SPSS 24.0系统进行分析检验,比较各组之间的差异。结果:1.年龄与性别的关系:369例冠心病猝死案例在20岁以上各年龄段均有分布,男女人数比为7.6:1,发病案例主要集中在40岁-69岁之间;男性平均年龄53.1岁,好发年龄集中在40岁-69岁之间,女性平均年龄59.3岁,好发年龄集中在50岁-59岁之间;男性在各个年龄阶段发病比例均大于女性;发病年龄与性别之间的显著性关系有统计学意义(P<0.05)。2.职业与性别分布:农民在各职业中发病比重最大;不同职业中男女发病率没有显著性差异(P>0.05)。3.时间分布:以每年第一季度高发,1-2月份是高发月份(P<0.05)。4.诱因特点:争执厮打是司法鉴定案例中冠心病猝死的主要诱因,其显著性具有统计学意义(P<0.05)。5.脏器病变提示:在因冠心病猝死的司法鉴定案例中具有高血压病理特征的占绝大多数。争执厮打诱发的冠心病猝死的案例中具有高血压病理特征的案例比安静状态下冠心病猝死的比率更高,病变更严重;高血压病与冠心病猝死之间的显著关联性有统计学意义(P<0.05)。6.心脏病变提示:争执厮打诱发的冠心病猝死案例中心肌梗死情况比安静状态下冠心病猝死的心肌梗死情况更严重,其显著性差异有统计学意义(P<0.05)。7.冠状动脉粥样硬化斑块的好发部位:最常发生于左前降支,并且常常同时累及右冠脉,两冠脉同时受累并狭窄Ⅲ级及以上者占95.9%,且两冠脉间显著的关联性有统计学意义(P<0.05)。争执厮打诱发的冠心病猝死案例中左前降支和右冠脉狭窄程度比安静状态下猝死的两冠脉情况更严重,其严重程度的显著差异有统计学意义(P<0.001)。8.斑块并发症:争执厮打诱发的冠心病猝死血栓形成的比例显著低于安静状态下血栓发生的比例,其显著差异具有统计学意义(P<0.01)。结论:本课题就某某大学司法鉴定中心2007年-2017年法医病理学检验案例中的369例冠心病猝死案例进行分析研究,并将其中因争执厮打诱发的冠心病猝死案例共计192例与安静状态下冠心病猝死案例共计123例进行比较研究后得出:1.因争执厮打诱发的冠心病猝死案例中具有高血压病变特点和心肌梗死的案例比安静状态下冠心病猝死具有高血压病变特点和心肌梗死的案例检出率更高,病变更严重。2.因争执厮打诱发的冠心病猝死案例中冠脉血栓形成的比例显著低于安静状态下冠心病猝死案例中冠脉血栓形成的比例。更多还原

【Abstract】 Background and purpose: Coronary heart disease(coronary atherosclerotic heart diseases,CHD)is a kind of common disease,frequently-occurring disease of human beings.The sudden death of coronary heart disease(sudden coronary death,SCD)is the most common type of sudden death.SCD is a kind of natural death.It can happen in a variety of incentives,such as,in the process of dispute and tussle,of working,of sports,of drinking,even during sleep,and so on.Because of its death quickly(often less than 1 hour from onset to death,sometimes in a few seconds to death,which is called the instant death),and the former half of patients without aura symptoms or mild easily overlooked,death appear unexpectedly,SCD is often suspected to be an abnormal death caused by trauma,fatigue,medical accident or poisoning,etc.And the cause of death is disputed.Resolving the cause of death dispute is an important task of forensic pathology examination.In the practice of judicial authentication,SCD caused disputes has a quite proportion of cases.For further ascertain the pathological changes and pathogenesis regularity,we selected 369 SCD cases from all kinds of forensic pathology cases in Judicial Authentication Center of the University in 2007-2017 for analysis.And we compared the total of 192 cases of SCD induced by dispute and tussleb with the total of 123 cases of SCD in quiet condition,in order to provide the beneficial reference for the prevention of SCD and forensic medical identification.Material: We selected 369 SCD cases from more than 2000 of forensic pathology cases in Judicial Authentication Center of the University in 2007-2017 for analysis,including 326 males and 43 females.Inclusion criteria: SCD with complete autopsy data and autopsy photos;the diagnosis of CHD was determined by forensic pathology;Original records and medical records excluded other death causes of violence,poison,suicide,etc.;Having a general specimen of the heart;There were pathological wax blocks and H.E.slices could be check.Exclusion criteria: All cases that do not meet the sudden coronary death or the causes of death are in competition.Method: Statistics of 369 cases of SCD from gender,age,occupation,the time of death,inducement,preserving heart,brain,spleen,kidney and so on various organs in general situation and characteristics of the lesions,the distribution of major coronary atherosclerosis plaque,the degree of stenoses and complications.SPSS 24.0 was used to analyze and verify the differences among the groups.Results: 1.Relationship between age and gender: 369 cases of SCD were distributed in all ages of 20 years old and above,with a ratio of 7.6 to 1.The incidence of cases of men was mainly between 40 ~ 69 years,the average age is 53.1 years old.The incidence of cases of women was mainly between predilection age is 50 ~59 years,the average age of women is 59.3 years old.The incidence rate of males was greater than that of women at all ages.There is a significant relationship between age and sex(P< 0.05).2.Occupational and gender distribution: The proportion of farmers in all occupation is the largest;there was no significant difference in male and female morbidity among different occupations(P< 0.05).3.Time distribution: SCD mostly occurs in the first quarter of each year,especially in January and February(P< 0.05).4.Inducement characteristics: Dispute and tussle is the main cause of SCD in forensic pathology practice,and its significance is statistically significant(P< 0.05).5.The pathological changes of the organs indicated that the majority of cases of SCD are characterized by hypertension.In the case of SCD induced by dispute and tussle,the ratio of patients with hypertension to sudden death of CHD is higher than that in the quiet state,and the disease is more serious.There is a significant correlation between hypertension and SCD(P< 0.05).6.Cardiac pathological changes suggested that the myocardial infarction of sudden death from CHD induced by dispute and tussle was more serious and significant difference than in the quiet state(P< 0.05).7.Predilection part of coronary atherosclerotic plaque: most commonly occurs in the left anterior descending artery(LAD),often involving the right coronary artery(RCA)at the same time,both the affected and narrow Ⅲ level and above accounted for 95.9%,and both in the SCD has significantly close correlation(P< 0.05).The severity of LAD and RCA stenoses between induced by dispute and tussle and in quiet state is different,the significant difference is statistically significant(P< 0.001).8.Plaque complications: the proportion of sudden thrombosis of CHD induced by dispute and tussle is significantly lower than that in the quiet state,and the significant difference was statistically significant(P< 0.01).Conclusion: This topic is a retrospective study of 369 SCD cases from forensic pathology cases in Judicial Authentication Center of the University in 2007-2017.And we compared the total of 192 SCD cases induced by dispute and tussle with the total of 123 SCD cases in quiet state,and we came to the following conclusions: 1.The characteristics of hypertensive disease and myocardial infarction in the SCD cases induced by dispute and tussle were more and worse than those in the SCD cases in the quiet state.2.The proportion of coronary artery thrombosis in the SCD cases induced by dispute and tussle was significantly lower than that in the quiet state.更多还原