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(Chest. 2004;126:528-533.)
© 2004 American College of Chest Physicians

Clinical Characteristics of Unexpected Death Among Young Enlisted Military Personnel*

Results of a Three-Decade Retrospective Surveillance

Howard Amital, MD, MHA; Michael Glikson, MD; Moshe Burstein, MD, MHA; Arnon Afek, MD, MHA; Ronit Sinnreich, PhD; Yuval Weiss, MD, MPH and Vered Israeli, MD, MHA

* From the Israeli Defense Forces-Medical Corps (Drs. Amital, Burstein, Afek, Weiss, and Israeli), Israeli Defense Forces, Jerusalem, Israel; Electrophysiology Unit (Dr. Glikson), Heart Institute, Sheba Medical Center and Tel Aviv University, Tel-Hashomer, Israel; and the Epidemiology Unit (Dr. Sinnreich), Hadassah Medical Center, Hebrew University, Jerusalem, Israel.

Correspondence to: Howard Amital, MD, MHA, Rheumatology Unit, Hadassah University Hospital, Ein–Kerem, PO box 12000, Jerusalem 91120, Israel; e-mail: amitalh{at}hadassah.org.il


   Abstract
TOP
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 References
 
Study objective: To explore the causes of sudden and unexpected death in a young and healthy military population, to examine the various patterns of diseases associated with these tragic events, and to investigate the factors found to be associated with this grave outcome.

Design: We retrospectively investigated 151 cases of Israeli military personnel who died unexpectedly over a 30-year period. We collected all the available medical records, autopsy results, and investigation committee reports.

Results: A total of 151 cases of sudden and unexpected death occurred among enlisted military personnel during the period. Cardiac disorders caused 47% of deaths, followed by neurologic causes (17%) and pulmonary causes (11%). In 30 events (20%), the cause of death remained undetermined. Symptoms (eg, syncope, chest pain, palpitations, and others) occurred prior to death in 52 cases (34%). Asthma was the most common risk factor in our study population having been previously recognized in 10 cases (6.7%). Eight of the 13 subjects with asthma died following an acute asthmatic attack.

Conclusion: Cardiac events are the leading cause of unexpected death in young healthy people. The frequency of subjects with asthma was found to be higher than that in the general age-adjusted population.

Key Words: asthma • cardiac death • soldiers • unexpected death


   Introduction
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 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 References
 
The unexpected death of a young individual is an alarming and dramatic event. It is defined as a sudden cardiopulmonary collapse occurring within 24 h from the onset of symptoms.1 It can be particularly upsetting when such a death occurs in seemingly healthy young soldiers who were medically screened prior to military service and given a clean bill of health.

Prior research concerning sudden cardiopulmonary collapse has focused on athletes in competitive sports, however, information on unexpected death among military personnel is largely unreported. Athletes gain extreme physical endurance through lengthy physical training and are not typical of the general population. In Israel, military service is compulsory among the general population, however, despite preinduction medical screening, soldiers tend to mirror the medical status of the general population, rather than that of athletes.

In this report, we retrospectively investigated all cases of Israeli military personnel who died suddenly and unexpectedly between January 1974 and March 2002. This is an extension of a previously published series.23 The main goal of this study was to investigate the details of the causes of unexpected death found among young soldiers, and to identify the predictive signs and symptoms to be used for medical screening and selection prior to military service.


   Patients and Methods
TOP
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 References
 
We retrospectively examined all unexpected death reports occurring among soldiers aged 18 to 39 years between 1974 and 2002. This population had been medically screened prior to military recruitment at the age of 17 years. Such screening was composed of an interview regarding personal and family medical history, and personal habits, and a physical examination.

Unexpected death was defined as an unexpected and sudden cardiorespiratory collapse, taking place within 24 h from the onset of symptoms. Subjects with underlying stable medical conditions such as asthma and epilepsy were included in the study. Deaths from trauma, poisoning, drug overdose or misuse, drowning, electrocution, burns, and suicide were excluded. We also excluded deaths due to an ongoing chronic or malignant disease that required hospitalization.

The clinical and autopsy details were obtained from personal medical records, autopsy records, and proceedings of investigation committees, and from data presented in previous publications dealing with this issue.23 The crude data of the series that were reported by Kramer et al23 15 years ago were not entirely available. Therefore, we were unable to encompass all of the study population in each analysis. In each analysis in which we had incomplete data, we stated the exact number of subjects that were included.

The wide range of ages found for military personnel in Israel originates from two distinct subgroups of enlisted subjects. The majority of the population is composed of young recruits aged 18 to 21 years, who serve a compulsory term of service (men, 3 years; women, 2 years). After the age of 21 years, the continuation of military service is on a voluntary basis. We tried to stratify the various etiologies for unexpected death that we analyzed according to age and therefore drew a line of distinction at the age of 30 years, assuming that these two age groups differed by the profile of illnesses that caused the grave outcome, as was done in the earlier analysis.23

All autopsies were performed at the National Institute of Forensic Medicine. In the absence of an autopsy, the cause of death was determined only if reliable clinical evidence suggested a diagnosis (eg, massive cerebral hemorrhage seen on a CT scan or a malignant arrhythmia seen on an ECG recording).

Statistical Analysis
Differences in all causes of death and in cardiac causes of death (eg, ischemic heart disease [IHD], myocarditis, hypertrophic obstructive cardiomyopathy [HOCM], and all other causes of cardiac death) by age group were assessed by the {chi}2 test. The likelihood ratio {chi}2 was preferred to the Pearson {chi}2 test when indicated by the Williams criterion.4

Differences in the cardiac causes of death by physical exertion prior to death were assessed by the Fisher exact test. Differences in the proportion of death attributed to asthma by time period were assessed by Z-test. Significant differences were considered at p < 0.05.


   Results
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 References
 
A total of 151 cases of unexpected death occurred between April 1974 and March 2002 among Israeli soldiers aged 18 to 39 years. A total of 104 deaths occurred in soldiers aged 18 to 29 years, and 47 deaths occurred among military personnel aged 30 to 39 years, 22 of them officers. Fourteen of the deceased soldiers served in combat units and were engaged in intense physical activity, while the others served in logistical or other noncombat posts. Only 10 of the deaths occurred in women. Autopsies were performed in 114 cases (75%).

Causes of Death
Cardiac diseases were the most frequent cause of unexpected death in the study population. They were responsible for 47% of all deaths and for 59% of deaths in which the diagnosis could be determined (Table 1 , Fig 1 ). Moreover, among the military personnel aged 30 to 39 years, cardiac diseases were the cause of death in 64% of cases. The two age groups differed significantly by their distribution of all-cause mortality (eg, cardiac, neurologic, pulmonary, and others) [{chi}2, 10.5 (3 degrees of freedom); p < 0.05]. Analysis of cardiac deaths by cause (sorted according to the following distribution: IHD; myocarditis; HOCM; and all other cardiac causes) revealed highly significant differences between age groups ({chi}2, 43.4 [4 degrees of freedom]; p < 0.0001). IHD was the leading cause of death in the older group, causing 84% of the deaths in comparison to 9.7% in the younger group, probably reflecting the prevalence of coronary diseases in the general population. The two other major causes of cardiac death were myocarditis and HOCM, comprising 16 and 12 cases, respectively. Myocarditis caused 34% of the cardiac deaths in the younger age group compared to 7% in the older age group, whereas death associated with HOCM was ascribed to 24% of the cardiac deaths in the younger group compared to 7% in the older group. In nine cases, the clinical presentation prior to death was highly suggestive of a fatal arrhythmia, however, no definite pathologic findings corroborated this suggestion.


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  		Table 1.. Distribution of Causes of Sudden Death by Clinical Condition and Age Group*

 


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  		Figure 1.. Distribution of causes of cardiac death among 71 subjects who died due to a cardiac disease. Marfan = Marfan syndrome; Con. Ab = conduction abnormalities.

 
Neurologic causes accounted for 17% of all unexpected deaths, with epilepsy and cerebral hemorrhage being the leading neurologic causes. Fatal asthmatic attacks were the direct cause of death in 9% of all cases and was the dominant pulmonary illness (81%) leading to death. Since asthma disqualifies a soldier from serving in a combat unit, unsurprisingly all of these fatalities occurred in personnel serving in maintenance units. There was a tendency toward an increasing proportion of cases in which asthma was cited as a cause of death in this study throughout the years. In the studies by Kramer et al,23 asthma accounted for 3 of 52 cases, and this proportion increased to 13 of 151 cases in the current registry. However, this difference did not reach statistical difference (Z test, 0.59; p = 0.6). Four fatal cases of heatstroke were recorded during the 27 years.

Unfortunately, we were able to obtain complete data on only 52 reports of the 114 autopsies. The previous data were summarized by Kramer et al3 and were integrated without disclosing the means by which cause of death was obtained. Thirty-three percent of all subjects died after an occurrence of a coronary vascular event, 15% as part of myocarditis. In 10% of all autopsies, a cardiomyopathy was detected, 8% had a fatal asthmatic attack, and two subjects expired following the rupture of an aortic aneurysm. In six cases (11.5%), autopsies reached no definite diagnosis. Furthermore, despite thorough attempts to reach a definite diagnosis in each case, in 30 cases (20%) the direct cause of death remained unclear.

Symptoms Preceding Unexpected Death
Symptoms were reported at some point prior to death in 53 cases (35%) [Table 2 ]. These symptoms included syncope, chest pain, palpitations, recent febrile disease (usually a few days prior to death), GI symptoms, dyspnea, headache, and visual disturbances (during the preceding 2 weeks).


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  		Table 2.. Reported Symptoms Prior to Death Among 53 Subjects for Whom Data Were Available

 
Syncope occurred in two cases of HOCM (17%), in all four cases of heat stroke, in three cases of cerebral hemorrhage, in two cases of epilepsy, in one case of myocarditis, in one case of IHD, and in one case of death due to conduction defects. In the other five cases, no anatomic pathology was found. Chest pain preceded death in 10 cases of IHD, in 3 cases of HOCM, in 2 cases of myocarditis, and in 1 case of an anomalous origin of the left coronary artery. Fever preceded death in nine cases (four cases, heat stroke; three cases, myocarditis; one case, meningitis; one case, Marfan syndrome).

Unexpected Death and Strenuous Exercise
In 37 cases (25%), death occurred during or within 6 h of physical activity (Table 3 ). In the group of soldiers who died from IHD, 28% of deaths occurred during or immediately after physical activity. In the myocarditis group, 25% of deaths occurred in this manner, and in the cardiomyopathy group 50% of deaths occurred in this manner. All deaths due to heat stroke occurred during or immediately after physical activity. There was no significant difference among these rates (p = 0.17 [Fisher exact test]).


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  		Table 3.. Causes of Death in 37 Soldiers Who Died During or Immediately After Exercise

 
Risk Factors Leading to Unexpected Death
Cases of unexpected death were investigated for various risk factors, which are listed in Table 4 . The risk factor profile was based on the medical information that was obtained by interviewing the deceased person’s family, following an examination of medical records prior to and during military service. A higher prevalence of the common risk factors for cardiovascular disease was detected among subjects in the older age group. We were able to detect the risk factor profile of 10 subjects, aged 30 to 39 years, who died from acute ischemic cardiac events. Hypertension was the most common risk factor, occurring in 4 subjects (40%) in this group, followed by obesity and smoking in three cases (30%), hypercholesterolemia and familial history of IHD in two cases (20%), and diabetes in one case (10%). Four of these subjects had one risk factor, while three had three risk factors and one subject had five risk factors. Interestingly, of the four soldiers in the younger age group who died we obtained data concerning two soldiers who had no known risk factors for coronary heart disease (Table 4).


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  		Table 4.. Frequency of Risk Factors Among 89 Subjects With Known Risk Factor Profile

 
The prior existence of asthma was the most common risk factor for unexpected death in our population. It was reported in 10 cases (6.7%), which is almost twice the rate of asthma recorded in young recruits who were 18 years of age (3.5%). Eight of the 13 subjects who had a fatal asthmatic attack were known to have moderate asthma. No particular military profession or field condition was found to be related to these lethal asthmatic attacks. As expected, 12 of the 13 soldiers who died from asthma did not serve in combat units due to their preexisting ailment. It should be noted that subjects with severe asthma are exempted from military service in Israel, yet highly motivated draftees tend to refrain from voluntarily reporting certain medical illnesses such as asthma in order to serve in elite units. This behavior on the part of highly motivated draftees explains the low reported rates of preinduction asthma. The risk factor profile of 89 individuals for whom such data were available is presented in Table 4.


   Discussion
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
References
 
Numerous medical conditions have been implicated in the occurrence of unexpected sudden cardiac death among healthy young adults. Many of the screening policies and therapeutic recommendations that are employed nowadays are based on incomplete data and provide limited risk reduction at a considerable cost. The incidence of sudden cardiac death in young athletes ranges between 1 in 100,000 and 1 in 300,000 individuals, and obviously increases with age.56 This report is the largest series dealing with this issue in enlisted military personnel and in healthy young adults in general.

Similar to earlier reports, we also have demonstrated that cardiac diseases were the primary death cause in this population study, accounting for 59% of causes of death in the diagnosed cases and for 47% of all deaths in the study population. This proportion is compatible with those in previous reports ranging between 20% and 56%, according to the age distribution of the population study.37891011

In our report, we drew a clear distinction between the following two age groups: young soldiers up to the age of 30 years; and an older group between the ages of 30 and 39 years. The distribution of causes of cardiac death differed significantly between these two age groups. In the older group, coronary risk factors were more prevalent. These findings are in concordance with previous observations in studies1213 linking common cardiovascular risk factors (eg, cigarette smoking, hypertension, and hyperlipidemia) to an elevated risk of sudden death from cardiac causes. Interestingly, compared to the earlier report of Kramer et al,3 the relative contribution of cardiac reasons to all causes of unexpected death decreased over the past 20 years in young Israeli military personnel from 54 to 39%. Although we had no tools to investigate this finding, one might relate the decrease to the improvements that have occurred in medical diagnostics.

This survey demonstrated that 24% of all deaths occurred within 6 h following vigorous physical activity. Furthermore, 50% of the subjects with HOCM died in this manner compared to 28% and 25%, respectively, of the subjects with IHD and myocarditis. Albert et al14 reported an extremely high association (by a factor of 14 to 45) between the risk of unexpected death to transiently elevated vigorous exertion. However, the average age of the population in that study was much older (reaching 60 years of age) than the one in this study. Additionally, despite this high relative risk, the actual risk per episode remained remarkably low (1 death per 1.51 million episodes of vigorous exertion). Other reports1516 elaborating on this issue have demonstrated a reduced long-term risk of sudden coronary events associated with habitual physical activity.

Myocarditis was the death cause in 9.3% of the victims in our report. It was the leading cardiac cause of death among young victims up to the age of 29 years. This finding is compatible with the one reported by Corrado et al,17 who detected myocarditis in 10% of 273 cases of sudden deaths in young individuals who were < 35 years of age. These rates are somewhat higher than the 1 to 5% of sudden death victims reported in other series. This difference might be related to the effect of medical prescreening of soldiers prior to their recruitment.1819 Given the high rate of recent febrile disease in our described population, we assume that the true rate of myocarditis might be even higher. A definitive diagnosis can be obtained only by the demonstration of myocardial involvement, which is unfortunately often missed in endomyocardial biopsies in vivo or in autopsies due to the patchy nature of the disease. Similar to other reports, we did not reveal the definite cause of death in 20% of the cases.

An unexpected finding in our study was the relatively high rate of acute asthmatic attacks leading to death in 9% of the cases. Approximately 7% of all the reported subjects had preexisting asthma, which is twice as high as the age-adjusted rate (3.5%) published by the Israeli Ministry of Health.7 Katz et al20 reported that service in combat units was associated with an increased frequency of exacerbation of asthma among recruits whose disease used to be quiescent. A higher prevalence of asthma also was detected in soldiers who were posted in combat and maintenance units compared to those performing clerical tasks. These differences probably can be partly attributed to the exposure to occupational and environmental hazards, which are encountered more often in these units. Interestingly, according to our registry, the partial contribution of asthma to unexpected death increased over the years from 3 of 52 cases to 13 of 151 cases, however, this difference did not reach statistical difference. These findings are concordant with data originating from the United States, where a rise in death due to asthma from 1,674 cases (0.8 per 100,000 population) in 1977 to 5,667 cases (2.1 per 100,000 population) in 1996 was recorded in the general population.21

The low incidence of unexpected death in young adults has questioned the effectiveness of mass screening in this population. Adding sophisticated noninvasive diagnostic tools will increase the predictability of specific risk populations but at an unfeasible level of cost-effectiveness. This has led the American Heart Association to recommend that a comprehensive personal and family history should be obtained, and that a physical examination should be performed by a qualified examiner in the first year before the beginning training and competition. In each of the subsequent 3 to 4 years, an interim history and a BP measurement should be obtained.22 Even though the cardiovascular evaluation of an athlete is by definition different from the prerecruitment medical screening requirements of a soldier, it seems that the optimal measures for the screening of both populations are far from being determined. Nevertheless, the analysis of the causes of death in this study raises the possibility that several measures could have reduced the incidence of sudden cardiac death in this particular population.

Given the fact that military personnel are checked on a regular basis, and the fact that military activity often may demand intense physical activity, one may argue in favor of exercise testing of military personnel with a high-risk profile (eg, > 10% predicted incidence of coronary disease according to the Framingham study tables), especially if they are engaged in or are planning to start intense physical activity.23242526

The relatively high percentage of subjects with chest pain and syncope preceding the event of unexpected death in our group underscores the importance of a thorough evaluation of these symptoms once they occur in this active population. The high percentage of febrile disease and the relatively high proportion of physical activity-related deaths, along with the difficulties involved with the diagnosis of myocarditis, underline the importance of the restriction of physical activity during and following acute febrile illnesses in order to prevent sudden cardiac deaths.

Although HOCM may be diagnosed in most cases by echocardiography, such screening is too costly and has not been recommended as a screening tool even in athletes.25 While a routine ECG may diagnose HOCM in most cases, it has a high false-positive rate in this young healthy population, which affects its usefulness as a screening tool.25 However, ECG is superior to other tools of mass screening of athletes as far as cost-effectiveness and should be considered in military personnel during enlisting or routine periodic examinations26

In conclusion, cardiac events are the leading cause of sudden death in healthy young military personnel, followed by asthma and cerebral hemorrhage. Several measures to reduce the rate of sudden cardiac death that should be investigated in military personnel include ECG in the enlisted personnel, exercise testing in the older personnel with multiple risk factors, prevention of physical activity during or shortly after febrile disease, and a thorough evaluation of syncope and chest pain in this population.


   Acknowledgements
 
The authors thank Ron Jager, MSW, for his editorial assistance. In addition, our thanks go to Judith Misch, BSc, and Major Alexander Gordin, BSc, for their significant contribution to the completion of this study.


   Footnotes
 
Abbreviations: HOCM = hypertrophic obstructive cardiomyopathy; IHD = ischemic heart disease

Received for publication January 22, 2003. Accepted for publication February 23, 2004.


   References
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 References
 

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