Background The earthquake that struck the Los Angeles area at4:31 a.m. on January 17, 1994, was one of the strongest earthquakesever recorded in a major city in North America. Once the life-threateningsituation was over, the Northridge earthquake, so called becauseits epicenter was near Northridge, California, just north ofLos Angeles, provided investigators an unusual opportunity toexamine the relation between emotional stress and sudden cardiacdeath.
Methods We reviewed the records of the Department of Coronerof Los Angeles County for the week before the earthquake, theday of the earthquake, the six days after the earthquake, andcorresponding control periods in 1991, 1992, and 1993.
Results On the day of the earthquake, there was a sharp increasein the number of sudden deaths from cardiac causes that wererelated to atherosclerotic cardiovascular disease, from a dailyaverage (±SD) of 4.6±2.1 in the preceding weekto 24 on the day of the earthquake (z = 4.41, P<0.001). Sixteenvictims of sudden death either died or had premonitory symptoms,usually chest pain, within the first hour after the initialtremor. Only three sudden deaths occurred during or immediatelyafter unusual physical exertion. During the six days after theearthquake, the number of sudden deaths declined to below thebase-line value, to an average of 2.7±1.2 per day.
Conclusions The Northridge earthquake was a significant triggerof sudden death due to cardiac causes, independently of physicalexertion. This finding, along with the unusually low incidenceof such deaths in the week after the earthquake, suggests thatemotional stress may precipitate cardiac events in people whoare predisposed to such events.
On January 17, 1994, at 4:31 a.m., Los Angeles County was joltedby an earthquake centered near Northridge, California —one of the strongest earthquakes ever recorded in a major cityin North America.1,2 In this unusual situation, millions ofpeople were awakened simultaneously at 4:31 a.m. by a life-threateningsituation; the earthquake created a "natural experiment," providinga rare opportunity to investigate features of the relation betweenemotional stress and sudden death due to cardiac causes.
Sudden death from cardiac causes is the leading cause of deathdue to cardiovascular disease in this country, resulting inmore than 300,000 deaths per year.3 Because many such deathsare unwitnessed, however, many features of the mechanism andonset of sudden death remain unclear. Muller, Tofler, Willich,and their associates4-6 have suggested that certain "triggers"are responsible for the onset of sudden death. These investigatorsfound a significantly higher incidence of myocardial infarction,ventricular tachyarrhythmias, and sudden death due to cardiaccauses in the morning hours than at other times of day,6-10and they have suggested that these events may be triggered byincreases in adrenergic activity, heart rate, systemic arterialpressure, and blood coagulability that occur in the morning.6-8,11
A few observational studies12-18 have investigated mortalityfrom cardiac causes after stressful events, with conflictingresults. None of these studies, however, specifically investigatedthe relation between environmental stress and sudden death.The purpose of our study was to investigate the relation betweenwidespread emotional stress experienced simultaneously in adefined population and the occurrence of sudden death from cardiaccauses. To address this issue, we reviewed the records of theDepartment of Coroner of Los Angeles County, which compilesdata on the circumstances, onset, and causes of death.
Methods
Acquisition of Data
The Department of Coroner of Los Angeles County investigatescases of sudden, unexpected death, the deaths of persons whodid not visit a physician in the 20-day period before they died,deaths not from natural causes, and cases in which the familydoctor refuses to sign a death certificate. Most of the deathstake place outside the hospital.
We reviewed the daily mortality figures and determined the underlyingcauses of death, the age, and the sex of all persons whose deathswere investigated by the Los Angeles County coroner's officefor the seven-day period before the earthquake (January 10 through16, 1994), the day of the Northridge earthquake (January 17,1994), and the six days thereafter (January 18 through 23, 1994);we obtained similar data for the corresponding period (January10 through 23) in 1991, 1992, and 1993.
To study the details of the deaths listed as due to atheroscleroticcardiovascular disease or sudden death due to cardiac causes,we reviewed the case records of all such deaths from January10 through 23, 1994. The coroner's records included case reportsas well as brief medical histories and information derived fromwitnesses regarding the circumstances, time, and mode of death.In addition, they included copies of death-investigation reportsfrom the Los Angeles Police Department, emergency-medical-systemrecords, emergency room records (when applicable), results ofautopsies (if performed), and death certificates.
Definitions
We considered the specification of atherosclerotic cardiovasculardisease as the underlying cause of death to be confirmed byone or more of the following: acute myocardial infarction orsudden death from cardiac causes (excluding known cardiomyopathyand valvular or congenital heart disease) as the cause of death;a history of myocardial infarction, angina pectoris, or coronaryartery disease confirmed by coronary angiography or a noninvasivestress test; the results of an autopsy indicating the presenceof coronary artery disease; and the exclusion of other lethaldiseases in subjects who had at least one risk factor for atheroscleroticcardiovascular disease. The final criterion (exclusion of otherlethal diseases) was required for the determination of deathfrom atherosclerotic cardiovascular disease. Risk factors foratherosclerotic cardiovascular disease were diabetes mellitus,hypertension, smoking, hyperlipidemia, obesity, and an age greaterthan 50 years.
Sudden death from cardiac causes was defined according to theclassification of the Framingham Heart Study.8 All four of thefollowing conditions had to be met: the subject had been apparentlywell and stable; the subject had died within one hour afterthe onset of acute symptoms; the death had been witnessed; andthe death could not be attributed to some potentially lethaldisease other than atherosclerotic cardiovascular disease orcardiomyopathy.
Statistical Analysis
All statistical analyses were carried out at Research TriangleInstitute, Research Triangle Park, North Carolina. Chi-squaretests or two-tailed Fisher's exact tests were used to comparecategorical data. Continuous variables, such as age, were comparedby means of t-tests.
To calculate the relative risk of death from a specific cause,we constructed two-by-two tables; 95 percent confidence intervalswere calculated for relative risks.19
To assess the differences between the number of sudden deathsfrom cardiac causes on the day of the earthquake and the dailyaverages before and after the earthquake, we assumed that thenumbers of sudden deaths due to cardiac causes in these threeperiods divided by the total number of sudden cardiac deathsin the two-week period were trinomial proportions. Two questionsof interest were whether the proportion of deaths occurringon the day of the earthquake was the same as the average dailyproportion for the previous week, and whether it was the sameas the average for the subsequent six days. Hence, we computedtwo z statistics for these two tests, taking into considerationthat the proportions were correlated and that the two proportionsin each comparison were computed for periods of different lengths.We assumed that the sample sizes were large enough to use thenormal distribution in calculating the two-tailed P values forthese tests.
A similar strategy was used for other causes of death and forthe comparison of deaths before and after the earthquake. Alltests were two-sided. Results are presented as means ±SD.
Results
A total of 1952 deaths were investigated by the Department ofCoroner of Los Angeles County during the week before the earthquake(January 10 through 16, 1994), the week beginning with the earthquake(January 17 through 23, 1994), and the same periods in 1991,1992, and 1993.
Deaths Investigated by the Coroner on the Day of the Earthquake
Figure 1 shows the number of deaths investigated by the coronerthat occurred each day from January 10 through 23, 1994, andduring the control periods. There was a sharp increase in thenumber of deaths, from a daily average of 35.7±5.9 duringthe seven days before the 1994 Northridge earthquake to 101deaths on the day of the earthquake (relative risk of deathon the day of the earthquake, as compared with previous years,2.4; 95 percent confidence interval, 1.9 to 3.0).
Figure 1. Daily numbers of Deaths Listed by the Department of Coroner of Los Angeles County from January 10 through 23, 1991, 1992, 1993, and 1994.
There was a sharp rise in the total number of deaths (n = 101) on January 17, 1994, the day of the Northridge earthquake (relative risk of death on the day of the earthquake as compared with other days, 2.4; 95 percent confidence interval, 1.9 to 3.0).
Table 1 shows the causes of deaths assigned by the coroner'soffice on the day of the earthquake. Fifty percent of the deaths(n = 51) were found to be related to underlying atheroscleroticcardiovascular disease. Not surprisingly, trauma was the secondmost frequent cause of death assigned by the coroner (n = 29).
Table 1. Causes of Deaths on the Day of the Northridge Earthquake (January 17, 1994) That Were Investigated by the Department of Coroner of Los Angeles County.
Deaths Related to Atherosclerotic Cardiovascular Disease
There were 109 deaths due to atherosclerotic cardiovasculardisease during the week before the earthquake and 109 duringthe week of the earthquake. However, analysis of the numberof deaths each day that were determined to be related to atheroscleroticcardiovascular disease (Figure 2) revealed a sharp increase,from an average of 15.6±3.9 deaths per day during theseven days before the earthquake to 51 on the day of the earthquake(relative risk as compared with the same period in previousyears, 2.6; 95 percent confidence interval, 1.8 to 3.7). Theaverage age of those who died from atherosclerotic cardiovasculardisease was 70.2±13.5 years, and 33 (65 percent) weremen. These age and sex characteristics were similar to thoseof the people who died during the week before the earthquakeand during the control periods (age, 69.8±13.6 years;62 percent male). This similarity suggests that the increasein the number of deaths on the day of the earthquake occurredamong people already at risk of death from atherosclerotic cardiovasculardisease.
Figure 2. Daily numbers of Deaths Found to Be Related to Atherosclerotic Cardiovascular Disease from January 10 through 23, 1991, 1992, 1993, and 1994.
On the day of the earthquake (January 17, 1994), there was a sharp rise in the number of deaths related to atherosclerotic cardiovascular disease (n = 51; relative risk, 2.6; 95 percent confidence interval, 1.8 to 3.7). The daily number of deaths related to atherosclerotic cardiovascular disease declined in the six days after the earthquake (z = 3.15, P = 0.002).
The average daily number of deaths determined by the coroner'soffice to be due to atherosclerotic cardiovascular disease declinedfrom the seven days before the earthquake to the six days afterit (from 15.6±3.9 to 9.7±3.4, z = 3.15, P = 0.002).This pattern — a sharp increase in the number of deaths,followed by a decrease — suggests that the earthquakeprecipitated death among people who were at risk of dying duringthe week of the earthquake. Because of this trigger, they dieda few days earlier.
Sudden Death Due to Cardiac Causes
Figure 3 shows the number of sudden deaths related to atheroscleroticcardiovascular disease each day from January 10 through January23, 1994. Of the 51 deaths from atherosclerotic cardiovasculardisease on the day of the earthquake, 24 (47 percent) were witnessedsudden deaths. This number was unusually high as compared withthe coroner's office average of 4.6±2.1 sudden deathsper day in the week before the earthquake (z = 4.41, P<0.001).Another case of sudden death on the day of the earthquake wasrelated to hypertrophic cardiomyopathy.
Figure 3. Daily numbers of Sudden Deaths Related to Atherosclerotic Cardiovascular Disease from January 10 through23, 1994.
On January 17, the day of the earthquake, there were 24 cases of sudden death related to atherosclerotic cardiovascular disease (z = 4.41, P<0.001). There was a decline in number of sudden deaths on each of the six days after the earthquake(z = 1.73, P = 0.084).
Table 2 shows the characteristics of the 25 persons who diedsuddenly. Twenty-four of the 25 subjects had either risk factorsfor or a history of atherosclerotic cardiovascular disease.The average age of the victims of sudden death who had atheroscleroticheart disease was 68.0±13.1 years. There were 18 men(75 percent; age, 64.0±11.8 years) and 6 women (25 percent;age, 80.0±8.8 years; P = 0.006 for the comparison betweenthe sexes).
Table 2. Characteristics of 25 People with Witnessed Sudden Death Due to Cardiac Causes on the Day of the Earthquake.
The age and sex distribution of these persons who died suddenlyon the day of the earthquake were similar to that of those whodied during the seven days before the earthquake (age, 62.9±13.6years; 69 percent male).
Only one case of sudden death due to cardiac causes on January17, 1994, occurred before 4:31 a.m., the time the earthquakebegan (Table 2, Case 19). In two thirds of the cases relatedto atherosclerosis (16 of 24), symptoms developed or the victimdied immediately or within the first hour after the earthquake.In two other cases, symptoms started during the second hour.Chest pain was the most frequent premonitory symptom. Of the13 people with atherosclerotic heart disease who had premonitorysymptoms before dying suddenly, 10 (77 percent) were reportedto have had chest pain (Table 2). Three sudden deaths occurredduring unusual physical exertion, such as running out of a shakinghouse or cleaning up earthquake debris, but the remaining deathswere not associated with unusual physical effort and may havebeen related to emotional stress.
Figure 4 shows the distribution of the times of day when suddendeath occurred (as noted on the death certificates or in thevictims' medical records) on the day of the earthquake and duringthe seven days before the earthquake. Over half the deaths relatedto atherosclerosis on the day of the earthquake (13 of 24) occurredbetween midnight and 6 a.m., whereas only 3 of 32 deaths (9percent) during the seven days before the earthquake occurredduring this period (P = 0.002).
Figure 4. Times of Sudden Deaths Related to Atherosclerotic Cardiovascular Disease on the Day of the Earthquake and the Seven Days before the Earthquake.
Over half the deaths related to atherosclerosis (13 of 24) on the day of the earthquake occurred between midnight and 6 a.m., whereas only 3 of 32 (9 percent) of the deaths during the seven days before the earthquake occurred at that time of day (P = 0.002).
We also analyzed the locations of sudden deaths. Whereas onthe day of the earthquake 13 of the 23 deaths with known locations(57 percent) occurred within 15 miles of the epicenter of theearthquake, only 1 of 31 deaths during the seven days beforethe earthquake (3 percent) occurred within this radius (P<0.001).
There were 17 additional cases of possible (unwitnessed) suddendeath due to cardiac causes on the day of the earthquake. Thecircumstances in these cases suggested strongly that suddendeath was associated with the earthquake; most of the victimswere found dead within the first four hours after the earthquake.
Role of Daily Triggers in Causing Sudden Death Related to Atherosclerotic Cardiovascular Disease
There was a "compensatory deficit" in the number of sudden deathsdue to atherosclerotic cardiovascular disease that were recordedby the coroner's office in the six days after the earthquake(Figure 3). The number of such sudden deaths declined from 32in the week before the earthquake (average, 4.6±2.1 perday) to 16 in the six days after the earthquake (average, 2.7±1.2per day) (z = 1.73, P = 0.084). This decrease suggests, onceagain, that people who were at risk for sudden death due tocardiac causes during that week died several days earlier asa result of the earthquake.
On the basis of these findings, we hypothesized that under ordinarycircumstances a certain fraction of sudden deaths are initiatedby a triggering mechanism. To quantify that fraction, we usedthe average number of sudden deaths per day in the seven daysbefore the earthquake (4.6) to estimate the average number ofdeaths that would have occurred each day from January 18 throughJanuary 23, 1994, if the earthquake had not occurred. From thisnumber we subtracted the average number of sudden deaths thatdid occur per day in the six days after the earthquake (2.7).Thus, we estimate that there were 1.9 fewer deaths per day duringthe six days after the earthquake than there would otherwisehave been. In the absence of a major stressor, such as an earthquake,therefore, 41 percent (1.9 ÷ 4.6) of sudden deaths maybe related to triggers. Similarly, we estimate that approximatelyfive deaths would have occurred on January 17, 1994, if theearthquake had not occurred. Subtracting 5 from the number ofsudden deaths that did occur (24), we estimate that 19 of thesudden deaths due to atherosclerotic cardiovascular diseasethat took place on January 17, 1994, could be attributed tothe earthquake.
Deaths Due to Other Causes
Figure 5 shows the number of deaths due to trauma for each dayfrom January 10 through January 23 in 1991, 1992, 1993, and1994. As expected, there was a significant increase in the numberof deaths due to trauma (n = 29) on the day of the earthquake(relative risk, 6.1; 95 percent confidence interval, 2.7 to13.5). In contrast, there was no significant difference in thenumber of deaths due to other causes, such as violence, alcoholor drugs, and cancer, between the day of the earthquake andthe average for the days during the control periods (data notshown).
Figure 5. Daily Numbers of Deaths due to Trauma from January 10 through 23, 1991, 1992, 1993, and 1994.
There was a significant increase in the number of deaths due to trauma (n = 29) on January 17, 1994, the day of the earthquake (relative risk, 6.1; 95 percent confidence interval, 2.7 to 13.5).
Discussion
The Northridge earthquake provided an unusual opportunity tostudy features of the relation between emotional stress andthe triggering of sudden death due to cardiac causes. The informationwe obtained from the Department of Coroner of Los Angeles Countyindicated that there was a sharp increase — to five timesthe previous average — in the number of sudden deathsdue to cardiac causes on the day of the earthquake. The lengthof time between the trigger (the earthquake) and sudden deathwas, in most of the cases, less than an hour. Unusual physicalexertion was an uncommon trigger. On the basis of the unusualpattern of mortality in the weeks surrounding the earthquake,we estimated that such triggering is likely to play a part ina substantial proportion (>40 percent) of cases of suddendeath due to cardiac causes under ordinary circumstances. Thepattern of mortality and the characteristics of the victimssuggest that the earthquake precipitated death primarily inpeople already at risk for sudden death.
The direct association between the earthquake and the onsetof sudden death due to cardiac causes was further supportedby other findings. These included the obliteration of the "normal"circadian variation in the incidence of sudden death, with asignificant increase in number of deaths that occurred duringthe first quarter of the day, and the relative increase in thenumber of sudden deaths occurring within a 15-mile radius ofthe epicenter near Northridge.
Stress as a Trigger for Sudden Death
Muller, Tofler, Willich, and their associates4-6 have suggestedthat both the act of waking and emotional or physical stresscan trigger the onset of cardiac events, perhaps by stimulatingthe release of catecholamines and hypercoagulability factorsthat may contribute to the rupture of a vulnerable atheroscleroticplaque and subsequent coronary-artery thrombosis.11,20 Sucha triggering mechanism is likely to have played a part in theincreased number of sudden deaths and deaths associated withatherosclerotic cardiovascular disease on the day of the Northridgeearthquake. The hypothesis that such triggering occurred issupported by our observation of a 35 percent increase in thenumber of hospital admissions for acute myocardial infarctionin 72 coronary care units in southern California in the weekafter the earthquake.21 In another study, we detected an increasein the number of episodes of ventricular tachycardia or fibrillationamong patients with implantable cardioverter–defibrillatorsduring the two weeks after the earthquake.22 The precipitationof myocardial ischemia and serious arrhythmias by emotionalstress is the most likely underlying mechanism for these observations.
Comparison with Previous Observations
Although anecdotal case reports have suggested that mental oremotional stress can trigger sudden death, the few observationalstudies of mortality from cardiac causes after extremely stressfulevents such as earthquakes or wars have yielded conflictingconclusions.12-18 Whereas some investigators14,16,17 have failedto find a significant association between the event and an increasedrisk of mortality due to cardiac causes, others12,13,15,18 havesuggested that such an association does exist. These investigators,however, studied total mortality due to cardiac causes. Ourstudy, on the other hand, focused on sudden death due to cardiaccauses.
Limitations of the Study
The Department of Coroner of Los Angeles County did not investigateall deaths in Los Angeles County but, rather, cases in severaldefined categories. The increase in the number of deaths relatedto trauma during the earthquake that were investigated by thecoroner's office suggests that its records reflect actual changesin daily mortality.
One might speculate that the Department of Coroner was moreactive because of the earthquake and that this factor accountsfor the increase in deaths in its records. If such were thecase, however, we would anticipate a similar increase in deathsdue to other causes, such as violence, drugs or alcohol, andcancer. No such rise was observed.
Preliminary results of other studies we are conducting providefurther support for our conclusions in the present study. Theseobservations suggest that the occurrence of sudden death dueto cardiac causes after the earthquake was related to an increasein incidence of ischemic episodes21 and serious arrhythmias.22
Another important limitation is the fact that most of the peoplewho died suddenly on the day of the earthquake were not examinedby autopsy. The finding that 10 of 24 (42 percent) of the patientswho died suddenly from atherosclerotic cardiac causes had chestpain before death suggests that myocardial ischemia was involved.This finding is compatible with the association observed byothers between myocardial ischemia and sudden death.23,24
Practical Considerations and Future Implications
Our findings suggest that a substantial fraction (41 percent)of sudden deaths in persons with atherosclerotic cardiovasculardisease that occur under ordinary circumstances are relatedto a triggering mechanism. Thus, a reasonable strategy for theprevention of sudden death would be to interrupt the linkagebetween a trigger and the event. The administration of drugs,such as beta-adrenergic–blocking agents and aspirin, topatients who are at high risk because of atherosclerotic cardiovasculardisease might be beneficial. These drugs have been shown toprevent the onset of myocardial ischemia25,26 and may protecthigh-risk patients from the adverse effects of stress. Anotherimplication is that the emergency services in an area wherea disaster has occurred should be prepared for an increase inthe number of patients with acute myocardial infarction or abortedsudden death.
Further research is warranted to determine which patients withcoronary artery disease are most susceptible to sudden deathfrom cardiac causes after a stressful event and what other kindsof triggers may be involved. Identifying these high-risk patientsand defining potential triggers will help in the developmentof strategies to prevent sudden death due to cardiac causes.
We are indebted to the following people who helped us in ourstudy: Joseph Muto, Christopher Rogers, M.D., Michele Bringier,and Janie Ito from the Department of Coroner of Los AngelesCounty for allowing and helping us to collect and review thedata from the coroner's records; Rebeca L. Perritt from ResearchTriangle Institute, Research Triangle Park, N.C., for statisticalanalysis of the data; and Kevin J. Alker and Sharon Hale fromthe Heart Institute, Good Samaritan Hospital, Los Angeles, forassistance in creating our data base.
Source Information
From the Heart Institute, Good Samaritan Hospital, University of Southern California, Los Angeles (J.L., R.A.K.), and Research Triangle Institute, Research Triangle Park, N.C. (W.K.P.).
Address reprint requests to Dr. Kloner at the Heart Institute, Good Samaritan Hospital, 1225 Wilshire Blvd., Los Angeles, CA 90017.
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Writing Committee Members, , Zipes, D. P., Camm, A. J., Borggrefe, M., Buxton, A. E., Chaitman, B., Fromer, M., Gregoratos, G., Klein, G., Moss, A. J., Myerburg, R. J., Priori, S. G., Quinones, M. A., Roden, D. M., Silka, M. J., Tracy, C., ESC Committee for Practice Guidelines, , Priori, S. G., Blanc, J.-J., Budaj, A., Camm, A. J., Dean, V., Deckers, J. W., Despres, C., Dickstein, K., Lekakis, J., McGregor, K., Metra, M., Morais, J., Osterspey, A., Tamargo, J. L., Zamorano, J. L., ACC/AHA Task Force Members, , Smith, S. C. Jr, Jacobs, A. K., Adams, C. D., Antman, E. M., Anderson, J. L., Hunt, S. A., Halperin, J. L., Nishimura, R., Ornato, J. P., Page, R. L., Riegel, B.
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