Given the rampant mistrust of all levels of government, it’s understandable that the sudden death of Senator Lindsey Graham would spawn dark conspiracy theories. I don’t subscribe to them. First, the death investigation is under the jurisdiction of one of America’s premier medicolegal death investigation offices. Second, aortic dissection is a relatively uncommon but plausible cause of sudden death, one that’s difficult (maybe impossible) to fake.
This article focuses on the medicolegal investigation into the senator’s death and on aortic dissection, an often-missed cause of sudden death.
Could I be wrong? Sure, after all, we don’t even have the toxicology results yet. Could there be a cover-up? Maybe. But there are easier ways than this…
Timeline of the medicolegal investigation
Saturday, July 11, 2026, 8:27 pm: District of Columbia (D.C.) EMS responds to a complaint of “chest pain” from U.S. Senator Lindsey Graham’s Washington home. [Comment: Almost all cases of acute aortic dissection present with severe chest pain.]
Sunday, July 12, morning: Graham’s office issues an official statement: “On the evening of Saturday, July 11, U.S. Senator Lindsey Graham passed away from a brief and sudden illness. Senator Graham’s family appreciates prayers at this time and asks for privacy during this incredibly difficult period.”
Sunday, July 12, afternoon: After an autopsy, the D.C. Office of the Chief Medical Examiner (OCME) reports the preliminary cause of death as “aortic dissection due to arteriosclerotic cardiovascular disease.” [Comment: Regulations established by the mayor of the District of Columbia govern which deaths are investigated by the OCME. Graham’s death would have fallen under the category of “sudden, unexpected or unexplained deaths not caused by readily recognizable disease.” The OCME would have made the decision whether to perform an autopsy, which is not mandatory.]
What we don’t (yet) know about the medicolegal investigation
Was Senator Graham pronounced dead in his home by EMS or by a deputy medical examiner from the OCME?
Who transported/removed the body? Was the senator’s body removed directly from his home to the OCME morgue? Or did EMS first take the body to a hospital?
Did an OCME deputy medical examiner do their own scene investigation (with or without the body in evidence)?
Besides “arteriosclerotic cardiovascular disease,” did Senator Graham have other predisposing medical conditions? Hypertension, hyperlipidemia, and left ventricular hypertrophy are common contributing factors in aortic dissection
The Office of the Chief Medical Examiner
Francisco Diaz, M.D., a board-certified forensic pathologist appointed by the city’s mayor in 2021, is the Chief Medical Examiner of the District of Columbia (D.C.), population approximately 700,000.
The D.C. (OCME) is accredited by both the National Association of Medical Examiners (NAME) and the International Organization for Standardization (ISO).
According to its most recently published annual report, in 2023 the OCME investigated almost 4000 deaths. It accepted jurisdiction (issued death certificates) in almost 2,000 of those cases, and performed autopsies in approximately 70 percent of those accepted cases.
The pending death certificate
“The death certificate will be PENDING until all the toxicological and microscopic testing are finalized and at that point the death certificate will be updated to reflect the cause of death and appropriately classify the manner of death.” So read a statement from the D.C. OCME, published on the Senator’s office social media account.
Pending death certificates are routine practice in both coroner and medical examiner death investigation offices.
A final determination of the cause and manner of death in a pending case requires consideration of all available evidence. That includes scene investigation, law enforcement and EMS reports, medical records, gross autopsy findings, histology (microscopic tissue examination), and toxicology testing.
Toxicology is usually the rate-limiting step. The D.C. OCME has its own toxicology unit. Their turnaround time for this type of death is not available, but is between 30 – 90 days for most DUI cases. I’m guessing it will be on the shorter end for this case.
Aortic dissection as a cause of death
The basics
The aorta, the largest blood vessel in the body, has three layers, the intima, the media, and the adventitia. It rises from the level of the aortic valve of the heart, then arches down and becomes the abdominal aorta after entering the abdominal cavity.
When the intimal lining, the inner layer of the aorta is torn, high-pressure blood pumped from the heart can enter the opening and tear apart—dissect—the layers, forming a channel of blood.
About two-thirds of aortic dissections are Type A. That’s when the tear and dissection occur in the part of the aorta closest to the heart. This is likely what happened to Senator Graham. The dissecting blood can encase the heart, causing cardiac tamponade, a rapidly fatal event.
How often is aortic dissection fatal?
Type A aortic dissection is estimated to be fatal in more than half the cases. About 7-8 percent of out-of-hospital cardiac arrest cases may be due to aortic dissection.
One autopsy study found that 60 percent of aortic dissection cases had been misdiagnosed before death.
The true incidence of aortic dissection as a cause of death isn’t known. That’s because not every sudden death gets an autopsy.
Which raises the question: Did Lindsey Graham’s father truly die from “a massive heart attack” at the age of 69, or did he perhaps suffer an aortic dissection? There’s no record of an autopsy or any investigation into what appeared to be a natural death at home. Of course, either way the underlying cause would likely be atherosclerotic (aka arteriosclerotic) cardiovascular disease (ASCVD).
What predisposes someone to aortic dissection?
The aforementioned ASCVD, which causes fragile and brittle arteries, is a key factor. So is hypertension. Elevated blood pressure stresses already weakened walls of the aorta and other arteries. A finding of left ventricular hypertrophy or an enlarged heart at autopsy suggests hypertension during life.
Genetic research is ongoing. Marfan syndrome, a relatively rare genetic condition that affects connective tissue, carries an increased risk of aortic disease, including aortic dissection. For important information on genetics and aortic disease (primarily aneurysms), I recommend Dr. Cecile Gounder’s article.
Final thoughts
The medicolegal investigation into the death of Senator Graham proves once again the importance of transparency in our coroner and medical examiner offices. These public servants should adhere to a code of medical ethics and be independent of political influence. I look forward to the OCME’s final determination of the cause and manner of death. Release of the full scene narrative, autopsy report, and toxicology report in this case will bolster trust in the OCME.
Featured image credit: Marah Bashir on Unsplash