Plaque Rupture and Sudden Death Related to Exertion in Men With Coronary Artery Disease

University of Maryland, Baltimore, Baltimore, Maryland, United States
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 03/1999; 281(10):921-6. DOI: 10.1001/jama.281.10.921
Source: PubMed


Exertion has been reported to acutely increase the risk of sudden coronary death, but the underlying mechanisms are unclear.
To determine the frequency of plaque rupture in sudden deaths related to exertion compared with sudden deaths not related to exertion.
Autopsy survey. Coronary arteries were perfusion fixed and segments with more than 50% luminal narrowing were examined histologically. Ruptured plaques were defined as intraplaque hemorrhage with disruption of the fibrous cap and luminal thrombus. Exertion before death was determined by the investigator of the death.
Medical examiner's office.
A total of 141 men with severe coronary artery disease who died suddenly, including 116 whose deaths occurred at rest (mean [SD] age, 51 [11] years) and 25 who died during strenuous activity or emotional stress (age, 49 [9] years).
The frequency and morphology of plaque rupture was compared in men dying at rest vs those dying during exertion. Independent association of risk factors (total cholesterol, high-density lipoprotein cholesterol, glycosylated hemoglobin, cigarette smoking) in addition to acute exertion with plaque rupture were determined.
The mean (SD) number of vulnerable plaques in the coronary arteries of men in the exertional-death group was 1.6 (1.5) and in the at-rest group was 0.9 (1.2) (P=.03). The culprit plaque in men dying during exertion was plaque rupture in 17 (68%) of 25 vs 27 (23%) of 116 men dying at rest (P<.001). Hemorrhage into the plaque occurred in 18 (72%) of 25 men in the exertional-death group and 47 (41%) of 116 men in the rest group (P=.007). Histological evidence of acute myocardial infarction was present in 0 of 25 in the exertion group and in 15 (13%) of 116 in the rest group. Men dying during exertion had a significantly higher mean (SD) total cholesterol-high-density lipoprotein cholesterol ratio (8.2 [3.0]) than those dying at rest (6.2 [ 2.7]; P=.002), and the majority (21/25) were not conditioned. In multivariate analysis, both exertion (P=.002) and total cholesterol-high-density lipoprotein cholesterol ratio (P=.002) were associated with acute plaque rupture, independent of age and other cardiac risk factors.
In men with severe coronary artery disease, sudden death related to exertion was associated with acute plaque rupture.

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    • "Autopsy findings generally indicate prior or acute MI, but evidence of coronary thrombosis is not always identified. Notwithstanding the limited data available, exercise is considered to be a risk factor for acute and vulnerable atherosclerotic plaque (Hammoudeh and Haft 1996;Burke et al. 1999;Giri et al. 1999;Chevalier et al. 2009). The fissuring of fragile, non-occlusive plaque may induce acute coronary artery occlusion and (or) malignant arrhythmia; however, it is not clear what mechanisms unique to exercise are involved. "
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