Plaque rupture and sudden death related to exertion in men with coronary artery disease

Context Exertion has been reported to acutely increase the risk of sudden c oronary death, but the underlying mechanisms are unclear. Objective To determine the frequency of plaque rupture in sudden deaths rel ated to exertion compared with sudden deaths not related to exertion. Design 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 fibr ous cap and luminal thrombus. Exertion before death was determined by the i nvestigator of the death. Setting Medical examiner's office. Patients A total of 141 men with severe coronary artery disease who died su ddenly, 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). Main Outcome Measures The frequency and morphology of plaque rupture was co mpared in men dying at rest vs those dying during exertion. Independent ass ociation of risk factors (total cholesterol, high-density lipoprotein chole sterol, glycosylated hemoglobin, cigarette smoking) in addition to acute ex ertion with plaque rupture were determined. Results 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 grou p 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 dyi ng during exertion had a significantly higher mean (SD) total cholesterol-h igh-density lipoprotein cholesterol ratio (8.2 [3.0]) than those dying at r est (6.2 [2.7]; P = .002), and the majority (21/25) were not conditioned. I n multivariate analysis, both exertion (P = .002) and total cholesterol-hig h-density lipoprotein cholesterol ratio (P = .002) were associated with acu te plaque rupture, independent of age and other cardiac risk factors. Conclusion In men with severe coronary artery disease, sudden death related to exertion was associated with acute plaque rupture.