Heart 2000;83:361-366 ( March )

Education in Heart

CORONARY DISEASE

The pathophysiology of acute coronary syndromes

Michael J Davies

St George's Hospital Medical School, Histopathology Department, London, UK

Correspondence to: Professor M J Davies, St George's Hospital Medical School, Histopathology Department, Cranmer Terrace, London SW17 0RE, UK

The first 150 words of the full text of this article appear below.

	Introduction

Virtually all regional acute myocardial infarcts are caused by thrombosis developing on a culprit coronary atherosclerotic plaque. The very rare exceptions to this are spontaneous coronary artery dissection, coronary arteritis, coronary emboli, coronary spasm, and compression by myocardial bridges. Thrombosis is also the major initiating factor in unstable angina, particularly when rest pain is recent and increasing in severity. Necropsy studies suggest that a new thrombotic coronary event underlies 50-70% of sudden deaths caused by ischaemic heart disease.

	The culprit plaque

Given the importance of thrombosis as the trigger for acute myocardial ischaemia, it is necessary to know something about the structure of plaques before thrombotic events occur and why there should be a sudden change from a stable state (no thrombus) to an unstable state (thrombus).

The fully developed human fibrolipid plaque, designated by the American Heart Association (AHA) as type IV or type Va,¹ has a core of lipid surrounded by . . . [Full text of this article]

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• Bjorck, L, Rosengren, A, Wallentin, L, Stenestrand, U (2009). Smoking in relation to ST-segment elevation acute myocardial infarction: findings from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions. Heart 95: 1006-1011 [Abstract] [Full Text]  
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• Gu, Y.L., Fokkema, M.L., Zijlstra, F. (2008). The Emerging Role of Thrombus Aspiration in the Management of Acute Myocardial Infarction. Circulation 118: 1780-1782 [Full Text]  
• Pell, J. P., Haw, S., Cobbe, S., Newby, D. E., Pell, A. C.H., Fischbacher, C., McConnachie, A., Pringle, S., Murdoch, D., Dunn, F., Oldroyd, K., MacIntyre, P., O'Rourke, B., Borland, W. (2008). Smoke-free Legislation and Hospitalizations for Acute Coronary Syndrome. NEJM 359: 482-491 [Abstract] [Full Text]  
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• Falk, E., Schwartz, S. M., Galis, Z. S., Rosenfeld, M. E. (2007). Putative Murine Models of Plaque Rupture. Arterioscler. Thromb. Vasc. Bio. 27: 969-972 [Full Text]  
• Schwartz, S. M., Galis, Z. S., Rosenfeld, M. E., Falk, E. (2007). Plaque Rupture in Humans and Mice. Arterioscler. Thromb. Vasc. Bio. 27: 705-713 [Abstract] [Full Text]  
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• Basso, C, Thiene, G (2006). The pathophysiology of myocardial reperfusion: a pathologist's perspective. Heart 92: 1559-1562 [Full Text]  
• Hemdahl, A.-L., Gabrielsen, A., Zhu, C., Eriksson, P., Hedin, U., Kastrup, J., Thoren, P., Hansson, G. K. (2006). Expression of Neutrophil Gelatinase-Associated Lipocalin in Atherosclerosis and Myocardial Infarction. Arterioscler. Thromb. Vasc. Bio. 26: 136-142 [Abstract] [Full Text]  
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• Wong, C-K, White, H D (2002). Relation between blood pressure after an acute coronary event and subsequent cardiovascular risk. Heart 88: 555-558 [Full Text]  
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• Wright, R. S., Murphy, J. G., Bybee, K. A., Kopecky, S. L., LaBlanche, J.-M. (2002). Statin Lipid-Lowering Therapy for Acute Myocardial Infarction and Unstable Angina: Efficacy and Mechanism of Benefit. Mayo Clin Proc. 77: 1085-1092 [Abstract]  
• Gonzalez-Conejero, R., Corral, J., Roldan, V., Martinez, C., Marin, F., Rivera, J., Iniesta, J. A., Lozano, M. L., Marco, P., Vicente, V. (2002). A common polymorphism in the annexin V Kozak sequence (-1C>T) increases translation efficiency and plasma levels of annexin V, and decreases the risk of myocardial infarction in young patients. Blood 100: 2081-2086 [Abstract] [Full Text]  
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• Mulvihill, N T, Foley, J B (2002). Inflammation in acute coronary syndromes. Heart 87: 201-204 [Abstract] [Full Text]  
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• KNIGHT, C. J (2001). National Institute for Clinical Excellence guidance: too NICE to glycoprotein IIb/IIIa inhibitors?. Heart 85: 481-483 [Full Text]  
• Newby, D. E., McLeod, A. L., Uren, N. G., Flint, L., Ludlam, C. A., Webb, D. J., Fox, K. A. A., Boon, N. A. (2001). Impaired Coronary Tissue Plasminogen Activator Release Is Associated With Coronary Atherosclerosis and Cigarette Smoking : Direct Link Between Endothelial Dysfunction and Atherothrombosis. Circulation 103: 1936-1941 [Abstract] [Full Text]  
• Rapaport, E. (2000). Erythrocyte sedimentation rate: is it a useful risk marker for coronary heart disease?. Eur Heart J 21: 1567-1569  
• HERITY, N. A (2000). Interleukin 6: a message from the heart. Heart 84: 9-10 [Full Text]  
• Fox, K. A A (2000). CORONARY DISEASE: Acute coronary syndromes: presentation---clinical spectrum and management. Heart 84: 93-93 [Full Text]