A specific search for intramyocardial platelet aggregates was made in 90 patients who died suddenly of ischemic heart disease. Platelet aggregates in small intramyocardial vessels were found in 27 (30%). There was a significant difference (p < .05) in the incidence of platelet aggregates in patients with chest pain of recent onset (unstable angina) before death (16/36, 44.4%) and that in those without it (1 1/54, 20.4%). Multifocal microscopic necrosis with involvement of the full thickness of the ventricular wall, including the subpericardial zone, was significantly more common (p = < .005) in the patients with platelet emboli (55.6% vs 12.7%). With one exception, aggregates were confined to the segment of myocardium immediately downstream of a major epicardial coronary artery containing an atheromatous plaque that had undergone fissuring and on which mural thrombus had developed. The results support the view that platelet aggregates in the myocardium represent an embolic phenomenon and are a potential cause of unstable angina. The association of myocardial necrosis with such emboli could precipitate sudden death from ventricular fibrillation. Circulation 73, No. 3, 418-427, 1986. WHEN PATIENTS with stable and unstable angina are compared the degree and distribution of stenosis is similar, but unstable angina is associated with stenotic lesions that have a characteristic angiographic morphology.' These type II lesions have morphologic features, including an irregular outline and the presence of intraluminal filling defects outlined by contrast medium,2 that are observed on postmortem angiograms.3'4 Under these circumstances histologic examination reveals atheromatous plaques that have undergone fissuring, rupture, or ulceration and over which nonocclusive (mural) thrombus has formed.When thrombus projects into, but does not totally occlude, the lumen of an artery, there is the potential for emboli to pass distally into the segment of myocardium supplied by that artery. Such embolization has been postulated to be responsible for the crescendo
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