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Acute circumferential subendocardial infarction
1Department of Pathology, Duke University Medical Center, Durham, North Carolina 27710.
Insights
A patient experienced worsening angina pectoris, progressing to myocardial necrosis despite coronary artery bypass surgery. Autopsy revealed severe three-vessel coronary artery disease, highlighting the critical nature of advanced atherosclerosis.
Area of Science:
- Cardiology
- Pathology
Background:
- Coronary artery disease (CAD) can progress asymptomatically.
- Angina pectoris is a symptom of myocardial ischemia due to CAD.
Observation:
- A 48-year-old man presented with exertional chest pain (angina pectoris).
- Symptoms progressed to "pre-infarct" angina, followed by myocardial necrosis.
- The patient underwent saphenous vein coronary artery bypass surgery but died postoperatively.
Findings:
- Autopsy confirmed severe three-vessel coronary artery disease.
- Myocardial changes consistent with global ischemia were observed.
- The case discusses differences between subendocardial and transmural infarcts and subendocardial hemorrhage.
Implications:
- This case underscores the severity of advanced coronary atherosclerosis.
- It highlights the risks associated with surgical intervention in end-stage CAD.
- Understanding infarct types and hemorrhage is crucial for diagnosis and treatment.
Abstract:
A 48-year-old black man had his first attack of chest pain on exertion, radiating to both arms, in December 1982 (angina pectoris). It was undoubtedly preceded by a period of asymptomatic coronary atherosclerosis of unknown duration. The first anginal attack was followed by three to four similar episodes over the next four months. The attacks became more prolonged, frequent, and severe thereafter (so-called "pre-infarct" angina), and six days later the patient showed signs of having developed actual myocardial necrosis. The patient underwent saphenous vein coronary artery bypass surgery but could not be weaned from the pump. He died late on the day of surgery. He was found at autopsy to have severe old three-vessel coronary artery disease with the myocardial changes that would be expected from the severe global ischemia to which this heart was undoubtedly subjected. Several basic and important differences between this sort of a circumferential subendocardial infarct and a transmural infarct are discussed, as is the basis for the striking subendocardial hemorrhage.