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Unstable angina, myocardial infarction and sudden death after an exercise stress test
1Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands.
Insights
Physical exercise can trigger acute coronary events, even with normal or minimally obstructed arteries. This may be due to exercise-induced plaque rupture leading to coronary occlusion.
Area of Science:
- Cardiology
- Exercise Physiology
Background:
- Exercise stress tests are commonly used to evaluate for coronary artery disease.
- Normal or minimally obstructive coronary arterial disease is typically considered low risk.
Observation:
- Seven patients experienced acute coronary events shortly after a normal exercise stress test.
- Six of these patients had normal stress test results.
- Previous angiography in four patients showed no significant obstructive coronary arterial disease.
Findings:
- Acute coronary events included unstable angina, myocardial infarction, and ventricular fibrillation.
- Coronary angiography revealed occluded or sub-totally obstructed arteries in all patients.
- Plaque rupture, thrombosis, and vasospasm were identified as mechanisms of coronary occlusion.
Implications:
- Physical exercise can precipitate severe coronary events in individuals with seemingly normal or minimally diseased coronary arteries.
- Exercise-induced plaque rupture is a likely mechanism for acute coronary occlusion.
- These findings challenge the interpretation of normal stress tests in certain contexts and highlight the risk of plaque instability.
Abstract:
We performed coronary angiography within 95 minutes of the onset of symptoms in seven patients with an acute coronary event after an exercise stress test. The test was normal in six patients. Previous angiography in four patients revealed no evident or moderate obstructive coronary arterial disease. After the test, unstable angina developed in two patients, acute myocardial infarction in four and ventricular fibrillation in one, who was successfully resuscitated. At acute angiography the coronary artery involved was occluded in four and sub-totally obstructed in three. In three cases, coronary occlusion was due to thrombosis, vasospasm, or both. In six vessels there was an eccentric lesion, which is consistent with a ruptured plaque. These findings show that physical exercise can unexpectedly provoke an acute coronary event with sub-total or total occlusion of a previous angiographically normal or moderately obstructed coronary artery. The mechanism is probably related to exercise-induced plaque rupture which can produce coronary (sub)occlusion by coronary thrombosis, spasm, or both.