Small coronary vessel disease and sudden coronary death

In an attempt to determine the importance of atherosclerosis in medium-sized coronary arteries, the hearts of 20 patients dying of cardiac disease, within 24 hours of the onset of symptoms, were compared with 19 controls. Post-mortem coronary angiograms were performed and the coronary arteries dissected in detail. Severe stenoses, or complete occlusions, were present in 34 of 80 major coronary arteries in the sudden cardiac death (SCD) group and 5 of 76 in the controls. Medium-sized branch vessels were severely stenosed or occluded in 20.5 per cent (37 of 180 vessels) in the SCD group and 6.4 per cent (11 of 171 vessels) in the controls. Forty of the 48 diseased branch vessels arose from the left anterior descending artery. In the SCD group, 18 patients died from major coronary artery atheroma, one from hypertensive heart disease and only one from disease of a branch vessel. We conclude that, in most cases of SCD, careful macroscopic examination of the major coronary vessels will provide an adequate explanation for death. Detailed dissection of all medium-sized branch vessels is unlikely to be of value as a routine procedure but, at the very least, pathologists should identify and dissect the first septal and diagonal branches of the left anterior descending artery in every post-mortem.