The kind of plaque that underlies a coronary thrombus

The life span of the human species is about 70 years. The evolutionary strategy used by the species to attain this unusually long life span was not to avoid all coronary plaque formation, but rather to live a long time with coronary plaques in place. Only a rare kind of coronary plaque is thrombogenic and, therefore, fatal in young people. In a forensic service, the author has repeatedly encountered cases of sudden death in men under age 40 wherein a tiny, pale nonocclusive thrombus over a focal plaque was determined to be the cause of death. The histology of these plaques was consistently different from the commonplace innocuous plaques in older subjects. The thrombogenic plaque was marked by the triad: 1) cell-rich, bulky fibrous cap and base accompanying atheronecrosis, 2) phagocytosis in the necrosis-base boundary, and 3) adventitial inflammation. Atheronecrotic bases were commonplace in most innocuous plaques as well as universal in thrombogenic ones. These matters have not been subjected to systematic objective confirmation, and are offered here as hypotheses.