Correspondence

Coronary-Plaque Rupture in Acute Coronary Syndromes Triggered by Snow Shoveling

N Engl J Med 1996; 335:2001-2002December 26, 1996

Article

To the Editor:

The acute coronary syndromes — myocardial infarction, unstable angina, and sudden cardiac death — have been shown to be triggered by heavy physical exertion, including snow shoveling,1 anger, and other types of emotional or physical stress.2 Although the underlying mechanism has been postulated to be rupture of a vulnerable coronary plaque and the development of intraluminal thrombus, such acute coronary changes have not been demonstrated in living patients.

During the blizzard and subsequent snowstorms that affected New Jersey in 1996, 19 patients (16 men and 3 women; mean age, 61 years [range, 40 to 78]; 9 with at least two risk factors for coronary artery disease and 3 others with known coronary artery disease) had acute chest pain, dyspnea, or both while shoveling snow or immediately thereafter. Acute myocardial infarction was diagnosed in nine patients (seven of whom received tissue plasminogen activator), unstable angina in six, and aortic dissection in two. Two patients had ventricular fibrillation on presentation and died. Coronary arteriography was performed in 16 patients within 72 hours of hospital admission. In all nine who had myocardial infarction and four of the six patients who had unstable angina, there was arteriographic evidence of rupture of a coronary plaque 3-5 (Figure 1Figure 1Coronary Arteriogram of the Proximal Right Coronary Artery, Showing Rupture of an Atherosclerotic Plaque (Arrows).); six patients also had intraluminal thrombus. In 12 patients the culprit artery was the only artery that was severely affected, but 4 patients had severe multivessel disease, including 2 who had vein-graft disease. One of the two patients with aortic dissection had normal coronary arteries; the other also had an acute myocardial infarction but did not undergo coronary angiography.

Coronary-plaque rupture, found in 13 (87 percent) of the 15 patients who had myocardial infarction or unstable angina, may be caused by the increases in arterial blood pressure, plasma catecholamines, vascular tone, and hypercoagulability associated with physical exertion. Aortic dissection, found in two of our patients, has also been associated with increased shear stress due to strenuous physical exertion, but it has not been related specifically to snow shoveling. The acute myocardial infarction in one of these patients may have been due to either the rupture of a coronary plaque or extension of the dissection to the coronary artery.

These findings indicate that acute coronary syndromes triggered by the heavy physical exertion of shoveling snow may be caused by acute rupture of a coronary atherosclerotic plaque. Aortic dissection is another potential complication of snow shoveling.

Ayman J. Hammoudeh, M.D.
Jacob I. Haft, M.D.
St. Michael's Medical Center, Newark, NJ 07102

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   Robert B. Nichols, William F. McIntyre, Salina Chan, David Scogstad-Stubbs, Wilma M. Hopman, Adrian Baranchuk. (2011) Snow-shoveling and the risk of acute coronary syndromes. Clinical Research in Cardiology
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   Jack M. Goodman, Scott G. Thomas, Jamie Burr. (2011) Evidence-based risk assessment and recommendations for exercise testing and physical activity clearance in apparently healthy individuals ^{1 1} This paper is one of a selection of papers published in this Special Issue, entitled Evidence-based risk assessment and recommendations for physical activity clearance, and has undergone the Journal’s usual peer review process.. Applied Physiology, Nutrition, and Metabolism 36:S1, S14-S32
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   Rajesh Janardhanan, Zachary Henry, David J. Hur, Christine M. Lin, David Lopez, Patrick M. Reagan, Sean R. Rudnick, Travis J. Koshko, Ellen C. Keeley. (2010) The Snow-Shoveler's ST Elevation Myocardial Infarction. The American Journal of Cardiology 106:4, 596-600
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   Jeremy S. Windsor, Jildou Van Der Kaaij, George W. Rodway, Rahul Mukherjee, Hugh E. Montgomery. (2009) Sudden Cardiac Death in the Mountain Environment. Medicina Sportiva 13:4, 197-202
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   Ayman J. Hammoudeh, Imad A. Alhaddad. (2009) Triggers and the Onset of Acute Myocardial Infarction. Cardiology in Review 17:6, 270-274
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   Susumu Sakurai, Akihiko Kitamura, Renzhe Cui, Kazumasa Yamagishi, Takeshi Tanigawa, Hiroyasu Iso. (2009) Relationships of Soluble E-Selectin and High-Sensitivity C-Reactive Protein with Carotid Atherosclerosis in Japanese Men. Journal of Atherosclerosis and Thrombosis 16:4, 339-345
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   &NA;. (2007) Exercise and Acute Cardiovascular Events. Medicine & Science in Sports & Exercise 39:5, 886-897
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    C Vyssier Belot. (1997) Consommation de tabac et risque cardiovasculaire. La Revue de Médecine Interne 18:9, 702-708
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11. 11

    (1997) More on Coronary-Plaque Rupture Triggered by Snow Shoveling. New England Journal of Medicine 336:23, 1678-1679
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