Correspondence

More on Coronary-Plaque Rupture Triggered by Snow Shoveling

N Engl J Med 1997; 336:1678-1679June 5, 1997

Article

To the Editor:

Hammoudeh and Haft (Dec. 26 issue)1 report on 15 patients in whom acute coronary syndromes developed during or immediately after shoveling snow. They suggest that evidence of rupture of coronary plaque and acute thrombosis associated with physical exertion has not previously been observed in living patients. On the contrary, Ciampricotti et al., using coronary angiography, found irregular coronary lesions “consistent with” plaque rupture in 8 of 13 patients who had a myocardial infarction or cardiac arrest within an hour of vigorous athletic activity.2

Furthermore, in 1975 Black et al. reported autopsy, angiographic, or clinical evidence of acute plaque rupture in 13 patients with acute coronary syndromes related to vigorous exertion.3 In what now reads as a very clairvoyant discussion, Black et al. suggested that the increased “twisting and bending” of coronary arteries during vigorous exertion increased the frequency of plaque rupture and that “Black's crack in the plaque” was responsible for most exertion-related acute coronary events. Once again we are reminded that what seems new in medicine is often a rediscovery of what we knew, but forgot.

Paul D. Thompson, M.D.
University of Pittsburgh Medical Center, Pittsburgh, PA 15213-2582

3 References

1. 1

   Hammoudeh AJ, Haft JI. Coronary-plaque rupture in acute coronary syndromes triggered by snow shoveling. N Engl J Med 1996;335:2001-2001
   Full Text | Web of Science | Medline

2. 2

   Ciampricotti R, el Gamal MI, Bonnier JJ, Relik TH. Myocardial infarction and sudden death after sport: acute coronary angiographic findings. Cathet Cardiovasc Diagn 1989;17:193-197
   CrossRef | Medline

3. 3

   Black A, Black MM, Gensini G. Exertion and acute coronary artery injury. Angiology 1975;26:759-783
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: The purpose of our report was to draw attention to the fact that the acute coronary syndromes associated with the common activity of shoveling snow occur by means of plaque rupture. Men and women in the age group that places them at increased risk of coronary events should be warned against shoveling snow and, if this activity is unavoidable, they should lift only small amounts of snow at a time and should take seriously any chest discomfort, persistent shortness of breath, weakness, or excessive diaphoresis and seek help immediately.

The concept that the rupture of plaque in a coronary artery can cause myocardial infarction has been with us for some time,1 but its importance and frequency have been appreciated only since modern high-resolution coronary arteriography became available.2 Black et al.3 reported on 13 patients who had myocardial infarction associated with exertion. Of the nine patients who died, all five examined at autopsy had ruptured plaques. The one patient with a patent culprit vessel among the four who underwent coronary arteriography had an ulcerated plaque. Ciampricotti et al.4 presented coronary arteriographic evidence of plaque rupture in 8 of the 13 seasoned amateur athletes who died suddenly (6 patients) or had myocardial infarction during or shortly after athletic activity in which they regularly engaged.

Our patients were all sedentary and unaccustomed to sudden, vigorous exertion, as are most people who shovel snow. As with many pathophysiologic phenomena that originally appear to be rare, plaque rupture is emerging as the common mechanism in triggered myocardial infarction and other acute coronary events.

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

4 References

1. 1

   Daoud AS, Jarmolych J, Jakovic LG, Rosenberg AA, Hedberg RF. Possible relationship of coronary thrombosis and rupture of arteriosclerotic plaque. Lab Invest 1963;12:863-863
   Web of Science

2. 2

   Ambrose JA, Winters SL, Arora RR, et al. Coronary angiographic morphology in myocardial infarction: a link between the pathogenesis of unstable angina and myocardial infarction. J Am Coll Cardiol 1985;6:1233-1238
   CrossRef | Web of Science | Medline

3. 3

   Black A, Black MM, Gensini G. Exertion and acute coronary artery injury. Angiology 1975;26:759-783
   CrossRef | Web of Science | Medline

4. 4

   Ciampricotti R, el Gamal MI, Bonnier JJ, Relik TH. Myocardial infarction and sudden death after sport: acute coronary angiographic findings. Cathet Cardiovasc Diagn 1989;17:193-197
   CrossRef | Medline