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You are watching: Why might a thrombus cause sudden death

StatPearls . Treasure Island (FL): StatPearls Publishing; 2021 Jan-.


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Continuing Education Activity

The pathogenesis of acute myocardial infarction (AMI) and also unsecure angina is the rupture of the coronary artery plaque bring about acute thrombotic occlusion of a coronary artery. Thus, the thrombus develops an integral component of the atherosclerotic coronary plaques. Tright here is a consensus that intracoronary thrombus provides up a daunting tarobtain for revascularization because of its distinctive characteristics. It has actually a vital affect on the performance and also outcome of the percutaneous coronary intervention (PCI). This activity reviews the cause and also presentation of coronary artery thrombus and highlights the duty of the interskilled team in its monitoring.

Objectives:
Describe the pathophysiology of coronary artery thrombus.
Rewatch the review of a patient with coronary artery thrombus.
Summarize the therapy choices for coronary artery thrombus.
Exordinary interexperienced team methods for enhancing care coordination and communication to breakthrough the management of coronary artery thrombi and boost outcomes.
Access free multiple alternative questions on this topic.


Introduction

Coronary artery thrombus occurs because of rupture or erosion of preexisting coronary artery plaque, leading to the artery"s complete occlusion. <1> It manifests clinically as an acute coronary syndrome, including ST-elevation MI, Non-ST elevation myocardial infarction, and unstable angina<2>. The coronary thrombus have the right to happen in both symptomatic and asymptomatic patients via substantial or less than 50% stenosis. Coronary thrombus is just one of the frequent reasons of sudden cardiac death<3><4>. The literature review reflects that coronary thrombus causes one-third of the sudden cardiac death, complete occluding the culprit artery on autopsy. The amount and duration of coronary thrombus play a vital duty in determining the prognosis of ACS patients. <5> The coronary thrombus has actually a critical impact on percutaneous coronary intervention"s performance and also outcome (PCI). <6> It is a solid predictor of PCI-induced major adverse coronary events, distal embolization, and stent thrombosis. <7> This chapter will certainly testimonial etiology, public health, pathophysiology, histopathology, background and physical examination, treatment, differential diagnosis, staging, and prognosis of coronary thrombus.


Etiology

The risk factors connected in coronary thrombus initiation incorporate cigarette smoking, diabetes mellitus, hyperanxiety, hyperlipidemia, tension, and family members history of atherosclerosis.


Epidemiology

Coronary thrombosis via acute myocardial infarction is a life-threatening problem and also connected with raised morbidity and also mortality around the world.<8> Coronary thrombus causes death in 200,000 persons a year in the United States, affecting males even more than females


Pathophysiology

Understanding the structure of thrombus and also its physical characteristics are necessary to make correct treatment selections in the revascularization of atherosclerotic lesions. <9> Following the rupture of the plaque"s fibrous cap, the internal necrotic core becomes exposed to the arterial luguys. This call of a highly thrombogenic subendothelial matrix with the circulating plateallows and also white blood cells activates the coagulation cascade. It activates the platelets and also promotes their adhesion and aggregation. Activated plateallows release strong mediators of vasoconstriction and aggregation prefer serotonin, adenosine diphosphate (ADP), thromboxane A2 (TXA2), and also endothelin, among others. The released tconcern element from the subendothelial matrix straight activates the extrinsic coagulation cascade and results in fibrin buildup. All this finally accumulates to develop a thrombus, which causes acute occlusion and also impaired distal circulation, with resultant clinical ischemic complications. <10> A thrombus comprises a conglomeprice of plateallows, red blood cells, vasoconstrictors, and procoagulant anchored to a scaffolding matrix of crisscrossing fibrin fibers. Two distinct forms of branching fibrin fibers exist. The thick, thin fibers withstand dedeveloping mechanical forces and are poorly disresolve by thrombolytic agents. Thick fibrin fibers are vulnerable to external mechanical forces and obtain dissolved by thrombolytic agents.<11><12>


Histopathology

A thrombus comprises a conglomerate of platelets, red blood cells, vasoconstrictors, and also procoagulant anchored to a scaffolding matrix of crisscrossing fibrin fibers. Two distinct kinds of branching fibrin fibers exist. The dense, thin fibers withstand decreating mechanical pressures and are poorly disdeal with by thrombolytic agents. Thick fibrin fibers are prone to exterior mechanical forces and acquire liquified by thrombolytic agents.<11><12>


History and Physical

The clinical features depend on the duration and also the severity of ischemia, depending upon whether the obstruction is wholly or partly occlusive, transient, or persistent. Coronary artery thrombus presents clinically as sudden cardiac arremainder or acute coronary syndrome. <13> The background may encompass chest pain, shortness of breath, and syncope. Sinus tachycardia is common in patients presenting with the acute coronary syndrome. <14> The patient might have actually hypostress as a result of low cardiac output and also a bad outcome predictor. Tachypnea deserve to occur as a result of congestive heart failure due to left ventricle dysfeature. <15>

On physical examicountry, the patient might have actually S4 gallop or S3 as a result of LV dysfeature. Heart murmurs of mitral regurgitation and ventricular septal rupture may existing, particularly in patients via delayed presentation. <16>


Evaluation

On laboratory tests, an elevated blood level of a cardiac enzyme (troponin)can happen in patients with coronary artery thrombus. Electrocardiogram show ST elevation in leads surveillance the artery containing thrombus. Several imaging modalities use for the diagnosis of intracoronary thrombus. Multiple researches have displayed the low sensitivity of angiography, although specificity ideologies 99-100% while making use of multiple angiographic views for confirmation. <17> Angiography continues to be the gold typical to identify thrombus, showing the timeless findings of diminished comparison density, staining, haziness, ircontinuous lesion contour, filling defects, or a smooth convex meniscus at the site of total thrombotic occlusion. Intravascular imaging can help in conditions where the presence of coronary thrombosis is not clear. Both IVUS (Intravascular Ultrasound) and also OCT (Optical coherence tomography) both have the right to detect intracoronary thrombus. However before, the sensitivity of OCT is much higher than IVUS for diagnosing intracoronary thrombus as compare to angioscopy. <18>


Treatment / Management

Treatment for coronary artery thrombus involves medicines and revascularization to boost myocardial perfusion. The maincontinue to be pharmacologic treatment for regulating thrombus-containing lesions contains aspirin, thienopyridines (clopidogrel, prasugrel, ticagrelor), and also unfractionated heparin. <19><20> But in the instance of persistent thrombus, drugs such as GP IIb/IIIa inhibitors and also vasodilators have the right to assist to enhance epicardial and myocardial blood flow. <21><22>

Percutaneous devices such as aspiration catheter and embolic protector decrease distal embolization and also enhance myocardial blood circulation and also clinical outcomes. <23><24> Aspiration catheter hand-operated target to lessen thrombus burden while the embolic protector tarobtain to capture the debris release throughout PCI.

Following the publication of several landmark research studies, a rekindled interest in mechanical thrombus extraction emerged, particularly for STEMI monitoring. One can categorize the modern mechanical thrombus removal or dissolution tools right into four major forms according to their activation mode: (1) hand-operated aspiration catheters, (2) power-sourced thrombectomy, (3) ultrasound-induced sonication, and (4) embolic protection.

Manual thrombus aspiration of the infarct-related vessel is a useful technique for the quick decrease in the thrombotic burden, avoiding the distal embolization of thrombus, preserving the microvascular integrity, and also reducing infarct size. Manual thrombectomy, therefore, boosts myocardial perfusion grade. TAPAS trial verified a mortality reduction, which led the guidelines to recommend program hand-operated aspiration. <25> However, the latest trials have presented no clear-cut advantage of routine manual aspiration in acute myocardial infarction. <26><27><26>

Increased thrombus burden might affect stent opposition, which can result in low TIMI flow and also poor outcomes. The ideal technique of primary percutaneous treatment in the establishing of coronary thrombus has actually been reported in the SINCERE database. <28> According to it, if the thrombus size is small, straight stenting might be adequate. If the thrombus burden is more, it is wise to perdevelop aspiration thrombectomy prior to stenting to minimize distal embolization and no-recirculation. If the thrombus burden is vast, then more aggressive thrombectomy tools such as Angio jet Rt are much better to rerelocate thrombus.


Differential Diagnosis

The differential diagnoses based on symptoms include pulmonary embolism, acute peptic ulcer, pericarditis, and herpes zoster.

The differential diagnoses based on angiography include coronary artery disarea, coronary calcification, and also no-reflow phenomenon.


Staging

Grading units are crucial for the adequate assessment of thrombus burden to help management decisions prior to and throughout interventions. The TIMI Study Group introduced the most commonly provided thrombus grading classification. Their strategy based on a visual angiographic assessment of the thrombus size using a score that ranges from grade 0 to grade 5. <29>


Grade 1: Possibility of thrombus on angiography, lessened thickness, haziness, irconsistent lesion contour
Grade 2: Definite thrombus, considerable filling defects, the biggest measurement is 1/2 of vessel diameter
Grade 3: Definite thrombus via the biggest measurement is better than 1/2 to less than 2 vessel diameter
Grade 4: Definite big thrombus via the biggest measurement is greater than 2 vessel diameter

Prognosis

The presence of coronary thrombus on angiogram is an adverse predictor connected through higher MACE (Major adverse cardiovascular events). <30> The coronary thrombus have the right to occlude the coronary artery and also its branches, resulting in an impairment of epicardial and also myocardial blood circulation. The thrombus dimension and consistency are likewise crucial prognostic markers of distal embolization. Multiple researches have presented that distal embolization is linked via an increase in mortality.

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Complications

Complications connected through coronary thrombus incorporate sudden cardiac fatality, congestive heart faitempt, and cardioembolic stroke.