Burke A P, Farb A, Malcom G T, Liang Y, Smialek J, Virmani R
Department of Cardiovascular Pathology, Armed Forces Institute of Pathology, Washington, DC 20306-6000, USA.
Circulation. 1998 Jun 2;97(21):2110-6. doi: 10.1161/01.cir.97.21.2110.
Traditional risk factors have been linked to atherosclerotic heart disease in women. However, the effect of risk factors and menopausal status on the mechanism of sudden coronary death is unknown.
We examined 51 cases of sudden coronary death and 15 hearts from women who died of trauma. Coronary deaths were divided into four mechanisms of death: ruptured plaque with acute thrombus (n = 8), eroded plaque with acute thrombus (n = 18), stable plaque with healed infarct (n = 18), and stable plaque without infarction (n = 7). Vulnerable plaques prone to rupture were defined as those with a thin, fibrous cap infiltrated by macrophages and were quantitated in coronary deaths and control subjects. Total cholesterol (TC), HDL cholesterol, glycosylated hemoglobin, cigarette smoking, and hypertension were determined in each case. Compared with control subjects, women with plaque ruptures had elevated TC (270 +/- 55 versus 194 +/- 44 mg/dL, P = 0.002), and those with erosions were more likely to be smokers (78% versus 33%, P = 0.01). Women with stable plaque and healed infarct had elevated glycosylated hemoglobin (10.2 +/- 5.0% versus 6.4 +/- 0.4% in control subjects, P = 0.001) and were more likely to be hypertensive (50% versus 15% in control subjects, P = 0.03). By multivariate analysis, cigarette smoking was associated with plaque erosion (P = 0.03, odds ratio [OR] 21), glycoslyated hemoglobin with stable plaque and healed infarct (P = 0.03, OR 41), TC with plaque rupture (P = 0.02, OR 7), and hypertension with stable plaque with healed infarct (P = 0.02, OR 15). Seven of 8 plaque ruptures occurred in women > 50 years of age versus 3 of 18 erosions (P = 0.001). In cases of coronary death, vulnerable plaques were associated with elevated cholesterol (P = 0.002) and age > 50 years (P = 0.002), independent of other risk factors.
In women, traditional risk factors have distinct effects on the mechanisms of sudden coronary death, which vary by menopausal status. Effective risk factor modification may therefore differ between younger and older women and may be targeting different mechanisms of plaque instability.
传统危险因素已被证实与女性动脉粥样硬化性心脏病相关。然而，危险因素和绝经状态对冠心病猝死机制的影响尚不清楚。
我们研究了51例冠心病猝死病例以及15例因外伤死亡女性的心脏。冠心病死亡被分为四种死亡机制：斑块破裂伴急性血栓形成（n = 8）、斑块侵蚀伴急性血栓形成（n = 18）、稳定斑块伴陈旧性梗死（n = 18）以及稳定斑块无梗死（n = 7）。易于破裂的易损斑块定义为具有薄纤维帽且有巨噬细胞浸润的斑块，并在冠心病死亡病例和对照受试者中进行定量分析。测定了每个病例的总胆固醇（TC）、高密度脂蛋白胆固醇、糖化血红蛋白、吸烟情况和高血压情况。与对照受试者相比，斑块破裂的女性TC升高（270±55对194±44mg/dL，P = 0.002），而斑块侵蚀的女性更可能吸烟（78%对33%，P = 0.01）。有稳定斑块和陈旧性梗死的女性糖化血红蛋白升高（10.2±5.0%对对照受试者的6.4±0.4%，P = 0.001），且更可能患高血压（50%对对照受试者的15%，P = 0.03）。多因素分析显示，吸烟与斑块侵蚀相关（P = 0.03，比值比[OR]21），糖化血红蛋白与稳定斑块和陈旧性梗死相关（P = 0.03，OR 41），TC与斑块破裂相关（P = 0.02，OR 7），高血压与稳定斑块和陈旧性梗死相关（P = 0.02，OR 15）。8例斑块破裂中有7例发生在年龄>50岁的女性，而18例斑块侵蚀中有3例（P = 0.001）。在冠心病死亡病例中，易损斑块与胆固醇升高（P = 0.002）和年龄>50岁（P = 0.002）相关，独立于其他危险因素。
在女性中，传统危险因素对冠心病猝死机制有不同影响，且因绝经状态而异。因此，年轻和老年女性有效的危险因素干预可能不同，可能针对不同的斑块不稳定机制。
