Out-of-hospital coronary heart disease death: acute pathological lesions.

BACKGROUND: The majority of deaths due to acute coronary heart disease (CHD) occur outside hospital, unexpectedly, within the first few hours following the onset of the terminal event. Data on the incidence and nature of acute pathological findings in the affected hearts as seen in routine autopsies are somewhat controversial. Detailed pathological examination of coronary arteries and myocardium of such decedents was performed to clarify the situation. METHODS AND RESULTS: Full autopsy and detailed macroscopic and microscopic examination of the coronary arteries and myocardium were performed in 170 men, all registered in the Kaunas Acute Myocardial Infarct Register, who died outside hospital of CHD within 6 hours from the onset of symptoms. Out-of-hospital coronary death was in all cases related to acute ischaemic myocardial lesions, either myocardial infarction (MI) in 92.9% of cases or patchy micronecrosis in 7.1%. In the former group, the following stages of acute infarction were found: early MI (hyperacute phase) in 48.8% of cases, definite MI (displaying grossly identifiable coagulative necrosis) in 21.8% and progressing MI (presence of signs of early MI adjacent to a healing infarction) in 22.3%. Signs of new thrombotic coronary events were found in relation to these acute ischaemic myocardial lesions in 88.8% of cases, as occlusive thrombus in 41.2%, non-occlusive, mural thrombus in 37.0% and microthrombi/microemboli in intramyocardial vessels in 10.6%. CONCLUSIONS: Out-of-hospital coronary death most commonly was related to the early or definite stages of myocardial infarction. Accurate identification of these acute ischaemic lesions was based on detailed microscopic examination of the entire ventricular myocardium, with consideration being paid to signs of cardiomyocyte involvement and early inflammatory reaction associated with it. Acute pathology of the affected coronary artery usually confirmed that these myocardial infarct lesions were the cause of the sudden out of-hospital CHD-related deaths.

[Changes of heart geometry in patients with ischemic heart disease]. / Serganciuju isemine sirdies liga sirdies geometrijos pokyciai.

OBJECTIVE: The aim of the study was to determine ventricular and atrial cardiometric parameters at preinfarction and postinfarction stage of ischemic heart disease. OBJECT AND METHODS: Cardiometric parameters (mass, endocardial surface area, the tracts of flow and outflow, etc.) of 132 men (mean age of 49.7+/-8.9 years) who had died suddenly during prehospital period (within 6 hours) after the first or repeated acute event of "pure" ischemic heart disease were investigated. These patients had no other, except ischemia, factors predisposing myocardial hypertrophy as well as clinical symptoms of heart failure. The decedents were divided into preinfarction (71 men) and postinfarction ischemic heart disease (61 men) groups. RESULTS: At preinfarction stage of ischemic heart disease, mass and endocardial surface area of all parts of the heart were increased, the tracts of flow and outflow--longer. At postinfarction stage, only corresponding left ventricular and atrial parameters were more increased. CONCLUSIONS: Eccentric type of left ventricular hypertrophy (proportional increase of mass and endocardial surface area) and concentric type of right ventricular and right and left atrial hypertrophy (the part of myocardium mass per unit of endocardial area is greater) were determined at preinfarction stage of ischemic heart disease. At postinfarction stage, at least as far as evidence of heart failure is not overt, only the corresponding left ventricular and atrial hypertrophy progresses.

Cardiomyocyte remodeling in ischemic heart disease.

OBJECTIVE: The aim of the study was to detect changes in left ventricular cardiomyocyte size and shape in response to chronic ischemia and loss of cardiac tissue (myocardial infarction) during the course of ischemic heart disease (IHD). MATERIAL AND METHODS: Left ventricular cardiomyocyte dimensions (diameter and length) were estimated histomorphometrically, and their cross-sectional area and volume were assessed in 85 males who died suddenly out of hospital (within 6 hours of the onset of the terminal event) due to the acute first (preinfarction IHD group, n=53, aged 48.6+/-2.9 years) or repeated (postinfarction IHD group, n=32, aged 51.7+/-2.9 years) IHD attack, and had no other causes for the increased heart load. Twenty-nine males of similar age (mean age, 46.0+/-3.1 years) who succumbed to external causes served as controls. RESULTS: We have found cardiomyocyte hypertrophy in the preinfarction IHD group already. The cardiomyocyte volume was increased by 32.0% in comparison with the same index in the control group, and cross-sectional area and length--by 17.2 and 12.5%, respectively. In postinfarction IHD group, all studied cardiomyocyte parameters did not differ significantly from the analogous indices in the preinfarction IHD group (P>0.05). Cardiomyocyte hypertrophy was related to the increase in left ventricular cardiomyocyte parameters. CONCLUSIONS: Left ventricular cardiomyocyte hypertrophy occurs before the first myocardial infarction. In postinfarction myocardium, cardiomyocyte dimensions do not differ significantly at least prior to the appearance of congestive heart failure syndrome.

[Ischemic heart disease: structural changes of the atria in preinfarction and postinfarction stages]. / Isemine sirdies liga: priesirdziu strukturos pokyciai ikiinfarktiniu ir poinfarktiniu laikotarpiais.

OBJECTIVE: The aim of this study was to determine atrial structural remodeling during the development of ischemic heart disease. MATERIAL AND METHODS: Quantitative histomorphometric parameters of interstitial collagen network (the percentage volume, perimeter, number of fibers per field and collagen-cardiomyocyte volume ratio) of the atria of 132 autopsied men (mean age 49.7+/-8.9 years) who had died suddenly (within 6 hours since the onset of terminal heart attack symptoms) due to the first (no postinfarction scars) and repeated (postinfarction scars present) acute "pure" ischemic heart disease were investigated. RESULTS: The main remodeling feature of the wall of the both atria among ischemic heart disease subjects is hypertrophy of cardiomyocytes and hyperplasia of interstitial fibrillar collagen network with the maintenance of the same proportion of contractile myocardium and fibrillar collagen network volume. This proportion in the case of the left atrium persists in both pre- and postinfarction ischemic heart disease groups, while myocardium of the right atrium in preinfarction group subjects is characterized by an excess increase of collagen network as compared to cardiomyocyte hypertrophy, which levels again with that of the control in postinfarction group. CONCLUSIONS: At preinfarction stage of ischemic heart disease, remodeling of both atria develops and progresses in the left atrium at postinfarction stage in the relationship with increase of left ventricular dysfunction.

[Fifty years of creative work (Society of Lithuanian Pathologists, 1954-2004)]. / Penkiasdesimt kurybos metu (Lietuvos patologu draugija, 1954-2004).

The article deals with the activity stages and forms of Society of Lithuanian Pathologists (in 1954-1991--Republic Scientific Society of Pathologoanatomists, in 1991-1996--Society of Lithuanian Pathologoanatomists). Founder of the Society and the first President (in 1954-1976) was prof. Janina Mackevicaite-Lasiene, in 1976-1996--prof. Elena Stalioraityte and since 1996 up till now--prof. Dalia Pangonyte. Taking into account the needs of medical research and practice, its activities varied. According to the tasks there are 4 stages of Society activity. The first--establishment of pathological practice, introduction into clinic and pathological practice of pathogenetic and nosologic diagnosis; the second--consolidation and development of pathological practice, conveyance of pathology knowledge, optimization of pathology teaching and training of specialists; the third--reforming of Society and pathological practice, widening of international relations; the fourth--introduction of recent methods and information technologies in pathological practice and teaching. The Society has organized ten republic conference and two congresses, four school-seminars, its members published 19 monographs and collections of articles, 6 textbooks, 28 learning books, 26 methodical recommendations, more than fifty members acquired academic degree.

[Reliability of data of death causes: comparison of premortem and verified by autopsy postmortem diagnoses]. / Mirties priezasciu duomenu tikrumas: priesmirtines ir pomirtines, verifikuotos autopsija, diagnoziu palyginimas.

OBJECTIVE: The goal of the investigation was to evaluate the accuracy of medical diagnostics of death causes. MATERIAL AND METHODS: In the framework of population-based postmortem examination program the latest premortem and postmortem diagnoses of the underlying (principal disease), direct (lethal complication) and contributory (contributory pathology) causes of death of 1030 deceased and autopsied people of local randomized unit (Jonava district) autopsy study were compared. RESULTS: The discrepancy between premortem and postmortem diagnoses was 35.3% in the category "circulatory system diseases", 26.5% in the category "malignant neoplasms", 41.1% in the category "lethal complications", and more than 50% in the category "contributory pathology". CONCLUSIONS: The accuracy of data on underlying death cause is significantly limited due to overstating of circulatory system diseases, especially ischemic heart disease and understating of malignancies. Among mismatches in lethal complication cases more significant for outcome of disease were pneumonia and embolism of lung arteries, in contributory pathology--chronic bronchitis and ischemic heart disease.

[Pathobiological determinants of atherosclerosis in youths: data from a macromorphometric and histomorphometric investigation of the aorta and coronary arteries]. / Patobiologiniai jaunu zmoniu aterosklerozes determinantai: makromorfometrinio ir histomorfometrinio arteriju tyrimo duomenys.

We present a review of data from epidemiological and morphological studies carried out in Kaunas of atherosclerosis in youths. Since 1985, Kaunas has been a Collaborating Center involved with the World Health Organization and International Society and Federation of Cardiology studying the pathobiological determinants of atherosclerosis in youth. During the pilot study (1985-1987), we estimated the prevalence and extent of atherosclerotic lesions in the aorta and coronary arteries correlated to various risk factors in Kaunas residents aged 5 to 44 years. Within the framework of this international study, we compared histomorphometric characteristics of arteries collected from trauma victims aged 5 to 34 years in Budapest (Hungary), Heidelberg (Germany), Kaunas (Lithuania), Yaounde (Cameroon), and Mexico City (Mexico). These data revealed that males from countries with a high mortality from ischemic heart disease (Hungary, Lithuania, Germany) tended to have thicker intima in the thoracic and abdominal aorta and left anterior descending coronary artery than did males from countries with low mortality from ischemic heart disease (Mexico, Cameroon). We detected an increased mean intimal thickness of the abdominal aorta in male smokers aged 25-34 years. Males with hypertension aged 15-24 and 25-34 years had a thicker intima in the aorta and left anterior descending coronary artery than normotensive males. The morphological and epidemiological studies of atherosclerosis in youths carried out in Kaunas demonstrated that aortic and coronary atherosclerotic lesions appeared as early as childhood and advanced until the lesions become clinically apparent in adulthood. Histomorphometric findings support the postulate that increased intimal thickness can be considered a structural determinant of atherogenesis. These data draw attention to the means for the primary prevention of atherosclerosis in youth.

[Myocardial pathology in sudden ischemic death: peculiarities of morphologic diagnosis]. / Nuo isemines sirdies ligos staiga mirusiuju miokardo patologija: morfologines diagnostikos ypatybes.

OBJECTIVE: The aim of the investigation was to determine morphological criteria of acute myocardial injures in sudden ischemic death. MATERIAL AND METHODS: Morphological investigation of the whole myocardium and coronary arteries in 170 victims of sudden out-of-hospital death due to ischemic heart disease was performed in the framework of the international WHO program "Myocardial Infarction Register in Population" and joint (at that time) USSR-USA project on sudden death. RESULTS: It was established, that out-of-hospital sudden death due to ischemic heart disease in all cases is related to irreversible myocardial injury: 92.9% - to acute myocardial infarction, and 7.1% - to micronecrosis. The following phases of morphological development of infarction were determined: early myocardial infarction--in 48.8, definite--in 21.8, and progressing--in 22.3%. Since the signs of early infarction were also found in 34 cases of progressing myocardial infarction, it was reasonable to suppose that in 117 (71.1%) patients the occurrence of sudden out-of-hospital death due to ischemic heart disease was somehow connected with the very early and early phases of acute myocardial infarction. CONCLUSIONS: Accurate identification of early myocardial infarction is available only by microscopic investigation of histotopograms of the whole myocardium considering the complex of signs of cardiomyocyte alteration as well as early inflammatory reaction. Acute pathology (erosion or rupture of atherosclerotic plaque and thrombosis) of "culprit" coronary artery indirectly indicates regional myocardial irreversible injury.

[Results of morphologic epidemiologic study of coronary arteries in Kaunas population aged 20-69 years: atherosclerotic lesions and their interrelationship]. / 20-69 metu Kauno gyventoju sirdies vainikiniu arteriju morfologinio epidemiologinio tyrimo duomenys: ateroskleroziniai pazeidimai ir ju sasaja.

OBJECTIVE: The object of study was the type, frequency and extent, as well as correlation of atherosclerotic lesions in Kaunas population aged 20-69 years. RESULTS: The frequency and intimal area of raised atherosclerotic lesions (fibrous and complicated plaque and calcinosis) are age-dependent. The increase of raised lesions area seems to alter at different decades of life. In men the most substantial progression in left anterior descending artery was observed at the fourth-fifth, in right coronary artery--at the fifth, and in both arteries of women - at the sixth decade of life. The area of fatty streaks is not dependent on age and comprises approximately 4-5% of intimal surface. We observed weak negative correlation between area of raised lesions and fatty streaks, and strong correlation between the area of all type of raised lesions in all three coronary arteries. CONCLUSIONS: The coronary artery atherosclerosis is progressing with age. Age decades, when increase of raised lesion area is observed, correspond to age periods, in which mortality due to ischemic heart disease increases significantly.

[Trends in the development of atherosclerosis in Kaunas population]. / Kauno gyventoju aterosklerozes raidos tendencijos.

The trends of development of atherosclerosis were evaluated by comparing the epidemiological morphological data from the seventh decade (first study, 1962-1965) and the tenth decade (second study, 1991-1993) of the 20th century. The first study included arteries from 818 patients (422 men and 396 women); whereas the second study included arteries from 1252 patients (958 men and 294 women). We have observed an age-independent increase in frequency and extent of the raised atherosclerotic lesions in aortas and coronary arteries of Kaunas men in the second study. Thus, the atherosclerosis has become more severe. The trends of development of atherosclerosis in aortas of Kaunas women were similar to those of men, but the atherosclerosis of coronary arteries did not progress until the fifth decade of life (the frequency of fibrous plaques in the left anterior descending artery was even lower, p < 0.05), and the area of raised lesions became larger only in the sixth-seventh decades. During the latter 20-30 years, the area of raised atherosclerotic lesions of abdominal aortas also increased in men in Riga, Tallinn, Tartu, Yalta, and elder men in Malmö as well as in Kaunas and Malmö women, aged 40-59.