Acute Coronary Events

In the United States alone, >400 000 Americans die annually of coronary artery disease, and >1 000 000 suffer acute coronary events, ie, myocardial infarction and sudden cardiac death.1 Considering the aging of our population and increasing incidence of diabetes mellitus and obesity, the morbidity from coronary artery disease and its associated costs will place an increasing, substantial burden on our society.2 Between 2010 and 2030, total direct medical costs spent in the United States for cardiovascular diseases are projected to triple from $273 billion to $818 billion.2 Although effective treatments are available and considerable efforts are ongoing to identify new strategies for the prevention of coronary events, predicting such events in an individual has been challenging.3 In hopes of improving our ability to determine the risk of coronary events, it is prudent to review our knowledge of factors that lead to acute coronary events.Coronary atherosclerosis is the underlying condition for coronary events with few exceptions. Events are rarely caused by coronary dissection, arteritis, myocardial bridging, thromboembolism, or coronary vasospasm without obvious coronary artery disease.4 In some of these instances, more sensitive tools for the detection of coronary artery disease revealed its presence after all.5 Coronary atherosclerosis is known to develop in childhood and adolescence, as evident from fatty streaks seen in pathology studies of individuals who died of trauma or other noncardiac causes.6 Depending on the constellation of genetic and environmental factors, coronary artery disease progresses throughout adulthood and is found in most middle-aged individuals in developed nations. Autopsy series in US communities among young adults (mean age, 36±14 years) who died of nonnatural causes revealed coronary atherosclerosis in >80% of the autopsy sample, with ≈8% having obstructive disease.7 Thus, most individuals ≥40 years of age in our society have …