Sudden death from coronary artery disease in a 28-year-old munitions worker: An example of stenosing intimal proliferation as an exaggerated response to injury

A 28-year-old munitions worker died suddenly and unexpectedly early on a Monday morning. At autopsy, the major epicardial coronary arteries were diffusely and concentrically thickened, and the luminal cross-sectional area was reduced by at least 90%. Examination by light microscopy showed extensive intimal smooth muscle hyperplasia without atheroma formation. The intimal proliferation was similar to that reported in response to various forms of coronary artery injury, including balloon angioplasty, surgical endarterectomy, and chronic cardiac allograft vasculopathy. In addition, there was evidence of acute and chronic myocardial ischemia. The patientʹs only known risk factor for ischemic heart disease was occupational exposure to nitrates, in conjunction with lack of exposure on weekends. Although symptoms of myocardial ischemia in munitions employees are generally considered functional in origin (attributable to vasospasm), the findings in this case suggest that nitrates or, more accurately, repetitive nitrate withdrawal for several days at a time may also induce structural changes within coronary arteries.