Coronary Thrombosis Theory of Heart Attacks: Science or Creed?
The thrombogenic theory, that advocates the myocardial infarction as consequence of coronary thrombosis, was introduced by the American Dr. James Bryan Herrick in 1912, being entrenched worldwide in the medical culture in spite of important clinical, pathological and cardiac images studies showing discrepancies in their findings, basically conflicting with the conceived pathophysiology for this theory.
Myocardial Infarction: Credit to med.utah.edu
It is interesting to notice that Herrick in his classic paper have written about his therapeutic experience praising the use of digitalis and strophanthin for angina and in the event of coronary thrombosis, with the hope for the damaged myocardium in the direction of securing a supply of blood through friendly neighbouring vessels, so as to restore so far as possible its functional integrity. He also said that the timely use of this remedy may occasionally in such cases save live and quick results should also be thought by using it hypodermically or intravenously. Herrick’s thrombogenic theory was adopted, but his therapeutic conduct was forgotten.
The Failure of Anticoagulants
The introduction of anticoagulants - coumadin derivatives and heparin - started in 1944 with the great hope that these specific and logic agents could avoid the myocardial infarction as occurred in the prevention and in the treatment of thrombophlebitis processes. Allen B Weisse, discussing about the controversies over coronary thrombosis in myocardial infarction, said in his paper from 2006:
“Initial efforts to apply anticoagulant therapy early in the treatment of acute myocardial infarction and then long- term did not serve to further the cause of the coronary thrombosis hypothesis. In addition to some flaws in study design (e.g. failure to achieve true randomization in the selection of treatment and control groups), trials of anticoagulation for acute myocardial infarction were not very encouraging; any improvement in survival statistics were more likely due to prevention of thromboembolic complications (e.g. fatal pulmonary embolism) than in the treatment of the offending coronary artery thrombus itself, and the risk of bleeding sometimes life-threatening, was another consideration.
“In retrospect, such findings could have been expected. The early agents used for anticoagulation, coumadin derivatives, and later heparin, while preventing clot formation, have no effect of dissolving thrombi once formed. However, long-term studies using these agents following an initial myocardial infarction were similar disappointing in preventing recurrences”
Studies claiming about the failure of the anticoagulant use for the treatment or prevention of acute myocardial infarction were presented in 1969-1970 through the publication of reports in important medical journals like the British Medical Journal, American Medical Association Journal, Lancet, etc. [4,5,6,7]
However, some groups still using anticoagulants in acute coronary syndromes. An important study published in 2008 found that compared to placebo, patients treated with heparins had similar risk of mortality, revascularization, recurrent angina, major bleeding and thrombocytopenia.
The Failure of Thrombolysis
David K Cundiff, in a review in 2002, said the proof of efficacy of thrombolysis for acute myocardial infarction depends on 9 randomized placebo-controlled trials totalling 58,511 patients. The meta-analysis of these trials showed an overall survival advantage of 2% (11.5% vs 9.6%) in favour of thrombolysis. Iatrogenic deaths from thrombolysis complications occur in about 1% of AMI patients.
Incidentally, studies also have shown the failure of thrombolytics in restraining unstable angina pectoris. Bar and colleagues expressed about the matter: “Angiographic but no clinical improvement after thrombolytic treatment with anistreplase was found in patients with unstable angina with an excess of bleeding complications. Therefore, thrombolytic treatment cannot be recommended in patients diagnosed as having unstable angina until proven otherwise.”[10 - 15]
Myocardial Reperfusion Injury
On the other hand, in patients with myocardial infarction (MI), the current treatment of choice for reducing acute myocardial ischemic injury and limiting MI size is the use of myocardial reperfusion either with thrombolytic therapy, primary percutaneous coronary intervention or coronary bypass surgery. However, the process of reperfusion can itself induce cardiomyocyte death (minor infarction/infarctlet), known as myocardial reperfusion injury, for which there is still no effective therapy.  These myocardial infarctlets may lead to an adverse long-term prognosis, and particularly to an increase in late mortality.
The Dogmatism on Coronary Thrombosis as the Cause of Myocardial Infarction
Allen B Weisse also told in his paper about the low occurrence of coronary occlusion related with the myocardial infarction, found in many studies. He said:
“Although the later studies indicated a higher percentage of thrombosis found, the number of studies performed almost contemporaneously by equally respected and competent researchers and showing much lower percentages of coronary thrombi in acute myocardial infarction was disturbing. Also of important among some of these researchers was the belief that coronary thrombosis might have occurred as the result of the myocardial infarction and not the other way around.”
Weisse noticed that in 1973 at the National Heart and Lung Institute of the National Institutes of Health in Bethesda, Maryland, a workshop was convened in which the various investigators who had grappled with the problem discussed their views.
About this meeting he said that “attempts were made to reconcile the discordant findings among different groups of investigators, noting the integral relations between the alterations in the artery wall (i.e. atheroma) and thromboses that had been reported in the past. However, the end result, for the most part, consisted of a restatement of positions previously held. Although the joint conclusion emphasized the importance of coronary thrombosis, it also concluded that the idea that coronary thrombosis was a secondary event, following the infarction, was provocative and deserved serious consideration.”
In Weisse’s point of view the role of coronary thrombosis in acute myocardial infarction was resolved, once for all, through a study from Marcus DeWood and colleagues published in 1980. This study involved 322 patients, all studied by coronary arteriography. The patients studied within 4 hours of the event's onset 87 percent demonstrated an occluding coronary artery thrombus on angiography. Among those studied 12 to 24 hours after the onset of symptoms, there was a decline in the frequency of thrombi, 65 percent, evidence according to Weisse showing that soon after formation coronary thrombi begin to undergo lysis. He stated that this supported the contention that among those post-mortem studies previously performed in patients who died several days after their infarction, thrombi would be reduced in size (non-occluding) or absent.
The prevalence of total coronary occlusion during the early hours in patients presenting with transmural infarction by means of coronary arteriography, found by DeWood and colleagues, was accepted peacefully by the large majority of the cardiological community as the definitive clinical evidence about the causal role of thrombosis in acute myocardial infarction (AMI). It also brought some relief in this area by keeping intact the medical options and directions dictated by the Mainstream and thus passing over necropsy findings and other pathological studies contradicting the coronary thrombosis concept.
Then, the voice of dissenters advocating coronary thrombosis as consequence of myocardial infarction has been mostly lost since the eighties, due to the mainstream discourse in favour of the coronary thrombosis theory as cause of myocardial infarction.
Even thus the acute myocardial infarction occurring in the absence of obstructive coronary artery disease (CAD), still generating questions as occurred in 2016 through a position of a working group from the European Heart Journal. Some of their questions are: “What is the mechanism of the myocardial damage in these patients?” and “Do these patients differ from those with obstructive CAD?”
Coronary Thrombosis: Cause or Consequence of Myocardial Infarction?
Taking in view the controversies already mentioned and the results obtained in the study by Marcus DeWood and colleagues we present here old and new pathological studies aside critical reasoning about coronary thrombosis as the cause of myocardial infarction:
a. Friedberg and Horn suggested in 1939 that the term coronary thrombosis should be abandoned in favour of the more generic one of acute myocardial infarction. In their paper they say that “the clinical and electrocardiographic features of coronary thrombosis may be observed in patients in whom a coronary artery thrombus is subsequently not found at necropsy as has been noted by Libman, Obendorfer, Buchner, Hamburger and Saphir, Dietrich, Levy and Bruenn and others;”
b. Hermann and colleagues published in 1941 their findings that the thrombotic occlusion could occur without infarction when the collateral circulation appeared adequate and if an infarct has happened, it could be attributed to an occlusive thrombus at a critical location in the coronary tree;[22-24]
c. Miller and colleagues in 1951 pointed out that subendocardial infarcts were rarely associated with coronary thrombi;
d. Spain and Bradess published in 1960 their findings showing complete coronary obstruction of atherosclerotic nature, representing around of 75% of the cases and recent coronary thrombosis in just 25% of the autopsied cases. Also, they have observed crescent incidence of coronary thrombosis with the crescent duration of survival after the myocardial infarction. Less than a hour with 16% of thrombosis, between 1 and 24 hours with 37% and in more than 24 hours with 52% of coronary thrombosis*;[26,27]
e. Hellstrom in 1970 demonstrated experimentally the coronary thrombosis secondary to acute myocardial infarction caused by ligature of the coronary artery;
f. William Roberts suggested in 1972 that the coronary arterial thrombi are consequences rather than causes of acute myocardial infarction. In his study involving 107 patients who were submitted to necropsy he found that only 54% of those with a transmural infarction, and only 10% of those with subendocardial necrosis, had a thrombus in the infarct related artery; 
g. Quintiliano H. de Mesquita pointed out in 1996 that the interpretation given by DeWood in 1980  about the angiographic images, suggestive of intracoronary thrombus, do not correspond to the absolute reality whether it represents a true thrombus or just aggregated platelets that are precocious, unstable or reversible commonly registered in the first hours of unstable angina and in the course of the acute myocardial infarction;
h. Giorgio Baroldi and colleagues in a study from 2005, discussing the findings from DeWood, told that the first main question is how many of the 87% cineangio occlusion are pseudo-occlusion and whether the "layered" thrombus recovered at bypass surgery was a true thrombus or a coagulum which frequently show a layering of blood elements not seen in thrombus formation. Also saying that "Red" thrombus, namely a coagulum, is frequently and erroneously considered as thrombus;
i. Giorgio Baroldi and colleagues in a study published in 2005 discussed about the findings that the frequency of an occlusive thrombus is significantly higher in the largest infarcts supporting its secondary formation;[32,33]
j. In a study from 2001 Yasunori Ueda and colleagues show that in a significant number of cases angioscopic examination continues to find thrombus on the presumed culprit lesion, at 6 months after myocardial infarction;
k. Murakami in a study published in 1998 using intracoronary catheters to aspirate occlusive tissues, performed during the acute myocardial infarction, have confirmed the pathological findings that intracoronary thrombus is absent in a substantial number of patients indicating it contributes little to the pathogenesis of average acute myocardial infarction;
l. Rittersma and colleagues in a study published in 2005 examined retrieved thrombus material aspirated using the percutaneous thrombectomy catheter in 211 patients undergoing primary percutaneous coronary intervention within six hours of symptom onset. They then established, by histological indicators, the age of the aspirated thrombi. The researchers found thrombus in 199 of the 211 patients, of whom fresh thrombus was identified in just under half. By contrast, 51% of patient samples contained thrombus that had lytic or organized changes suggesting that it had originated days or weeks before the occlusive event. They said that “Strikingly, clinical characteristics did not differ between the patients with fresh thrombus and those with ‘older’ thrombus, although men were more likely to have fresh thrombus than were women.”;
m. The Post-hoc analysis of the PASSION trial, published in 2012, found that the use of thrombus aspiration in adjunct to primary percutaneous coronary intervention (PPCI) did not affected rates of major adverse cardiac events at 2 years follow-up, as compared with conventional PPCI;
n. Bo Lagerqvist and colleagues in a study published in 2014 confirm the findings from the Passion Trial that routine aspiration of thrombus before primary percutaneous coronary intervention in patients with ST segment elevation (STEMI) has not been proved to reduce the rate of death and rehospitalization for myocardial infarction at 1 year after the procedure;
o. Myocardial infarction associated with normal coronary arteries is a well-known condition. The overall prevalence rate of myocardial infarction with normal coronary arteries is considered to be low, varying from 1% to 12% depending on the definition of ‘normal’ coronary arteries;[39,40]
p. Arbustini and colleagues in a study published in 1993 found in a series of 132 autopsies of hearts from patients who died of noncardiac causes that coronary thrombi were shown to overlay the intima of a coronary vessel independently of plaque type and severity; 
q. Ambrose and colleagues found in 1988 that the risk of a heart attack or other acute myocardial events is not proportional to the severity of coronary stenosis. Several studies in which more than one angiography was performed in patients who developed acute syndromes showed that most of these syndromes appear to be developed from lesions that on the first angiography caused not significant stenosis. Also saying these less severe stenotic lesions lead to myocardial infarction because they have not developed a sufficient collateral circulation around that would prevent or limit the extent of myocardial necrosis. This means that a 30% reduction in arterial caliber may have an increased risk for a myocardial infarction than an obstruction of 90%;[42-44]
r. Recent papers confirm the finds that non-obstructive coronary artery disease is associated with significantly increased risk of myocardial infarctions, consistent with previous studies indicating the majority of myocardial infarctions are caused by non-significant stenoses. Interesting to mention is that one of these found in patients without obstructive CAD had equivalent rates of all-cause and cardiac rehospitalization as those with obstructive CAD, indicating that the downstream effects of the patients’ chest pain, whether truly ischaemic or not, were the same in these two groups;[45-47]
s. The plaque instability and rupture might start in a considerable time before the AMI, according to some studies.(36, 48) Stretching, tearing and perforation, related to cholesterol crystallization and expansion, may play a role in the process.(49,50) Also, sympathetic overstimulation and hemodynamic forces like left ventricular muscle mass and elevated heart rate may be associated with the future development of plaque disruption;
t. A recent study by Armin Arbab-Zadeh and Valentin Fuster, says: “Despite major advancements in coronary artery imaging and identification of atherosclerotic lesion morphology associated with rupture, there is no conclusive evidence that individual plaque assessment better predicts acute coronary event risk than established risk factors, such as the extent and severity of coronary artery disease. Pathology and clinical studies consistently demonstrate that atherosclerotic plaques rupture without clinical symptoms much more frequently than is widely acknowledged, challenging the notion of a close association between plaque rupture and clinical events. Conversely, the atherosclerotic disease burden is a consistent, strong predictor of adverse cardiovascular events and deserves greater attention. Current data suggest that rather than focusing on individual coronary arterial lesions, we need a comprehensive, integrative approach for identifying and managing patients at risk of adverse cardiovascular events;
u. A “State-of-the-Art” review and commentary by Mario Marzilli and colleagues, published in 2012, have the following conclusion: “A large body of evidence conclusively suggests that coronary artery obstruction is only 1 element in a complex multifactorial pathophysiological process that leads to Ischemic Heart Disease (IHD) and that the presence of obstructive lesions in patients with IHD does not necessarily imply a causative role. A more comprehensive approach seems necessary to refocus preventive and therapeutic strategies and to decrease morbidity and mortality. To this effect, we propose a shift in approach to include the myocardial cell as well as the coronary vessel”;
v. Erhardt and colleagues in 1973 published findings that radioactive fibrinogen administered to patients with AMI was incorporated into the entire coronary thrombus in non-survivors, supporting the view that myocardial infarction occurs first and thrombus formation is a secondary event. Another study published in 1976 by the same group confirmed the previous findings;[54,55]
w. Giorgio Baroldi, emphasizing the inconsistency of the current myths about the behaviour and meaning of components of the human coronary atherosclerotic plaque, told in 2004 that the degree and number of severe coronary plaques do no predict onset, course, complications and death in coronary heart disease (CHD);
x. Many other studies have advocated coronary thrombosis as consequence of myocardial infarction;[57-62]
y. A study published at JAMA in 2016 found that temporal increases in levels of cardiac troponin T by high-sensitive essay (hs-cTnT), suggestive of myocardial injury or progressive myocardial damage, was independently associated with later risk of death, coronary heart disease, and especially heart failure in apparently healthy middle-aged people. The study which enrolled 8.838 participants (mean age 56) was followed from January 1990 to December 2011, with an analysis of 6-year change in hs-cTnT. In their conclusion the authors say that their results indicated that 2 measurements of hs-cTnT appeared to be better than 1 for characterizing risk and that large increase in hs-cTnT are particularly deleterious. Also that temporal change in hs-cTnT may help guide the preventive management of asymptomatic persons at risk for coronary artery disease. This study didn’t discuss about the etiology of the progressive myocardial injury found. However one could notice and surmise from it the absence of relationship to the thrombocentric coronary heart disease universe. On the other hand, studies show that mental stress and exercise may induce cardiac troponin T (hs-cTnT) elevation, in apparently healthy individuals;[64-65]
z. George E Burch and colleagues raised an important point in 1972 when they said: “The patient with coronary artery disease does not die of coronary artery disease; he dies of myocardial disease. It is the heart muscle that is the pumping element. To accept the term “heart muscle disease” as the primary factor in coronary artery disease assists the physician in management of the patient.”.
The studies and reasoning listed above provide very strong evidences that can clarify once and for all any doubts about the matter, pointing out that the occasional coronary thrombosis is a consequence of the process and not the real cause of acute myocardial infarction or death of the patient with coronary-myocardial disease.
On the other hand there are poor or non-existent benefit results (In absolute risk reduction statistics - Scientific and clinical significance is usually set at 5% level), justifying the use of drugs, coronary bypass surgery, angioplasty and stents, current medical treatments based on the coronary thrombosis theory. These are treating symptoms and/or biomarkers not the disease itself, with the possible risk of harms to the patients.[67-76]
The Myogenic Theory of Myocardial Infarction
Our interest on the discussion about this subject is related to our position as advocates of the Myogenic Theory of Myocardial Infarction, developed by my father in law, the Brazilian Cardiologist Quintiliano H. de Mesquita, in 1972. In the myogenic theory point of view coronary thrombosis is a consequence of the myocardial infarction being cardiac glycosides (digitalis, strophanthin, etc..) the fundamental and specific therapeutic.[77-79].
Dr Mesquita (1918 - 2000†) Photo, 1983
Among other developments from Dr Mesquita are the Ventricular Aneurism Surgery of the Heart
performed by Charles Bailey in 1954 and the first diagnosis of Right Ventricular Infarction, in vivo, by ECG,
made in 1958. (He did more than 30 pioneer contributions to medical literature)
Anticoagulant Use by Dr Mesquita
One point I would like to emphasize is that Dr Mesquita received the introduction of the anticoagulants in 1944 with large enthusiasm and the hope that finally reached the solution for the prevention of myocardial infarction. Then, he applied anticoagulants, particularly in unstable angina, during a period of 10 years (1944-1954) with records of absolute failure in restraining unstable angina and in prevention of infarction, leading to his abandonment of this therapeutic. Thenceforth, he started to use only the coronary dilator having published in 1962 a study involving 296 patients with myocardial infarction treated at their home, recording the exceptional mortality of 7.7%, comprising 14 cases of heart failure, 6 cases of sudden death and 3 cases of cardiogenic shock. The low mortality found in his study was later justified due to the habitual conduct from Dr Mesquita to apply intravenous strophanthin in all cases presenting precocious pulmonary stasis in the acute myocardial infarction, ever interpreted as incipient left ventricular insufficiency.
Our tributes to Dr Quintiliano H de Mesquita
In November of 2012 I made a presentation about the myogenic theory in a lecture during the Fourth International Conference of Advanced Cardiac Sciences - the King of Organs Conference, held in Saudi Arabia.
(L-R) David Diamond, Malcolm Kendrick, Carlos Monteiro and Paul Rosch, during a break in proceedings at The King of Organs Conference
In 2014 was published our article Stress as Cause of Heart Attacks: The Myogenic Theory telling the history of its development and making a comparison between the thrombogenic theory versus the myogenic theory in its different philosophies, therapeutics and outcomes for the three stages of ischemic heart disease.
Book Myogenic Theory of Myocardial Infarction, 1979
The myogenic theory developed by Dr Mesquita was the template for our acidity theory of atherosclerosis launched in 2006. In our view the acidic environment evoked by chronic stress has an important role in the mechanism generating atherosclerotic lesions. It follows the response to injury concept of atherosclerosis.
“Science is a Method of Investigation to Search for Evidences, not Beliefs nor Wishes,
Conveniences or Preferences”
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Carlos ETB Monteiro said..
Through history there have been suggestions of dogmatism about coronary thrombosis as cause of myocardial infarction.
For example, 40 years ago, Dr. Giorgio Baroldi said in editorial at the American Heart Journal: “In conclusion, one is tempted to paraphrase the workshop statement* by saying that the classic concept of the primary role of the thrombus still deserves serious consideration. Presently, however, a substantial body of knowledge supports the concept of a secondary genesis of the thrombus. (Giorgio Baroldi. Coronary thrombosis: Facts and beliefs. Editorial, American Heart Journal, Volume 9; Number 6: 1976)
*The workshop from 1974 inferred: "The idea that coronary thrombosis is a secondary event following infarction is provocative and deserves serious consideration “and that.”Presently a substantial body of knowledge supports the classic concept of the primary role of thrombosis in pathogenesis of infarction." (Chandler BA, Chapman I, Erhardt LR, Roberts WC, Schwartz CJ, Sinapius D, Spain DM, Sherry S, Ness PM and Simon TL: Coronary thrombosis in myocardial infarction. Report of a workshop on the role of coronary thrombosis in the pathogenesis of acute myocardial infarction, Am. J. Cardiol. 34:823, 1974).