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J R Soc Med. 2002 October; 95(10): 528.
PMCID: PMC1279202

Myocardial infarction with angiographically normal coronary arteries

Among the possible causes listed by Dr Chandrasekaran and Dr Kurbaan (August 2002, JRSM1) for the enigmatic condition of myocardial infarction with angiographically normal coronary arteries are atheroma, hypercoagulable state, emboli, endothelial dysfunction, dissection and inflammation. The observations of Bogren2, as well as ours3, indicate that functional coronary artery disease in the presence of seemingly normal coronary arteries may also be caused by abnormal stiffness of the aortic wall (syndrome X). To understand the mechanism, one has to recall the fact that the lion's share of coronary flow occurs during diastole and this flow equals the ‘back-flow’ from the aortic arch, which is entirely dependent on aortic wall compliance. In other words, during systole the aorta expands proportionally with the pressure and with the elasticity of its wall, and in diastole the flow reverses and the compliant aorta ‘pays back’ the amount of blood that it stored. As aortic compliance decreases because of fibrosis or for other reasons, so does the aortic back-flow. In severe cases, aortic wall stiffness could lead to coronary underperfusion and myocardial ischaemia.


1. Chandrasekaran B, Kurbaan AS. Myocardial infarction with angiographically normal coronary arteries. J R Soc Med 2002;95: 398-400 [PMC free article] [PubMed]
2. Robicsek F, Thubrikar MJ. Role of sinus wall compliance in the aortic leaflet function. Am J Cardiol 1999;84: 944-6 [PubMed]
3. Bogren HG, Mohiaddin RH, Yang GZ, Kilner PJ, Firmin DN. Magnetic resonance velocity vector mapping of blood flow in thoracic aortic aneurysms and grafts. J Thorac Cardiovasc Surg 1995;110: 704-14 [PubMed]

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