Monckeberg’s medial calcification in coronary arteries: Three case reports

How to cite this article:
Swami SY, Gadkari RU, D’Costa G. Monckeberg’s medial calcification in coronary arteries: Three case reports. Ann Trop Med Public Health 2014;7:80-2

 

How to cite this URL:
Swami SY, Gadkari RU, D’Costa G. Monckeberg’s medial calcification in coronary arteries: Three case reports. Ann Trop Med Public Health [serial online] 2014 [cited 2021 Mar 2];7:80-2. Available from: https://www.atmph.org/text.asp?2014/7/1/80/145053

Dear Sir,

Heart specimens of 16 medicolegal post mortem cases received by the pathology department of a rural medical college were examined microscopically.

Cases 1 was a 52-year male, case 2 was a 60-year female and case 3 was a 54-year male who died due to suspected myocardial infarction.

Microscopically, case 1 showed right [Figure 1] and left [Figure 2] coronary atherosclerosis with medial wall calcification. Case 2 showed the atherosclerosis with medial wall calcification with luminal narrowing of the left [Figure 3] and right [Figure 4] coronaries 60% and 50% respectively. Case 3 showed medial calcific sclerosis of the left anterior descending [Figure 5] and right [Figure 6] coronary arteries with narrowing of the lumen 30% and 10%, respectively. It also showed mitral valve stenosis with left atrial dilatation with left ventricular hypertrophy and changes of atherosclerosis in the aorta.

Figure 1: Right coronary atherosclerosis with medial wall calcifi cation [×10]

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Figure 2: Left coronary atherosclerosis with medial wall calcifi cation [×10]

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Figure 3: Left coronary atherosclerosis, medial wall calcifi cation with 60% luminal narrowing

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Figure 4: Right coronary atherosclerosis, medial wall calcifi cation with 50% luminal narrowing

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Figure 5: Left anterior descending coronary with medial calcific sclerosis with 30% narrowing of lumen

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Figure 6: Right coronary with medial calcifi c sclerosis and 10% narrowing of lumen

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Discussion

The present study of 3 autopsy heart specimens showed calcification of the coronaries, 2 cases showed associated coronary artery atherosclerosis. Left ventricular hypertrophy was present in one case with mitral valve stenosis.

Monckeberg’s medial calcification is an age-related degenerative process in which the media of large and medium-sized arteries calcify. The vessels most commonly affected are the femoral, tibial, radial, ulnar, and uterine arteries; however, the coronaries are not commonly involved. [1],[2]

The clinical significance of this finding is unknown. It could lead to arterial stiffening and increased pulse pressure and impaired coronary blood supply. [3]

Following trauma and poisoning, heart disease is the most common cause of sudden death and in these cases coronary atherosclerosis is the predominant lesion.

According to Ahmad et al. the evidence of occlusive coronary thrombi as a cause of sudden cardiac death in their autopsy study was 56%, recent infarcts were 20.8% and old infarcts 35.1% respectively. [4]

In June 2000, the American College of Cardiology and American Heart Association Consensus Panel wrote the following in the Journal of the American College of Cardiology: “Coronary calcium is part of the development of atherosclerosis; …it occurs exclusively in atherosclerotic arteries and is absent in the normal vessel wall.” Simply put, the presence of calcification in the epicardial coronary arteries indicates that the patient has coronary atherosclerosis. [5]

Conclusion

Atherosclerosis is a common phenomenon which is seen with different prevalence in different races. It begins in childhood and progresses through young adulthood to form the lesions that cause coronary heart disease. Atherosclerotic lesions develop very early in life starting from 15 years onwards. The contribution of hypertension, serum cholesterol and cigarette smoking could not be assessed. The incidence of atherosclerosis is more in males as compared to females. [6]

Calcification of the vascular tree is common in physiologic and pathologic conditions, that is, aging, diabetes, dyslipidemia, genetic diseases, and diseases with disturbances of calcium metabolism. Increasing knowledge about calcification together with improved imaging techniques provided evidence that also vascular calcification also has to be divided into two distinct entities according to the specific sites of calcification within the vascular wall: Patchy calcification of the intima in the vicinity of lipid or cholesterol deposits as present in plaque calcification and calcification of the media in the absence of such lipid or cholesterol deposits, known as Mönckeberg-type atherosclerosis. The two types of calcification may vary according to the type of vessel (large elastic vs. smaller muscular type artery) and proximal versus distal sites of the arterial tree. Furthermore, clinical studies show that it is not purely academic to distinguish between intimal and medial calcification, but rather relevant for the clinical presentation, treatment, and prognosis because each type leads to different clinical consequences. [7]

The present study aims to create awareness about this rare finding in coronaries and needs further evaluation. Coronary artery disease due to atherosclerosis is an epidemic in India. The incidence of coronary artery disease has doubled during the past three to four decades.

References

 

1.
Micheletti RG, Fishbein GA, Currier JS, Singer EJ, Fishbein MC. Calcification of the internal elastic lamina of coronary arteries. Mod Pathol 2008;21:1019-28.
2.
Monkeberg JC. Over the pure media calcification of arteries and Extremely deeds their behavior to arteriosclerosis, Virchow′s arch A. Pathol Anat 1903;171:141.
3.
Floege J, Ketteler M. Vascular calcification in patients with end-stage renal disease. Nephrol Dial Transplant 2004;19 Suppl 5:V59-66.
4.
Ahmad M, Afzal S, Malik IA, Mushtaq S, Mubarik A. An autopsy study of sudden cardiac death. J Pak Med Assoc 2005;55:149-52.
5.
Emedicine. Available from: http://www.medscape.com/article/352189-overview# aw2aab6b3. March 17-20, 2002; Atlanta, Georgia.
6.
Garg M, Aggarwal AD, Kataria SP. Coronary atherosclerosis and myocardial infarction – An autopsy study. J Indian Acad Forensic Med 2011;33:1.
7.
Amann K. Media calcification and intima calcification are distinct entities in chronic kidney disease. Clin J Am Soc Nephrol 2008;3:1599-605.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.145053

Figures

[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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