Thrombosis and ischaemic heart disease.

The overwhelming dominance of the lipid hypothesis for atheroma has obscured the compelling evidence-some of it of many years standing' but some that is more recent2 3 -that both platelets and the coagulation system also contribute to the lesion. There is much epidemiological evidence4 5 of some other process besides atherogenesis to account for the clinical manifestations of coronary artery disease. Surprisingly late in the day, and despite the use for many years of the term coronary thrombosis, it became generally accepted that recent thrombus is usually to be found in fatal myocardial infarction and that the first is the precipitating cause of the second. "Recent" should include what may have happened within the preceding days6 as well as the preceding hours or minutes. Sudden death, though, is not a thrombotic event-or so we have been led to believe over the past 10 or 15 years. One of the reasons for this assertion has been the Seattle study, in which only 16% of those resuscitated after sudden death showed classical signs of myocardial infarction subsequently.7 Nevertheless, two other studies, much less often cited, gave figures of 39%8 and 44%.9 It is hardly surprising that those who have "died suddenly" once should be at high risk of doing so again, an observation which probably tells us more about the consequences than the causes of the initial event. It is,