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Coronary plaque instability assessed by positron emission tomography and optical coherence tomography. Ann Nucl Med 2021; 35:1136-1146. [PMID: 34273103 PMCID: PMC8408060 DOI: 10.1007/s12149-021-01651-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 06/27/2021] [Indexed: 11/10/2022]
Abstract
Background Non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (UA) are caused often by destabilization of non-flow limiting inflamed coronary artery plaques. 18F-fluorodeoxyglucose (FDG) uptake with positron emission tomography/computed tomography (PET/CT) reveals plaque inflammation, while intracoronary optical coherence tomography (OCT) reliably identifies morphological features of coronary instability, such as plaque rupture or erosion. We aimed to prospectively compare these two innovative biotechnologies in the characterization of coronary artery inflammation, which has never been attempted before. Methods OCT and FDG PET/CT were performed in 18 patients with single vessel coronary artery disease, treated by percutaneous coronary intervention (PCI) with stent implantation, divided into 2 groups: NSTEMI/UA (n = 10) and stable angina (n = 8) patients. Results Plaque rupture/erosion recurred more frequently [100% vs 25%, p = 0.001] and FDG uptake was greater [TBR median 1.50 vs 0.87, p = 0.004] in NSTEMI/UA than stable angina patients. FDG uptake resulted greater in patients with than without plaque rupture/erosion [1.2 (0.86–1.96) vs 0.87 (0.66–1.07), p = 0.013]. Among NSTEMI/UA patients, no significant difference in FDG uptake was found between ruptured and eroded plaques. The highest FDG uptake values were found in ruptured plaques, belonging to patients with NSTEMI/UA. OCT and PET/CT agreed in 72% of patients [p = 0.018]: 100% of patients with plaque rupture/erosion and increased FDG uptake had NSTEMI/UA. Conclusion For the first time, we demonstrated that the correspondence between increased FDG uptake with PET/CT and morphology of coronary plaque instability at OCT is high.
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Singh T, Newby DE. Time to look deeper into the plaque. Eur Heart J Cardiovasc Imaging 2020; 21:981-982. [PMID: 32535621 DOI: 10.1093/ehjci/jeaa081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Trisha Singh
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Room SU. 305, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Room SU. 305, Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK
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Arbab-Zadeh A, Fuster V. From Detecting the Vulnerable Plaque to Managing the Vulnerable Patient: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 74:1582-1593. [PMID: 31537269 DOI: 10.1016/j.jacc.2019.07.062] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 01/04/2023]
Abstract
The past decades have seen tremendous progress on elucidating mechanisms leading to acute coronary syndrome and sudden cardiac death. Pathology and imaging studies have identified features of coronary atherosclerosis that precede acute coronary events. However, many factors influence the risk of adverse events from coronary atherosclerotic disease and available data support our transition from focusing on individual "vulnerable plaque," coronary arterial stenosis, and inducible myocardial ischemia to understanding coronary heart disease as multifactorial, chronic disease. The concept of the vulnerable patient has evolved, with the atheroma burden, its metabolic activity, and the disposition to vascular thrombosis building a platform for assessing central aspects of coronary heart disease. In turn, this model has directed us to a focus on controlling the activity of atherosclerotic disease and on modifying the susceptibility of vascular thrombosis which has led to reduced morbidity and mortality from coronary heart disease.
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Affiliation(s)
- Armin Arbab-Zadeh
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Valentin Fuster
- Mount Sinai Heart Center, Icahn School of Medicine at Mount Sinai, New York, New York
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Detection of the Vulnerable Coronary Atherosclerotic Plaque—Promises and Limitations. CURRENT CARDIOVASCULAR IMAGING REPORTS 2017. [DOI: 10.1007/s12410-017-9427-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Arbab-Zadeh A, Fuster V. The Risk Continuum of Atherosclerosis and its Implications for Defining CHD by Coronary Angiography. J Am Coll Cardiol 2017; 68:2467-2478. [PMID: 27908353 DOI: 10.1016/j.jacc.2016.08.069] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/17/2016] [Accepted: 08/24/2016] [Indexed: 01/07/2023]
Abstract
Patients undergoing coronary angiography for suspected coronary heart disease who are found to have coronary atherosclerotic disease with <50% diameter stenosis may carry a risk of adverse cardiac events similar to that in patients with single-vessel obstructive disease. Yet clinical practice guidelines offer no direction for managing symptomatic patients with nonobstructive coronary atherosclerosis because current diagnostic criteria for coronary heart disease are not met. Accordingly, secondary preventive measures are not endorsed, and their role is not defined in this setting. Available data suggest that we are missing the opportunity to provide effective preventive measures in millions of patients with nonobstructive coronary heart disease. The emergence of noninvasive coronary angiography in patients with suspected coronary heart disease provides the opportunity to transition from a categorical perspective on the presence or absence of coronary heart disease to accepting the risk continuum from atherosclerosis and its implications for diagnosis and management.
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Affiliation(s)
- Armin Arbab-Zadeh
- Department of Medicine/Cardiology Division, Johns Hopkins University, Baltimore, Maryland.
| | - Valentin Fuster
- Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai Medical Center, New York, New York; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
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Assessment of atherosclerotic luminal narrowing of coronary arteries based on morphometrically generated visual guides. Cardiovasc Pathol 2017. [PMID: 28622581 DOI: 10.1016/j.carpath.2017.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIMS Determination of the degree of stenosis of atherosclerotic coronary arteries is an important part of postmortem examination of the heart, but, unfortunately, estimation of the degree of luminal narrowing can be imprecise and tends to be approximations. Visual guides can be useful to assess this, but earlier attempts to develop such guides did not employ digital technology. Using this approach, we have developed two computer-generated morphometric guides to estimate the degree of luminal narrowing of atherosclerotic coronary arteries. The first is based on symmetric or eccentric circular or crescentic narrowing of the vessel lumen and the second on either slit-like or irregularly shaped narrowing of the vessel lumens. METHODS Using the Aperio ScanScope XT at a magnification of 20× we created digital whole-slide images of 20 representative microscopic cross sections of the left anterior descending (LAD) coronary artery, stained with either hematoxylin and eosin (H&E) or Movat's pentachrome stain. These cross sections illustrated a variety of luminal profiles and degrees of stenosis. Three representative types of images were selected and a visual guide was constructed with Adobe Photoshop CS5. Using the "Scale" and "Measurement" tools, we created a series of representations of stenosis with luminal cross sections depicting 20%, 40%, 60%, 70%, 80%, and 90% occlusion of the LAD branch. Four pathologists independently reviewed and scored the degree of atherosclerotic luminal narrowing based on our visual guides. In addition, digital technology was employed to determine the degree of narrowing by measuring the cross-sectional area of the 20 microscopic sections of the vessels, first assuming no narrowing and then comparing this to the percent of narrowing determined by precise measurement. RESULTS Two of the observers were very experienced general autopsy pathologists, one was a first-year pathology resident on his first rotation on the autopsy service, and the fourth observer was a highly experienced cardiovascular pathologist. Interobserver reliability was assessed by determination of the intraclass correlation coefficient. The degrees of agreement for two H&E- and Movat-stained sections of the LADs from each of 10 decedents were 0.874 and 0.899, respectively, indicating strong interobserver agreement. On the average, the mean visual scores were ~8% less than the morphometric assessment (52.7 vs. 60.2), respectively. CONCLUSIONS The visual guides that we have generated for scoring atherosclerotic luminal narrowing of coronary arteries should be helpful for a broad group of pathologists, from beginning pathology residents to experienced cardiovascular pathologists.
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Michaud K, Grabherr S, Faouzi M, Grimm J, Doenz F, Mangin P. Pathomorphological and CT-angiographical characteristics of coronary atherosclerotic plaques in cases of sudden cardiac death. Int J Legal Med 2015; 129:1067-77. [DOI: 10.1007/s00414-015-1191-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 04/09/2015] [Indexed: 11/28/2022]
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Zack F, Kutter G, Blaas V, Rodewald AK, Büttner A. Fibromuscular dysplasia of cardiac conduction system arteries in traumatic and nonnatural sudden death victims aged 0 to 40 years: a histological analysis of 100 cases. Cardiovasc Pathol 2014; 23:12-6. [DOI: 10.1016/j.carpath.2013.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/10/2013] [Accepted: 07/11/2013] [Indexed: 11/17/2022] Open
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Abstract
In the United States alone, more than 400,000 Americans die annually from coronary artery disease and more than 1,000,000 suffer acute coronary events, i.e., myocardial infarction and sudden cardiac death.1 Considering the aging of our population and increasing incidence of diabetes and obesity, the morbidity from coronary artery disease, and its associated costs, will place an increasing, substantial burden on our society.2 Between 2010 and 2030, total direct medical costs spent in the US for cardiovascular diseases are projected to triple from 273 to 818 billion dollars.2 Although effective treatments are available and considerable efforts are ongoing to identify new strategies for the prevention of coronary events, predicting such events in an individual has been challenging.3 In hopes of improving our ability to determine the risk of coronary events, it is prudent to review our knowledge of factors that lead to acute coronary events.
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Pan D, Lanza GM, Wickline SA, Caruthers SD. Nanomedicine: perspective and promises with ligand-directed molecular imaging. Eur J Radiol 2009; 70:274-85. [PMID: 19268515 DOI: 10.1016/j.ejrad.2009.01.042] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Accepted: 01/14/2009] [Indexed: 01/01/2023]
Abstract
Molecular imaging and targeted drug delivery play an important role toward personalized medicine, which is the future of patient management. Of late, nanoparticle-based molecular imaging has emerged as an interdisciplinary area, which shows promises to understand the components, processes, dynamics and therapies of a disease at a molecular level. The unprecedented potential of nanoplatforms for early detection, diagnosis and personalized treatment of diseases, have found application in every biomedical imaging modality. Biological and biophysical barriers are overcome by the integration of targeting ligands, imaging agents and therapeutics into the nanoplatform which allow for theranostic applications. In this article, we have discussed the opportunities and potential of targeted molecular imaging with various modalities putting a particular emphasis on perfluorocarbon nanoemulsion-based platform technology.
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Affiliation(s)
- Dipanjan Pan
- Department of Medicine, Washington University Medical School, St Louis, MO, USA.
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Wilson RF, White CW. Coronary Angiography. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Bezerra HG, Higuchi ML, Gutierrez PS, Palomino SA, Silvestre JM, Libby P, Ramires JA. Atheromas that cause fatal thrombosis are usually large and frequently accompanied by vessel enlargement. Cardiovasc Pathol 2001; 10:189-96. [PMID: 11600336 DOI: 10.1016/s1054-8807(01)00070-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Several lines of clinical evidence show that AMI frequently occurs at sites with mild to moderate degree of coronary stenosis. The degree of luminal stenosis depends on plaque deposition and degree of vessel remodeling, features poorly assessed by coronary angiography. This postmortem study tested the hypothesis that the size of coronary atheroma and the type of remodeling distinguish culprit lesion responsible for fatal AMI from equi-stenotic nonculprit lesion in the same coronary tree. The main coronary branches from 36 consecutive patients with fatal AMI were studied. The culprit lesion (Group 1) and an equi-stenotic nonculprit segment (Group 2) obtained in measurements of another coronary branch from the same patient were compared. Morphometry and plaque composition was assessed in both groups. Compared to Group 2, Group 1 had larger areas of: plaque 9.6 vs. 4.7 mm(2), vessel 12.7 vs. 7.4 mm(2) and lumen 1.7 vs. 1.2 mm(2); (P< .01). Positive remodeling was more frequent in Group 1 than Group 2: 21/30 (70%) vs. 8/26 (31%). Plaque area correlated positively with lipid core and macrophages and negatively with fibrosis and smooth muscle cells. Atherosclerotic plaques that cause fatal thrombosis are more frequently positively remodeled and tend to be larger than nonculprit plaques with the same degree of cross-sectional stenosis. We tested whether arterial remodeling and plaque size vary between segments containing a fatal thrombosed plaque versus an equi-stenotic nonculprit plaque. Culprit vessel segments had higher cross-sectional areas of intimal plaque and of vessel wall than equi-stenotic nonculprit plaques. The cross-sectional area of the vessel correlated positively with both the lipid core area and CD68(+) macrophage content, and negatively with fibrosis area and smooth muscle cell content. These results add elements explaining limitations of angiography in identifying plaques and provide new insights into the role of remodeling in plaque instability.
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Affiliation(s)
- H G Bezerra
- Heart Institute (InCor) of University of São Paulo Medical School, Av Dr Eneas Carvalho de Aguiar, 44, São Paulo, SP CEP 05403/000, Brazil.
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von Birgelen C, Klinkhart W, Mintz GS, Papatheodorou A, Herrmann J, Baumgart D, Haude M, Wieneke H, Ge J, Erbel R. Plaque distribution and vascular remodeling of ruptured and nonruptured coronary plaques in the same vessel: an intravascular ultrasound study in vivo. J Am Coll Cardiol 2001; 37:1864-70. [PMID: 11401124 DOI: 10.1016/s0735-1097(01)01234-7] [Citation(s) in RCA: 200] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study was designed to identify potential differences between the intravascular ultrasound (IVUS) characteristics of spontaneously ruptured and nonruptured coronary plaques. BACKGROUND The identification of vulnerable plaques in vivo may allow targeted prevention of acute coronary events and more effective evaluation of novel therapeutic approaches. METHODS Intravascular ultrasound was used to identify 29 ruptured plaques in arteries containing another nonruptured plaque in an adjacent segment. Intravascular ultrasound characteristics of these plaques were compared with plaques of computer-matched controls without evidence of plaque rupture. Plaque distribution was assessed by measuring the eccentricity of lumen location (inside the total vessel). Lumen cross-sectional area narrowing was calculated as [1 - (target/reference lumen area)] x 100%. A remodeling index was calculated as lesion/reference arterial area (>1.05 = compensatory enlargement, <0.95 = shrinkage). RESULTS Among the three groups of plaques, there was no significant difference in quantitative angiographic parameters, IVUS reference dimensions and IVUS lumen cross-sectional area narrowing. There was a difference in plaque distribution; lumen location by IVUS was significantly more eccentric in ruptured than in nonruptured (p = 0.002) and control plaques (p < 0.0001). The arc of disease-free vessel wall was larger in ruptured than in control plaques (p < 0.0001). The remodeling pattern of ruptured and nonruptured plaques differed significantly from that of the control plaques (p = 0.0001 and 0.003); compensatory enlargement was found in 66%, 48%, and 17%, whereas shrinkage was found in 7%, 10% and 48%, respectively. CONCLUSIONS Intravascular ultrasound assessment of plaque distribution and vascular remodeling may help to classify plaques with the highest probability of spontaneous rupture.
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von Birgelen C, Klinkhart W, Mintz GS, Wieneke H, Baumgart D, Haude M, Bartel T, Sack S, Ge J, Erbel R. Size of emptied plaque cavity following spontaneous rupture is related to coronary dimensions, not to the degree of lumen narrowing. A study with intravascular ultrasound in vivo. Heart 2000; 84:483-8. [PMID: 11040004 PMCID: PMC1729491 DOI: 10.1136/heart.84.5.483] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To identify any potential relations between the size of an emptied plaque cavity and the remodelling pattern, plaque or vessel dimensions, lumen narrowing, and other ultrasonic lesion characteristics. DESIGN Intravascular ultrasound was used to examine prospectively 51 ruptured ulcerated coronary plaques. Cross sectional area measurements comprised lumen, vessel, plaque, and emptied plaque cavity. Lumen narrowing was calculated as 1 - (lesion lumen area/reference lumen area) x 100%. A remodelling index was calculated as lesion vessel area/reference vessel area, and plaques were divided into those with values > 1.05 (group A) and </= 1.05 (group B). RESULTS Of the total of 51 plaques, 36 (71%) were assigned to group A and 15 (29%) to group B. In neither group was there a significant difference in reference dimensions and lumen narrowing. However, lesion vessel (mean (SD): 22.6 (8.1) mm(2) v 17. 5 (4.3) mm(2); p = 0.006) and plaque areas (15.8 (6.2) mm(2) v 12.8 (3.2) mm(2); p = 0.03) were greater in group A than in group B. The cavity inside the plaque was larger in group A than in group B (2.8 (1.6) mm(2) v 1.8 (0.9) mm(2); p = 0.007) and showed a positive linear relation with lesion and reference vessel size (r = 0.58 and 0.56, respectively; p < 0.001), but not with lumen narrowing. CONCLUSIONS The size of the emptied cavity inside ruptured plaques is on average larger in lesions with adaptive vascular remodelling, and shows a linear relation with lesion plaque and vessel size and with the reference dimensions, but not with the degree of lumen narrowing.
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Affiliation(s)
- C von Birgelen
- Department of Cardiology, University Hospital Essen, Hufelandstr 55, D-45122 Essen, Germany.
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Hort W, Schwartzkopff B. Anatomie und Pathologie der Koronararterien. PATHOLOGIE DES ENDOKARD, DER KRANZARTERIEN UND DES MYOKARD 2000. [DOI: 10.1007/978-3-642-56944-9_3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Smits PC, Pasterkamp G, Quarles van Ufford MA, Eefting FD, Stella PR, de Jaegere PP, Borst C. Coronary artery disease: arterial remodelling and clinical presentation. Heart 1999; 82:461-4. [PMID: 10490561 PMCID: PMC1760264 DOI: 10.1136/hrt.82.4.461] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To investigate the hypothesis that in coronary artery disease large plaques in compensatorily enlarged segments are associated with acute coronary syndromes, whereas smaller plaques in shrunken segments are associated with stable angina pectoris. METHODS Patients selected for percutaneous transluminal coronary angioplasty (PTCA) were divided into two groups, one with stable angina pectoris (stable group, n = 37) and one with unstable angina or postmyocardial infarction angina of the infarct related artery (unstable group, n = 32). In both groups, remodelling at the culprit lesion site was determined by intravascular ultrasound before the intervention. Remodelling was calculated as relative vessel area: [vessel area culprit lesion site / mean vessel area of both proximal and distal reference sites] x 100%. Compensatory enlargement was defined as remodelling of >/= 105%, whereas shrinkage was defined as remodelling of </= 95%. RESULTS In the unstable group, the vessel area at the culprit lesion site was larger than in the stable group, at mean (SD) 18.1 (5.3) v 14.6 (5.4) mm(2) (p = 0.008). Lumen areas were similar. Consequently, plaque area and percentage remodelling were larger in the unstable group than in the stable group: mean (SD) 14.8 (4.8) v 11.6 (4.9) mm(2) (p = 0.009) and 112 (31)% v 95 (17)% (p = 0.005), respectively. Significantly more culprit lesion sites were classified as shrunken in the stable group (21/37) than in the unstable group (8/32; p = 0.014). On the other hand, more lesion sites were classified as enlarged in the unstable group (16/23) than in the stable group (8/37; p = 0.022). CONCLUSIONS In patients selected for PTCA, the mode of remodelling is related to clinical presentation.
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Affiliation(s)
- P C Smits
- Department of Cardiology, Heart Lung Institute, University Hospital Utrecht, Netherlands.
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Mikkelsson J, Perola M, Laippala P, Savolainen V, Pajarinen J, Lalu K, Penttilä A, Karhunen PJ. Glycoprotein IIIa Pl(A) polymorphism associates with progression of coronary artery disease and with myocardial infarction in an autopsy series of middle-aged men who died suddenly. Arterioscler Thromb Vasc Biol 1999; 19:2573-8. [PMID: 10521390 DOI: 10.1161/01.atv.19.10.2573] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Glycoprotein IIIa (GPIIIa) has a key role in the aggregation of thrombocytes, and it also mediates intimal hyperplasia after endothelial injuries; the possible association of the Pl(A1/A2) polymorphism of the gene for GPIIIa with coronary thrombosis and with the progression of coronary artery disease (CAD) is still to be confirmed. Therefore, the association of the Pl(A) polymorphism with the development of coronary atherosclerosis, coronary narrowing, and myocardial infarction (MI) was studied in a prospective, consecutive autopsy series of 300 middle-aged, white Finnish men (33 to 69 years) suffering sudden out-of-hospital or violent death. Coronary atherosclerosis was measured morphometrically and the coronary stenosis percentage determined from a cast rubber model of the coronary tree. We found a significant inverse relation (P=0.01) between the Pl(A2)-positive genotype and coronary artery stenosis. The frequency of possessing the Pl(A2) allele was significantly (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.22 to 0.98) lower among men with >50% coronary stenosis (18.3%) than among those with <25% stenosis (32.9%). Although the Pl(A) polymorphism was not directly associated with MI, the Pl(A2) allele was present in 11 of the 22 men (50%) with MI and coronary thrombosis (OR 6.6, 95% CI 2.1 to 22.8) but in only 6 of the 47 (12.8%) with MI associated with severe stenosis in the absence of thrombosis. In line with this result, men possessing the Pl(A2) allele also had a larger area of fissured and ulcerated complicated lesions in their coronary arteries (P<0.05). The present results suggest that the Pl(A) polymorphism is involved in the development of CAD and MI. Men with the Pl(A2) allele may harbor more thin-walled, vulnerable coronary plaques, plaques prone to rupture, leading to massive, fatal thrombosis. In contrast, men homozygous for the Pl(A1) allele may more often show stable plaques and present with infarction caused by progressive coronary stenosis.
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Affiliation(s)
- J Mikkelsson
- Medical School, University of Tampere and Tampere University Hospital, Finland.
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Abstract
OBJECTIVE To determine the role of healed plaque disruption in the generation of chronic high grade coronary stenosis. METHODS Coronary arteries obtained at necropsy were perfuse fixed with formal saline for 24 hours at 100 mg Hg. The percentage lumen diameter stenosis was measured in each 3 mm segment containing a plaque, using the lumen size at the nearest histologically normal segment as the reference point. Each segment was prepared for histological examination and stained with Sirius red and immunohistochemistry for smooth muscle actin. Healed disruption was considered to be present when under polarised light there was a break in the yellow-white dense collagen of the cap filled in by more loosely arranged green collagen. Increased smooth muscle density in the green staining areas was required. Each section was read independently by two observers; any segment with discordant views was considered negative. MATERIAL 31 men aged 51-69 dying suddenly of ischaemic heart disease. 39 coronary arteries were studied containing 256 separate plaques, after excluding coronary arteries with old total occlusions, an acute culprit thrombotic lesion, diffuse disease without normal arterial segments, and arteries related to old myocardial scars. RESULTS 16 of 99 plaques causing < 20% diameter stenosis had prior disruption. In the 21-50% stenosis range 16 of 86 plaques showed healed disruption. Stenosis >/= 51% by diameter was present in 71 plaques, 52 of which showed a healed disruption pattern. The difference between stenosis < 50% and stenosis >/= 51% was significant by the chi(2) test (p < 0.001). CONCLUSIONS Subclinical episodes of plaque disruption followed by healing are a stimulus to plaque growth that occurs suddenly and is a major factor in causing chronic high grade coronary stenosis. This mechanism would explain the phasic rather than linear progression of coronary disease observed in angiograms carried out annually in patients with chronic ischaemic heart disease.
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Affiliation(s)
- J Mann
- St George's Hospital Medical School, British Heart Foundation Cardiovascular Pathology Unit, Cranmer Terrace, London SW17 ORE, UK
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Abstract
When atherosclerotic plaques develop, the cross-sectional area of the artery at that point often increases to accommodate the plaque without any reduction in lumen size. In consequence the angiogram does not detect a high proportion of atherosclerotic plaques. The increase in size of the artery (compensatory dilatation-arterial remodelling) varies widely in degree between different plaques even in the same artery. Dilatation of a degree to prevent any loss of lumen size is regarded as adequate compensatory dilatation. In contrast, other plaques are associated with no or minimal increase in the vessel cross-sectional area and a reduction in lumen size in present (inadequate compensation). High-grade stenosis is in particular associated with a total failure of remodelling. Such plaques may have had a rapid growth phase, out-pacing the ability of the medial smooth muscle cells to undergo a rearrangement. The phenomenon of remodelling has important consequences for pathologists who use the traditional method of comparing the lumen size relative to the cross-sectional area of the vessel at the site of a plaque to measure stenosis. The area of the vessel at this point may be anything up to 60% above its size before the plaque developed. An error is introduced which on average overestimates diameter stenosis by 30% when compared to an angiographic equivalent method in which the lumen size at the lesion is compared to the lumen size at an adjacent segment of artery without a plaque.
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Affiliation(s)
- M J Davies
- BHF Cardiovascular Pathology Unit, St George's Hospital Medical School, Tooting, London, UK
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Buchwald H, Hunter DW, Tuna N, Williams SE, Boen JR, Hansen BJ, Titus JL, Campos CT. Myocardial infarction and percent arteriographic stenosis of culprit lesion: report from the Program on the Surgical Control of the Hyperlipidemias (POSCH). Atherosclerosis 1998; 138:391-401. [PMID: 9690924 DOI: 10.1016/s0021-9150(98)00049-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The objective of this study was to assess the percent stenosis of the culprit lesion responsible for subsequent myocardial infarction in the Program on the Surgical Control of the Hyperlipidemias (POSCH). It is unknown if the susceptible coronary artery culprit lesion responsible for an acute myocardial infarction is relatively large ( > or = 50% arteriographic stenosis) and hemodynamically significant ( > or = 70% stenosis), or small ( < 50%, stenosis) and asymptomatic. Certain necropsy and arteriography studies support the large progenitor lesion concept, and other arteriography studies support the small lesion hypothesis. We analyzed the coronary arteriogram immediately preceding a Q wave (transmural) myocardial infarction for the degree of stenosis of the suspected culprit lesion, which was selected by visual inspection of the coronary circulation supplying the electrocardiogram-defined area of myocardial infarction. There was no perceptible difference with respect to vessel segment distribution of culprit lesions or time to infarction between the 52 control-group patients and the 27 intervention-group patients. For the two groups combined (n=79), the predominantly involved segments were the middle right coronary artery and the proximal left anterior descending coronary artery. The time interval from the preceding coronary arteriogram closest to the index myocardial infarction ranged from 0 days to 10 years; however, 64.6% of the arteriograms were performed 2 years or less prior to the myocardial infarction. Only 5.1% of the patients in both groups combined had a culprit lesion stenosis < 50%, while 88.6% of the patients in both groups combined had a culprit lesion stenosis > or = 70%. The results strongly favor the large lesion hypothesis of causation for myocardial infarction. It is premature, however, to state that the relative size of the culprit lesion has been indisputably determined. The resolution of this problem has exceedingly important practical implications for the management of patients with known atherosclerotic coronary heart disease and for those asymptomatic individuals with silent atherosclerotic coronary heart disease.
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Affiliation(s)
- H Buchwald
- Department of Surgery, University of Minnesota, St. Paul, USA.
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Abstract
BACKGROUND Regular cyclists have been found to have a lower incidence of coronary events (CHD) than the general public. Non-invasive studies have found that competitive cyclists develop a cardiac hypertrophy that is physiological and reversible. METHODS To obtain pathological support for these observations, the postmortem findings of 32 cyclists killed in accidents have been compared with those in a control group of 32 other road traffic accidents, which were matched with the cyclists by sex, age, and year of death. FINDINGS Large myocardial scars and complete blockage of a coronary artery were only found in the controls; serious stenoses of coronary arteries (> 50%) were found in eight controls but in only one of the cyclists. Of the cyclists, 25 had normal coronary arteries as compared with 14 of the controls. The mean age of the cyclists with evidence of CHD was greater than that of similarly affected controls. The heart weights of the two groups were almost the same but heart weight varied with the degree of CHD. The heart weight of the healthy cyclists (389 g) was greater than that of the healthy controls (371 g) but this was not statistically significant. INTERPRETATION The results are in keeping with the concept that regular exercise provides some protection from the development of CHD and that cycling may be a valuable form of exercise in this respect. This may be of importance as the number of physically active occupations declines.
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Affiliation(s)
- A Kennedy
- Department of Histopathology, Northern General Hospital, Sheffield
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Pasterkamp G, Wensing PJ, Hillen B, Post MJ, Mali WP, Borst C. Impact of local atherosclerotic remodeling on the calculation of percent luminal narrowing. Am J Cardiol 1997; 79:402-5. [PMID: 9052339 DOI: 10.1016/s0002-9149(96)00775-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The choice of the reference site in order to calculate percent luminal narrowing mainly depends on which diagnostic tool is used for examination. In intravascular ultrasound or histology, the local area encompassed by the internal elastic lamina (IEL) area is used as a reference. However, the local IEL area, and thereby the reference value, may have been altered by atherosclerotic remodeling. In the present study we examined the impact of local arterial remodeling on the calculation of luminal narrowing. Forty-five human femoral arteries were analyzed, 32 postmortem and 20 in vivo, by intravascular ultrasound. Cross sections were examined every 0.5 cm over an arterial segment length of 10 to 15 cm. In each cross section we measured the lumen area and the IEL area. Two reference areas were used to calculate percent luminal narrowing: (1) the lumen area in the cross section that contained the least amount of plaque (distant reference); and (2) the local IEL area (local reference). In each cross section, the IEL area was expressed as percent of the IEL area in the cross section that contained the least amount of plaque (relative IEL area). Using the distant reference, we found that less luminal narrowing was observed for cross sections with a relative IEL area > 100% (indicating compensatory enlargement) than for those with a relative IEL area < 100% (indicating shrinkage), whereas percent luminal narrowing calculated using the local reference hardly differed between cross section with a relative IEL area > 100% and < 100%. Thus, arterial wall remodeling makes the local IEL area an unreliable reference for calculation of percent luminal narrowing. The calculated percent luminal narrowing using a distant, nondiseased reference site reflects the actual change of the luminal area more accurately.
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Affiliation(s)
- G Pasterkamp
- Department of Cardiology, Utrecht University Hospital, The Netherlands
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Affiliation(s)
- M C Fishbein
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical, Center/University of California, Los Angeles, School of Medicine 90048, USA.
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Mann JM, Davies MJ. Vulnerable plaque. Relation of characteristics to degree of stenosis in human coronary arteries. Circulation 1996; 94:928-31. [PMID: 8790027 DOI: 10.1161/01.cir.94.5.928] [Citation(s) in RCA: 161] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The microanatomic features of the atherosclerotic plaque at risk of disruption include a large lipid core, a high macrophage content, and a thin cap. The relation between lipid core size, plaque size, and cap thickness either with each other or with the degree of stenosis has yet to be evaluated in human coronary arteries. METHODS AND RESULTS Atherosclerotic coronary plaques (n = 160) were obtained from 31 subjects who died suddenly of ischemic heart disease. In coronary arteries perfused with formol saline at a pressure of 100 mm Hg, stenosis was measured by comparison of the minimal lumen size at the site of a plaque with that of the lumen in an adjacent normal segment of artery. Plaque size, the size of the lipid core, and the thickness of the cap were measured in histological sections. Lipid core size ranged from 0% to 82% of overall plaque size. Seventeen percent of plaques had a core size of > 50%. Linear regression showed no relation of core size to stenosis (r = .21). Absolute plaque size bore no relation to core size (r = .14). Minimal cap thickness was not related to core size (r = .06). Ten percent of plaques predicted to be angiographically invisible had cores of > 50%. CONCLUSIONS Two major determinants of plaque vulnerability, core size and cap thickness, are not statistically related. Neither of these two factors that confer vulnerability are related to absolute plaque size or to the degree of stenosis.
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Affiliation(s)
- J M Mann
- British Heart Foundation Cardiovascular Pathology Unit, St George's Hospital Medical School, London, United Kingdom
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