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Vergallo R, Park SJ, Stone GW, Erlinge D, Porto I, Waksman R, Mintz GS, D'Ascenzo F, Seitun S, Saba L, Vliegenthart R, Alfonso F, Arbab-Zadeh A, Libby P, Di Carli MF, Muller JE, Maurer G, Gropler RJ, Chandrashekhar YS, Braunwald E, Fuster V, Jang IK. Vulnerable or High-Risk Plaque: A JACC: Cardiovascular Imaging Position Statement. JACC Cardiovasc Imaging 2025:S1936-878X(25)00028-2. [PMID: 40019413 DOI: 10.1016/j.jcmg.2024.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 11/06/2024] [Accepted: 11/10/2024] [Indexed: 03/01/2025]
Abstract
The concept of high-risk plaque emerged from pathologic and epidemiologic studies 3 decades ago that demonstrated plaque rupture with thrombosis as the predominant mechanism of acute coronary syndrome and sudden cardiac death. Thin-cap fibroatheroma, a plaque with a large lipidic core covered by a thin fibrous cap, is the prototype of the rupture-prone plaque and has been traditionally defined as "vulnerable plaque." Although knowledge on the pathophysiology of plaque instability continues to grow, the risk profile of our patients has shifted and the character of atherosclerotic disease has evolved, partly because of widespread use of lipid-lowering therapies and other preventive measures. In vivo intracoronary imaging studies indicate that superficial erosion causes up to 40% of acute coronary syndromes. This changing landscape calls for broader perspective, expanding the concept of high-risk plaque to the precursors of all major substrates of coronary thrombosis beyond plaque rupture. Other factors to take into consideration include dynamic changes in plaque composition, the importance of plaque burden, inflammatory activation (both local and systemic), healing mechanisms, regional hemodynamic pattern, properties of the fluid phase of blood, and the amount of myocardium at risk subtended by a lesion. Rather than the traditional focus limited to the thin-cap fibroatheroma, the authors advocate a more comprehensive approach that considers both morphologic features and biological activity of plaques and blood. This position paper highlights the challenges to the usual concept of high-risk plaque, proposes a broader definition, and analyzes its key morphologic features, the technological progress of plaque imaging (particularly using intracoronary imaging techniques), advances in pharmacologic therapies for plaque regression and stabilization, and the feasibility and efficacy of focal interventional treatments including preemptive plaque sealing.
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Affiliation(s)
- Rocco Vergallo
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Università di Genova, Genoa, Italy
| | | | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Italo Porto
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Università di Genova, Genoa, Italy
| | - Ron Waksman
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Gary S Mintz
- Cardiovascular Research Foundation, New York, New York, USA
| | | | - Sara Seitun
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luca Saba
- University of Cagliari, Cagliari, Italy
| | | | - Fernando Alfonso
- Hospital Universitario La Princesa, CIBERCV, IIS-IP, Universidad Autónoma Madrid, Madrid, Spain
| | | | - Peter Libby
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - James E Muller
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Robert J Gropler
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Valentin Fuster
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ik-Kyung Jang
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Hong H, Jia H, Zeng M, Gutiérrez-Chico JL, Wang Y, Zeng X, Qin Y, Zhao C, Chu M, Huang J, Liu L, Hu S, He L, Chen L, Wijns W, Yu B, Tu S. Risk Stratification in Acute Coronary Syndrome by Comprehensive Morphofunctional Assessment With Optical Coherence Tomography. JACC: ASIA 2022; 2:460-472. [PMID: 36339358 PMCID: PMC9627809 DOI: 10.1016/j.jacasi.2022.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 02/16/2022] [Accepted: 03/06/2022] [Indexed: 11/23/2022]
Abstract
Background Artificial intelligence enables simultaneous evaluation of plaque morphology and computational physiology from optical coherence tomography (OCT). Objectives This study sought to appraise the predictive value of major adverse cardiovascular events (MACE) by combined plaque morphology and computational physiology. Methods A total of 604 patients with acute coronary syndrome who underwent OCT imaging in ≥1 nonculprit vessel during index coronary angiography were retrospectively enrolled. A novel morphologic index, named the lipid-to-cap ratio (LCR), and a functional parameter to evaluate the physiologic significance of coronary stenosis from OCT, namely, the optical flow ratio (OFR), were calculated from OCT, together with classical morphologic parameters, like thin-cap fibroatheroma (TCFA) and minimal lumen area. Results The 2-year cumulative incidence of a composite of nonculprit vessel–related cardiac death, cardiac arrest, acute myocardial infarction, and ischemia-driven revascularization (NCV-MACE) at 2 years was 4.3%. Both LCR (area under the curve [AUC]: 0.826; 95% CI: 0.793-0.855) and OFR (AUC: 0.838; 95% CI: 0.806-0.866) were superior to minimal lumen area (AUC: 0.618; 95% CI: 0.578-0.657) in predicting NCV-MACE at 2 years. Patients with both an LCR of >0.33 and an OFR of ≤0.84 had significantly higher risk of NCV-MACE at 2 years than patients in whom at least 1 of these 2 parameters was normal (HR: 42.73; 95% CI: 12.80-142.60; P < 0.001). The combination of thin-cap fibroatheroma and OFR also identified patients at higher risk of future events (HR: 6.58; 95% CI: 2.83-15.33; P < 0.001). Conclusions The combination of LCR with OFR permits the identification of a subgroup of patients with 43-fold higher risk of recurrent cardiovascular events in the nonculprit vessels after acute coronary syndrome.
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Affiliation(s)
- Huihong Hong
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Haibo Jia
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ming Zeng
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Juan Luis Gutiérrez-Chico
- Department of Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yini Wang
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xiaoling Zeng
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuhan Qin
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chen Zhao
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Miao Chu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland Galway, Galway, Ireland
| | - Lili Liu
- Department of Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sining Hu
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Luping He
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland Galway, Galway, Ireland
| | - Bo Yu
- Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin, China
- Dr Bo Yu, Department of Cardiology, Second Affiliated Hospital of Harbin Medical University, 246 Xuefu Road, Harbin 150086, China.
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China
- Address for correspondence: Dr Shengxian Tu, Med-X Research Institute, Shanghai Jiao Tong University, No. 1954, Hua Shan Road, Room 123, Shanghai 200030, China.
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Ties D, van Dorp P, Pundziute G, Lipsic E, van der Aalst CM, Oudkerk M, de Koning HJ, Vliegenthart R, van der Harst P. Multi-Modality Imaging for Prevention of Coronary Artery Disease and Myocardial Infarction in the General Population: Ready for Prime Time? J Clin Med 2022; 11:2965. [PMID: 35683356 PMCID: PMC9181560 DOI: 10.3390/jcm11112965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/15/2022] [Accepted: 05/17/2022] [Indexed: 02/01/2023] Open
Abstract
Cardiovascular disease (CVD) remains a leading cause of death and disability worldwide. Acute myocardial infarction (AMI) causes irreversible myocardial damage, heart failure, life-threatening arrythmias and sudden cardiac death (SCD), and is a main driver of CVD mortality and morbidity. To control the forecasted increase in CVD burden for both the individual and society, improved strategies for the prevention of AMI and SCD are required. Current prevention of AMI and SCD is directed towards risk-modifying interventions, guided by risk assessment using clinical risk prediction scores (CRPSs) and the coronary artery calcium score (CACS). Early detection of more advanced coronary artery disease (CAD), beyond risk assessment by CRPSs or CACS, is a promising strategy to allow personalized treatment for the improved prevention of AMI and SCD in the general population. We review evidence for further testing, beyond CRPSs and CACS, and therapies focusing on promising targets, including subclinical obstructive CAD, high-risk plaques, and silent myocardial ischemia. We also evaluate the potential of multi-modality imaging to enhance the conduction of adequately powered trials to provide high-quality evidence on the impact of add-on tests and therapies in the prevention of AMI and SCD in asymptomatic individuals. To conclude, we discuss the occurrence of AMI and SCD in individuals currently estimated to be at "low-risk" by the current strategy based on CRPSs, and methods to improve prevention of AMI and SCD in this "low-risk" population.
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Affiliation(s)
- Daan Ties
- University Medical Center Groningen, Thorax Centre, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands; (D.T.); (P.v.D.); (G.P.); (E.L.)
| | - Paulien van Dorp
- University Medical Center Groningen, Thorax Centre, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands; (D.T.); (P.v.D.); (G.P.); (E.L.)
| | - Gabija Pundziute
- University Medical Center Groningen, Thorax Centre, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands; (D.T.); (P.v.D.); (G.P.); (E.L.)
| | - Erik Lipsic
- University Medical Center Groningen, Thorax Centre, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands; (D.T.); (P.v.D.); (G.P.); (E.L.)
| | - Carlijn M. van der Aalst
- Erasmus Medical Center, Department of Public Health, Erasmus University, 3015 CE Rotterdam, The Netherlands; (C.M.v.d.A.); (H.J.d.K.)
| | - Matthijs Oudkerk
- Institute for Diagnostic Accuracy, University of Groningen, 9713 GZ Groningen, The Netherlands;
| | - Harry J. de Koning
- Erasmus Medical Center, Department of Public Health, Erasmus University, 3015 CE Rotterdam, The Netherlands; (C.M.v.d.A.); (H.J.d.K.)
| | - Rozemarijn Vliegenthart
- University Medical Center Groningen, Department of Radiology, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands;
| | - Pim van der Harst
- University Medical Center Groningen, Thorax Centre, Faculty of Medicine, University of Groningen, 9713 GZ Groningen, The Netherlands; (D.T.); (P.v.D.); (G.P.); (E.L.)
- University Medical Center Utrecht, Department of Cardiology, University of Utrecht, 3584 CX Utrecht, The Netherlands
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Kosmopoulos M, Bartos JA, Raveendran G, Goslar T, Kalra R, Hoke L, Tsangaris A, Sebastian P, Walser E, Yannopoulos D. Coronary artery disease burden relation with the presentation of acute cardiac events and ventricular fibrillation. Catheter Cardiovasc Interv 2021; 99:804-811. [PMID: 34236756 DOI: 10.1002/ccd.29858] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/18/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Evaluate the differences in coronary artery disease (CAD) burden between patients with ischemic resuscitated, ischemic refractory VT/VF OHCA events and N/STEMI. BACKGROUND Refractory out-of-hospital cardiac arrest patients presenting with initial shockable rhythms (VT/VF OHCA) have the highest mortality among patients with acute cardiac events. No predictors of VT/VF OHCA refractoriness have been identified. METHODS A retrospective cohort design was used to assess baseline characteristics, clinical outcomes, and the angiographic severity of disease among patients with VT/VF OHCA undergoing emergent coronary angiography at the University of Minnesota Medical Center. The Gensini score was calculated for all patients to assess the angiographic burden of CAD. For patients with ischemia-related cardiac arrest, outcomes were further compared to an independent non-OHCA population presenting with N/STEMI. RESULTS During the study period, 538 patients were admitted after VT/VF OHCA. Among them, 305 presented with resuscitated, and 233 with refractory VT/VF. 66% of resuscitated and 70% of refractory VT/VF had an underlying, angiographically documented, ischemic etiology. Ischemic resuscitated and refractory VT/VF had significant differences in Gensini score, (80.7 ± 3.6 and 127.6 ± 7.1, respectively, p < 0.001) and survival (77.3% and 30.0%, respectively, p < 0.001). Both groups had a higher CAD burden and worse survival than the non-OHCA N/STEMI population (360 patients). Ischemic refractory VT/VF was significantly more likely to present with chronic total occlusion in comparison to both N/STEMI and ischemic resuscitated VT/VF. CONCLUSION Ischemia-related, refractory VT/VF OHCA has a higher burden of CAD and the presence of CTOs compared to resuscitated VT/VF OHCA and N/STEMI.
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Affiliation(s)
- Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jason A Bartos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ganesh Raveendran
- Center for Resuscitation Medicine, University of Minnesota Medical School, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tomaz Goslar
- Center for Resuscitation Medicine, University of Minnesota Medical School, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA.,Center for Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota Medical School, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lindsay Hoke
- Best Practices Integrated Informatics Core, University of Minnesota Clinical and Translational Science Institute, Minneapolis, Minnesota, USA
| | - Adamantios Tsangaris
- Center for Resuscitation Medicine, University of Minnesota Medical School, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pierre Sebastian
- Center for Resuscitation Medicine, University of Minnesota Medical School, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA
| | - Emily Walser
- Center for Resuscitation Medicine, University of Minnesota Medical School, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA
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Li M, Chen Y, Zhang Y, Li D, Liu J. Correlation between monocyte chemoattractant protein-1/chemokine (C-C motif) ligand 2 and coronary plaque characteristics. Exp Biol Med (Maywood) 2020; 245:1335-1343. [PMID: 32640896 DOI: 10.1177/1535370220941424] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPACT STATEMENT Vulnerable plaques are plaques which are susceptible to rupture or thrombosis and trigger a series of adverse events such as coronary disorders. CCL2 is a soluble basic protein belonging to the CC subfamily. Previous studies have been investigated on the correlation between inflammatory factors and clinical events, but there are few studies on the correlation between CCL2 and plaque characteristics. Our study found that the high expression of CCL2 is involved in multiple processes in the genesis and progression of coronary artery disease, and would be a potential clinical prognostic indicator. In addition, high expression of CCL2 may be related to gene pathways such as Nod-like receptor signaling pathway, suggesting that CCL2 is involved in the inflammatory response and immune process of coronary artery disease.
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Affiliation(s)
- Meng Li
- Department of Cardiology, Heart Center of Henan Provincial People's Hospital, Central China Fuwai Hospital, Zhengzhou University, Zhengzhou 450003, China
| | - Yan Chen
- Department of Cardiology, Heart Center of Henan Provincial People's Hospital, Central China Fuwai Hospital, Zhengzhou University, Zhengzhou 450003, China
| | - Yan Zhang
- Department of Cardiology, Heart Center of Henan Provincial People's Hospital, Central China Fuwai Hospital, Zhengzhou University, Zhengzhou 450003, China
| | - Danna Li
- Department of Ultrasound, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Jun Liu
- Department of Cardiology, Heart Center of Henan Provincial People's Hospital, Central China Fuwai Hospital, Zhengzhou University, Zhengzhou 450003, China
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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: 101] [Impact Index Per Article: 20.2] [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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Kilic S, Kocabas U, Can LH, Yavuzgil O, Zoghi M. The Severity of Coronary Arterial Stenosis in Patients With Acute ST-Elevated Myocardial Infarction: A Thrombolytic Therapy Study. Cardiol Res 2018; 9:11-16. [PMID: 29479380 PMCID: PMC5819623 DOI: 10.14740/cr639w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 12/01/2017] [Indexed: 11/12/2022] Open
Abstract
Background It is widely believed that ST-elevated myocardial infarction (STEMI) generally occurs at the site of mild to moderate coronary stenosis. The aim of this study was to determine the degree of stenosis of infarct-related artery (IRA) in STEMI patients who underwent coronary angiography (CAG) after successful reperfusion with thrombolytic therapy (TT). Methods A total of 463 consecutive patients between January 2008 and December 2013 with acute STEMI treated with TT were evaluated retrospectively. The patients in whom reperfusion failed (n = 120), death occurred before CAG (n = 12), IRA cannot be determined (n = 10), and CAG was not performed in index hospitalization (n = 54) were excluded from the study. To determine the severity of stenosis of IRA, two experienced cardiologists who were unaware of each other used quantitative CAG analysis. Significant stenosis was defined as a ≥ 50% stenosis in the coronary artery lumen. A total of 267 patients who were successfully reperfused with TT and in whom CAG was performed during hospitalization with median 8 (1 - 17) days after myocardial infarction were included in the study. Results The mean age of patients was 55.7 ± 10.8 years (85.5% male). Most of the patients had a significant stenosis in IRA ( ≥ 50%, n = 236, group 1) after successful TT; whereas only 11.6% had stenosis < 50% (n = 31, group 2). In addition, majority of the patients had ≥ 70.4% (n = 188, 70.4%) stenosis in IRA. Average of stenosis in IRA was 74±16%. Conclusions In contrast to the general opinion, we detected that majority of STEMI patients had a significant stenosis in IRA.
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Affiliation(s)
- Salih Kilic
- Department of Cardiology, Doctor Ersin Arslan Research and Training Hospital, Gaziantep, Turkey
| | - Umut Kocabas
- Department of Cardiology, Soma State Hospital, Manisa, Turkey
| | - Levent Hurkan Can
- Department of Cardiology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Oguz Yavuzgil
- Department of Cardiology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Mehdi Zoghi
- Department of Cardiology, Ege University Faculty of Medicine, Izmir, Turkey
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Natural History of Moderate Coronary Artery Stenosis After Surgical Revascularization. Ann Thorac Surg 2017; 105:815-821. [PMID: 29275826 DOI: 10.1016/j.athoracsur.2017.08.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 07/08/2017] [Accepted: 08/28/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND It remains controversial whether grafting moderately stenosed coronary arteries (MSCAs) influences native-vessel disease progression and whether grafting may protect against late myocardial ischemia. METHODS From 1972 to 2011, 55,567 patients underwent primary isolated coronary artery bypass grafting (CABG); 1,902 had a single coronary artery with angiographically moderate (50% to 69%) stenosis and ≥1 postoperative angiogram. Disease progression was studied in 489 nongrafted, 371 internal thoracic artery (ITA)-grafted, and 957 saphenous vein (SV)-grafted MSCAs, as well as patency of 376 ITA and 1,016 SV grafts to these MSCAs. RESULTS At 1, 5, 10, and 15 years, native-vessel disease progressed from moderate to severe stenosis/occlusion in 32%, 52%, 66%, and 72% of nongrafted MSCAs; 55%, 73%, 84%, and 87% of ITA-grafted MSCAs; and 67%, 82%, 90%, and 92% of SV-grafted MSCAs. After adjusting for patient characteristics, MSCA disease progressed 3.6 times faster with ITA and 10 times faster with SV grafting compared with nongrafting. At these same time points, occlusion of ITA grafts to MSCAs was 8%, 9%, 11%, and 15% and for SV grafts, 13%, 32%, 46%, and 56%; protection from myocardial ischemia by ITA-grafted versus nongrafted MSCAs was 29%, 47%, 59%, and 61%. CONCLUSIONS Most MSCAs progress to severe stenosis or occlusion in the long term. Progression is faster in grafted than nongrafted MSCAs, more so with SV than ITA grafts. However, ITA grafts to such arteries have excellent patency, providing long-term protection from myocardial ischemia. Therefore, ITA grafting of MSCAs should be considered.
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Higuma T, Soeda T, Yamada M, Yokota T, Yokoyama H, Nishizaki F, Xing L, Yamamoto E, Bryniarski K, Dai J, Lee H, Okumura K, Jang IK. Coronary Plaque Characteristics Associated With Reduced TIMI (Thrombolysis in Myocardial Infarction) Flow Grade in Patients With ST-Segment-Elevation Myocardial Infarction: A Combined Optical Coherence Tomography and Intravascular Ultrasound Study. Circ Cardiovasc Interv 2017; 9:CIRCINTERVENTIONS.116.003913. [PMID: 27609831 DOI: 10.1161/circinterventions.116.003913] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 08/09/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous studies reported that reduced TIMI (Thrombolysis in Myocardial Infarction) flow grade before procedure was associated with worse clinical outcomes in patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention. The aim of this study was to identify specific morphological characteristics of the culprit plaque associated with poor TIMI flow grade at baseline in patients with ST-segment-elevation myocardial infarction using both optical coherence tomography and intravascular ultrasound. METHODS AND RESULTS A total of 111 ST-segment-elevation myocardial infarction patients who underwent percutaneous coronary intervention within 24 hours of symptom onset were included. Both optical coherence tomography and intravascular ultrasound were performed after thrombectomy. Patients were divided into 2 groups according to preprocedural TIMI flow grade (TIMI 0-1 [n=82] and TIMI 2-3 [n=29]). Patients with preprocedural TIMI 0 to 1 had a greater lipid arc (P=0.037), a longer lipid length (P=0.021), and a greater lipid index (P=0.007) determined by optical coherence tomography and a larger external elastic membrane cross-sectional area (P=0.030) and plaque plus media cross-sectional area (P=0.030) determined by intravascular ultrasound, compared with patients with preprocedural TIMI 2 to 3. CONCLUSIONS ST-segment-elevation myocardial infarction patients with reduced TIMI flow grade at baseline have greater lipid burden, larger vessel sizes, and larger plaque areas.
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Affiliation(s)
- Takumi Higuma
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Tsunenari Soeda
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Masahiro Yamada
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Takashi Yokota
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Hiroaki Yokoyama
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Fumie Nishizaki
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Lei Xing
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Erika Yamamoto
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Krzysztof Bryniarski
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Jiannan Dai
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Hang Lee
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Ken Okumura
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.)
| | - Ik-Kyung Jang
- From the Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan (T.H., M.Y., T.Y., H.Y., F.N., K.O.); Cardiology Division (T.H., T.S., L.X., E.Y., K.B., J.D., I.-K.J.) and Biostatistics Center (H.L.), Massachusetts General Hospital and Harvard Medical School, Boston; and Division of Cardiology, Kyung Hee University, Seoul, Republic of Korea (I.-K.J.).
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Kajander OA, Pinilla-Echeverri N, Jolly SS, Bhindi R, Huhtala H, Niemelä K, Fung A, Vijayaraghavan R, Alexopoulos D, Sheth T. Culprit plaque morphology in STEMI - an optical coherence tomography study: insights from the TOTAL-OCT substudy. EUROINTERVENTION 2017; 12:716-23. [PMID: 27542783 DOI: 10.4244/eijv12i6a116] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Our aim was to compare stenosis severity and plaque content between STEMI culprit lesions with intact fibrous cap (IFC) and those with plaque rupture (PR) in a prospective study. METHODS AND RESULTS We evaluated 93 patients undergoing OCT and thrombectomy as part of a prospective substudy of the TOTAL (ThrOmbecTomy versus PCI ALone) trial. Culprit lesion morphology was assessable by OCT in 70/93 (75.3%). IFC was found in 31 (44.3%), PR in 34 (48.6%) and calcified nodule in five (7.1%) patients. Following thrombectomy, OCT demonstrated similar lumen area stenosis in IFC (79.3%) and PR (79.6%) (p=0.88). Lumen area stenosis <50% was observed in none of the patients with PR and in one patient with IFC. IFC had fewer quadrants with lipid plaque as compared to PR (28.16±15.02 vs. 39.12±14.23, p=0.004). However, in both lesion types, lipid was the predominant plaque type (83.9 vs. 63.7% of diseased quadrants). CONCLUSIONS In a prospective study of STEMI patients treated with thrombectomy, mild residual stenoses were uncommon in IFC lesions. Although lipid content was lower than in PR lesions, lipid composed the majority of the diseased segments in IFC.
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Affiliation(s)
- Olli A Kajander
- Heart Hospital, Tampere University Hospital and School of Medicine, University of Tampere, Tampere, Finland
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11
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Stenting versus non-stenting treatment of intermediate stenosis culprit lesion in acute ST-segment elevation myocardial infarction: a multicenter randomized clinical trial. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2017; 14:108-117. [PMID: 28491085 PMCID: PMC5409352 DOI: 10.11909/j.issn.1671-5411.2017.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background The benefit/risk ratio of stenting in acute ST-segment elevation myocardial infarction (STEMI) patients with single vessel intermediate stenosis culprit lesions merits further study, therefore the subject of the present study. Methods and results It was a prospective, multicenter, randomized controlled trial. Between April 2012 and July 2015, 399 acute STEMI patients with single vessel disease and intermediate (40%–70%) stenosis of the culprit lesion before or after aspiration thrombectomy and/or intracoronary tirofiban (15 µg/kg) were enrolled and were randomly assigned (1: 1) to stenting group (n = 201) and non-stenting group (n = 198). In stenting group, patients received pharmacologic therapy plus standard percutaneous coronary intervention (PCI) with stent implantation. In non-stenting group, patients received pharmacologic therapy and PCI (thrombectomy), but without dilatation or stenting. Primary endpoint was 12-month rate of major adverse cardiac and cerebrovascular events (MACCE), a composite of cardiac death, non-fatal myocardial infarction (MI), repeat revascularization and stroke. Secondary endpoints were 12-month rates of all cause death, ischemia driven admission and bleeding complication. Median follow-up time was 12.4 ± 3.1 months. At 12 months, MACCE occurred in 8.0% of the patients in stenting group, as compared with 15.2% in the non-stenting group (adjusted HR: 0.42, 95% CI: 0.19–0.89, P = 0.02). The stenting group had lower non-fatal MI rate than non-stenting group, (1.5% vs. 5.5%, P = 0.03). The two groups shared similar cardiac death, repeat revascularization, stroke, all cause death, ischemia driven readmission and bleeding rates at 12 months. Conclusions Stent implantation had better efficacy and safety in reducing MACCE risks among acute STEMI patients with single vessel intermediate stenosis culprit lesions.
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12
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Marini A, Naka KK, Vakalis K, Bechlioulis A, Bougiakli M, Giannitsi S, Nikolaou K, Antoniadou EI, Gartzonika C, Chasiotis G, Bairaktari E, Katsouras CS, Triantis G, Sionis D, Michalis LK. Extent of coronary artery disease in patients undergoing angiography for stable or acute coronary syndromes. Hellenic J Cardiol 2017; 58:115-121. [PMID: 28495650 DOI: 10.1016/j.hjc.2016.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 08/31/2016] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND We aimed to investigate whether the angiographic extent of coronary artery disease (CAD) differs in patients undergoing coronary angiography for stable CAD or acute coronary syndrome (ACS) and identify predictors of CAD extent in these patients. METHODS We enrolled 584 consecutive patients (463 with stable CAD, 121 with ACS) with angiographically established CAD (≥1 stenosis >25%). The Gensini score was used to assess the extent of coronary atherosclerosis. RESULTS Stable CAD patients had greater Framingham risk score and greater prevalence of hypertension, hypercholesterolemia, and diabetes (p<0.05 for all). Fasting glucose and systolic and diastolic blood pressure were higher, while high-sensitivity C-reactive protein (hsCRP) levels were lower in patients with stable CAD than in those with ACS (p<0.05 for all). No difference in Gensini score was observed between the two groups (p=0.118), but patients with ACS were more likely to have at least one significant epicardial angiographic lesion (>50% stenosis) (OR 2.0, p=0.022). Higher Gensini score was independently associated with (i) higher hsCRP and glucose levels, hypercholesterolemia, and increased age in stable CAD patients (R2 0.15, p<0001) and (ii) increased age and higher glucose and hsCRP levels in patients with ACS (R2 0.17, p<0001). CONCLUSIONS Patients undergoing coronary angiography for ACS or stable CAD presented with a similar extent of angiographic CAD, although patients with ACS had a higher prevalence of significant lesions in the presence of a better cardiovascular risk profile and higher inflammation levels. The extent of angiographic CAD in both the groups shared common determinants such as hsCRP, age, and hyperglycemia, but these appeared to explain only a small part of the variation of coronary atherosclerosis.
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Affiliation(s)
- Aikaterini Marini
- Michaelidion Cardiac Center, University of Ioannina, Ioannina, Greece
| | - Katerina K Naka
- Michaelidion Cardiac Center, University of Ioannina, Ioannina, Greece; 2(nd) Department of Cardiology, University of Ioannina, Ioannina, Greece
| | | | - Aris Bechlioulis
- Michaelidion Cardiac Center, University of Ioannina, Ioannina, Greece; 2(nd) Department of Cardiology, University of Ioannina, Ioannina, Greece
| | - Mara Bougiakli
- Michaelidion Cardiac Center, University of Ioannina, Ioannina, Greece
| | - Sophia Giannitsi
- Michaelidion Cardiac Center, University of Ioannina, Ioannina, Greece
| | | | | | | | - Georgios Chasiotis
- Laboratory of Biochemistry, University Hospital of Ioannina, Ioannina, Greece
| | - Eleni Bairaktari
- Laboratory of Biochemistry, University Hospital of Ioannina, Ioannina, Greece
| | - Christos S Katsouras
- Michaelidion Cardiac Center, University of Ioannina, Ioannina, Greece; 2(nd) Department of Cardiology, University of Ioannina, Ioannina, Greece
| | | | | | - Lampros K Michalis
- Michaelidion Cardiac Center, University of Ioannina, Ioannina, Greece; 2(nd) Department of Cardiology, University of Ioannina, Ioannina, Greece.
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Synetos A, Papaioannou S, Tousoulis D. Atherosclerosis and inflammation. Clinical aspects of a modern tale. Hellenic J Cardiol 2017; 58:122-123. [PMID: 28743520 DOI: 10.1016/j.hjc.2017.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/10/2017] [Indexed: 10/19/2022] Open
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14
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Sen T, Astarcioglu MA, Beton O, Asarcikli LD, Kilit C. Which Coronary Lesions Are More Prone to Cause Acute Myocardial Infarction? Arq Bras Cardiol 2017; 108:149-153. [PMID: 28099589 PMCID: PMC5344660 DOI: 10.5935/abc.20170003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 09/13/2016] [Indexed: 11/27/2022] Open
Abstract
Background According to common belief, most myocardial infarctions (MIs) are due to the
rupture of nonsevere, vulnerable plaques with < 70% obstruction. Data
from recent trials challenge this belief, suggesting that the risk of
coronary occlusion is, in fact, much higher after severe stenosis. The aim
of this study was to investigate whether or not acute ST-elevation MIs
result from high-grade stenoses by evaluating the presence of coronary
collateral circulation (CCC). Methods We retrospectively included 207 consecutive patients who had undergone
primary percutaneous coronary intervention for acute ST-elevation MI.
Collateral blood flow distal to the culprit lesion was assessed by two
investigators using the Rentrop scoring system. Results Out of the 207 patients included in the study, 153 (73.9%) had coronary
collateral vessels (Rentrop 1-3). The Rentrop scores were 0, 1, 2, and 3 in
54 (26.1%), 50 (24.2%), 51 (24.6%), and 52 (25.1%) patients, respectively.
Triglycerides, mean platelet volume (MPV), white cell (WBC) count, and
neutrophil count were significantly lower in the group with good collateral
vessels (p = 0.013, p = 0.002, p = 0.003, and p = 0.021, respectively). Conclusion More than 70% of the patients with acute MI had CCC with Rentrop scores of
1-3 during primary coronary angiography. This shows that most cases of acute
MI in our study originated from underlying high-grade stenoses, challenging
the common believe. Higher serum triglycerides levels, greater MPV, and
increased WBC and neutrophil counts were independently associated with
impaired development of collateral vessels.
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Affiliation(s)
- Taner Sen
- Dumlupinar University Kutahya Evliya Celebi Education and Research Hospital, Kutahya - Turkey
| | - Mehmet Ali Astarcioglu
- Dumlupinar University Kutahya Evliya Celebi Education and Research Hospital, Kutahya - Turkey
| | | | | | - Celal Kilit
- Dumlupinar University Kutahya Evliya Celebi Education and Research Hospital, Kutahya - Turkey
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15
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Sheng L, Li S, Li JQ, Xue JY, Sun YM, Gong YT, Jing L, Sun DH, Li WM, Wang DY, Li Y. Presence of Severe Stenosis in Most Culprit Lesions of Patients with ST-segment Elevation Myocardial Infarction. Chin Med J (Engl) 2016; 129:2074-8. [PMID: 27569234 PMCID: PMC5009591 DOI: 10.4103/0366-6999.189053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Previous studies revealed that culprit vessels of ST-segment elevation myocardial infarction (STEMI) were often related to mild or moderate stenosis. However, recent studies suggested that severe stenosis was primarily found in culprit lesions. The objective of this study was to analyze the stenosis severity of culprit lesions in STEMI patients and to clarify the paradoxical results. Methods: A total of 489 consecutive STEMI patients who underwent primary percutaneous coronary intervention were retrospectively studied from January 2012 to December 2014. The patients were divided into three groups based on stenosis severity using quantitative coronary analysis: Group A, 314 cases, stenosis ≥70%; Group B, 127 cases, stenosis 50–70%; and Group C, 48 cases, stenosis ≤50%. The clinical, demographic, and angiographic data of all groups were analyzed. Results: Patients in Group A exhibited a significantly higher prevalence of history of angina pectoris (95.9% vs. 62.5%, P < 0.001), multivessel disease (73.2% vs. 54.2%, P = 0.007), and lower cardiac ejection fraction (53.3 ± 8.6 vs. 56.8 ± 8.4, P = 0.009) than those in Group C. Multivariable analysis revealed that history of angina pectoris (odds ratio [OR]: 13.89, 95% confidence interval [CI]: 6.21–31.11) and multivessel disease (OR: 2.32, 95% CI: 1.25–4.31) were correlated with severe stenosis of the culprit lesion in Group A. Conclusions: Most culprit lesions in STEMI patients were severe stenosis. These patients exhibited a higher prevalence of angina history and multivessel diseases.
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Affiliation(s)
- Li Sheng
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang 150001, China
| | - Shuang Li
- Postgraduate Institute, Harbin Medical University, Harbin, Heilongjiang 150081, China
| | - Jian-Qiang Li
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang 150001, China
| | - Jing-Yi Xue
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang 150001, China
| | - Yan-Ming Sun
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang 150001, China
| | - Yong-Tai Gong
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang 150001, China
| | - Ling Jing
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang 150001, China
| | - Dang-Hui Sun
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang 150001, China
| | - Wei-Min Li
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang 150001, China
| | - Ding-Yu Wang
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang 150001, China
| | - Yue Li
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang 150001, China
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Cardiac Usage of Reducible Poly(oligo-D-arginine) As a Gene Carrier for Vascular Endothelial Growth Factor Expression. PLoS One 2015; 10:e0144491. [PMID: 26649571 PMCID: PMC4674056 DOI: 10.1371/journal.pone.0144491] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 11/19/2015] [Indexed: 11/20/2022] Open
Abstract
Developments of non-viral carriers have headed toward reducing cytotoxicity, which results from the use of conventional gene carriers, and enhancing gene delivery efficiency. Cys-(d-R9)-Cys repeated reducible poly(oligo-D-arginine) (rPOA) is one of the most efficient non-viral carriers for gene therapy; however, while its efficiency has been verified in the lung and brain, it is necessary to confirm its activity in each organ or tissue since there are differences of gene carrier susceptibility to among tissue types. We therefore tested the compatibility of rPOA in cardiac tissue by in vitro or in vivo experiments and confirmed its high transfection efficiency and low cytotoxicity. Moreover, substantial regenerative effects were observed following transfection with rPOA/pVEGF expression vector complexes (79% decreased infarct size) compared to polyethyleneimine (PEI) (34% decreased infarct size) in a rat myocardial infarction (MI) model. These findings suggest that rPOA efficiently enables DNA transfection in cardiac tissue and can be used as a useful non-viral therapeutic gene carrier for gene therapy in ischemic heart disease.
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17
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Ahmadi A, Leipsic J, Blankstein R, Taylor C, Hecht H, Stone GW, Narula J. Do plaques rapidly progress prior to myocardial infarction? The interplay between plaque vulnerability and progression. Circ Res 2015; 117:99-104. [PMID: 26089367 DOI: 10.1161/circresaha.117.305637] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is a common misperception in the cardiology community that most acute coronary events arise from ruptures of mildly stenotic plaques. This notion has emanated from multiple studies that had measured the degree of angiographic luminal narrowing in culprit plaques months to years before myocardial infarction. However, angiographic studies within 3 months before myocardial infarction, immediately after myocardial infarction with thrombus aspiration or fibrinolytic therapy, and postmortem pathological observations have all shown that culprit plaques in acute myocardial infarction are severely stenotic. Serial angiographic studies also have demonstrated a sudden rapid lesion progression before most cases of acute coronary syndromes. The possible mechanisms for such rapid plaque progression and consequent luminal obstruction include recurrent plaque rupture and healing and intraplaque neovascularization and hemorrhage with deposition of erythrocyte-derived free cholesterol. Moreover, recent intravascular and noninvasive imaging studies have demonstrated that plaques which result in coronary events have larger plaque volume and necrotic core size with greater positive vessel remodeling compared with plaques, which remain asymptomatic during several years follow-up, although these large atheromatous vulnerable plaques may angiographically seem mild. As such, it is these vulnerable plaques which are more prone to rapid plaque progression or are those in which plaque progression is more likely to become clinically evident. Therefore, in addition to characterizing plaque morphology, inflammatory activity, and severity, detection of the rate of plaque progression might identify vulnerable plaques with an increased potential for adverse outcomes.
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Affiliation(s)
- Amir Ahmadi
- From the Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.A., H.H., J.N.); Division of Cardiology (A.A., J.L., C.T.), and Division of Radiology (J.L.), University of British Columbia, Vancouver, BC, Canada; Division of Cardiovascular Medicine, Brigham and Women Hospital, Harvard Medical School, Boston, MA (R.B.); and Medical Center and the Cardiovascular Research Foundation, Columbia University, New York, NY (G.W.S.)
| | - Jonathon Leipsic
- From the Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.A., H.H., J.N.); Division of Cardiology (A.A., J.L., C.T.), and Division of Radiology (J.L.), University of British Columbia, Vancouver, BC, Canada; Division of Cardiovascular Medicine, Brigham and Women Hospital, Harvard Medical School, Boston, MA (R.B.); and Medical Center and the Cardiovascular Research Foundation, Columbia University, New York, NY (G.W.S.)
| | - Ron Blankstein
- From the Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.A., H.H., J.N.); Division of Cardiology (A.A., J.L., C.T.), and Division of Radiology (J.L.), University of British Columbia, Vancouver, BC, Canada; Division of Cardiovascular Medicine, Brigham and Women Hospital, Harvard Medical School, Boston, MA (R.B.); and Medical Center and the Cardiovascular Research Foundation, Columbia University, New York, NY (G.W.S.)
| | - Carolyn Taylor
- From the Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.A., H.H., J.N.); Division of Cardiology (A.A., J.L., C.T.), and Division of Radiology (J.L.), University of British Columbia, Vancouver, BC, Canada; Division of Cardiovascular Medicine, Brigham and Women Hospital, Harvard Medical School, Boston, MA (R.B.); and Medical Center and the Cardiovascular Research Foundation, Columbia University, New York, NY (G.W.S.)
| | - Harvey Hecht
- From the Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.A., H.H., J.N.); Division of Cardiology (A.A., J.L., C.T.), and Division of Radiology (J.L.), University of British Columbia, Vancouver, BC, Canada; Division of Cardiovascular Medicine, Brigham and Women Hospital, Harvard Medical School, Boston, MA (R.B.); and Medical Center and the Cardiovascular Research Foundation, Columbia University, New York, NY (G.W.S.)
| | - Gregg W Stone
- From the Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.A., H.H., J.N.); Division of Cardiology (A.A., J.L., C.T.), and Division of Radiology (J.L.), University of British Columbia, Vancouver, BC, Canada; Division of Cardiovascular Medicine, Brigham and Women Hospital, Harvard Medical School, Boston, MA (R.B.); and Medical Center and the Cardiovascular Research Foundation, Columbia University, New York, NY (G.W.S.)
| | - Jagat Narula
- From the Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY (A.A., H.H., J.N.); Division of Cardiology (A.A., J.L., C.T.), and Division of Radiology (J.L.), University of British Columbia, Vancouver, BC, Canada; Division of Cardiovascular Medicine, Brigham and Women Hospital, Harvard Medical School, Boston, MA (R.B.); and Medical Center and the Cardiovascular Research Foundation, Columbia University, New York, NY (G.W.S.).
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18
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Liang M, Kajiya T, Chan MY, Tay E, Lee CH, Richards AM, Low AF, Tan HC. High-grade culprit lesions are a common cause of ST-segment elevation myocardial infarction. Singapore Med J 2015; 56:334-8. [PMID: 26106241 DOI: 10.11622/smedj.2015092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Conventional knowledge holds that the majority of ruptured atherosclerotic plaques causing ST-segment elevation myocardial infarction (STEMI) are found in moderate stenoses that produce < 50% loss of arterial diameter. This study aimed to analyse the culprit lesions in patients who presented with STEMI and underwent primary percutaneous coronary intervention (PPCI) at our institution. METHODS Patients who underwent PPCI between June 2008 and August 2010 at our institution were included in the analysis. Quantitative coronary angiography was performed for the culprit lesions immediately after antegrade flow was restored by thrombectomy, low-profile balloon predilatation or guidewire crossing. RESULTS A total of 1,021 patients were included in the study. The mean age was 57 ± 12 years and 85.2% were male. Lesion measurement was done after coronary flow was restored by thrombectomy (73.1%), balloon dilatation (24.1%) and following guidewire passage across the lesion (2.8%). Mean minimal luminal diameter was 1.1 ± 0.5 mm, mean reference vessel diameter was 2.8 ± 0.6 mm, mean diameter stenosis was 61 ± 16% and mean lesion length was 16 ± 6 mm. Most (80.2%) of the culprit lesions had diameter stenoses > 50% (p < 0.01). Although balloon angioplasty was performed in 24.1% of the patients, the majority (64.2%) still had diameter stenoses > 50%. High-grade stenoses (> 50%) were more frequently observed in male patients (p = 0.04). CONCLUSION Contrary to the existing paradigm, we found that most of the patients with STEMI in our institution had culprit lesions with diameter stenosis > 50%.
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Affiliation(s)
- Michael Liang
- National University Heart Centre Singapore, Singapore
| | | | - Mark Y Chan
- National University Heart Centre Singapore, Singapore
| | - Edgar Tay
- National University Heart Centre Singapore, Singapore
| | - Chi-Hang Lee
- National University Heart Centre Singapore, Singapore
| | | | - Adrian F Low
- National University Heart Centre Singapore, Singapore
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Abstract
BACKGROUND Pressure wire assessment of the infarct-related artery (IRA) in ST-elevation myocardial infarction (STEMI) is not recommended until microcirculatory dysfunction recovers. OBJECTIVE The objective of this study was to assess serial fractional flow reserve (FFR) and the index of microcirculatory resistance (IMR) in the IRA of STEMI patients to better understand and interpret FFR during primary percutaneous coronary intervention (PPCI). METHODS Forty-one patients undergoing PPCI for STEMI were studied with a pressure wire at baseline after thrombectomy and after stenting. RESULTS The majority of STEMI culprit lesions in the IRA were haemodynamically significant (mean FFR pre-PPCI: 0.54±0.20); only 4/41 culprit lesions had FFR greater than 0.80. The FFR of the culprit lesion and the initial IMR were correlated (r=0.45, P=0.004). Patients with a normal initial IMR of less than 25 exhibited lower culprit lesion FFR values (0.47±0.20 vs. 0.60±0.18, P=0.03) despite milder angiographic stenoses [angiographic stenoses (%): 80.4±10.4 vs. 86.6±8.0, P=0.03] but showed a reduction in the IMR during PPCI (pre-PPCI: 16.9±5.7 vs. post-PPCI: 32.2±22.6, P=0.009). CONCLUSION STEMI culprit lesions are haemodynamically significant. A subset of STEMI IRAs has initially preserved microcirculatory function; thus, the culprit stenosis may feasibly be assessed through FFR.
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Arbab-Zadeh A, Fuster V. The myth of the "vulnerable plaque": transitioning from a focus on individual lesions to atherosclerotic disease burden for coronary artery disease risk assessment. J Am Coll Cardiol 2015; 65:846-855. [PMID: 25601032 DOI: 10.1016/j.jacc.2014.11.041] [Citation(s) in RCA: 323] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 11/04/2014] [Accepted: 11/25/2014] [Indexed: 01/04/2023]
Abstract
The cardiovascular science community has pursued the quest to identify vulnerable atherosclerotic plaque in patients for decades, hoping to prevent acute coronary events. However, despite major advancements in imaging technology that allow visualization of rupture-prone plaques, clinical studies have not demonstrated improved risk prediction compared with traditional approaches. Considering the complex relationship between plaque rupture and acute coronary event risk suggested by pathology studies and confirmed by clinical investigations, these results are not surprising. This review summarizes the evidence supporting a multifaceted hypothesis of the natural history of atherosclerotic plaque rupture. Managing patients at risk of acute coronary events mandates a greater focus on the atherosclerotic disease burden rather than on features of individual plaques.
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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, New York, New York
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Burgmaier M, Hellmich M, Marx N, Reith S. A score to quantify coronary plaque vulnerability in high-risk patients with type 2 diabetes: an optical coherence tomography study. Cardiovasc Diabetol 2014; 13:117. [PMID: 25248966 PMCID: PMC4148556 DOI: 10.1186/s12933-014-0117-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 07/21/2014] [Indexed: 11/16/2022] Open
Abstract
Background Patients with type 2 diabetes are at a high risk for acute cardiovascular events, which usually arise from the rupture of a vulnerable coronary lesion characterized by specific morphological plaque features. Thus, the identification of vulnerable plaques is of utmost clinical importance in patients with type 2 diabetes. However, there is currently no scoring system available to identify vulnerable lesions based on plaque characteristics. Thus, we aimed to characterize the diagnostic value of optical coherence tomography (OCT) - derived lesion characteristics to quantify plaque vulnerability both as individual parameters and when combined to a score in patients with type 2 diabetes. Methods OCT was performed in the coronary culprit lesions of 112 patients with type 2 diabetes. The score, which quantifies plaque vulnerability, was defined as the predicted probability that a lesion is the cause for an acute coronary syndrome (ACS) (vs. stable angina (SAP)) based on its specific plaque morphology. Results Multivariable logistic regression analysis demonstrated that plaque vulnerability was independently predicted by the minimal fibrous cap thickness overlying a lesion’s lipid core (odds ratio (OR) per 10 μm 0.478, p = 0.002), the medium lipid arc (OR per 90° 13.997, p < 0.001), the presence of macrophages (OR 4.797, p = 0.015) and the lipid plaque length (OR 1.290, p = 0.098). Receiver-operating-characteristics (ROC) analyses demonstrated that these parameters combined to a score demonstrate an excellent diagnostic efficiency to identify culprit lesions of patients with ACS (vs. SAP, AUC 0.90, 95% CI 0.84-0.96). Conclusion This is the first study to present a score to quantify lesion vulnerability in patients with type 2 diabetes. This score may be a valuable adjunct in decision-making and useful in guiding coronary interventions.
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Tian J, Dauerman H, Toma C, Samady H, Itoh T, Kuramitsu S, Domei T, Jia H, Vergallo R, Soeda T, Hu S, Minami Y, Lee H, Yu B, Jang IK. Prevalence and Characteristics of TCFA and Degree of Coronary Artery Stenosis. J Am Coll Cardiol 2014; 64:672-80. [DOI: 10.1016/j.jacc.2014.05.052] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/01/2014] [Accepted: 05/05/2014] [Indexed: 10/24/2022]
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Tian J, Ren X, Vergallo R, Xing L, Yu H, Jia H, Soeda T, McNulty I, Hu S, Lee H, Yu B, Jang IK. Distinct Morphological Features of Ruptured Culprit Plaque for Acute Coronary Events Compared to Those With Silent Rupture and Thin-Cap Fibroatheroma. J Am Coll Cardiol 2014; 63:2209-16. [DOI: 10.1016/j.jacc.2014.01.061] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 11/29/2013] [Accepted: 01/14/2014] [Indexed: 10/25/2022]
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Puri R, Nicholls SJ, Ellis SG, Tuzcu EM, Kapadia SR. High-Risk Coronary Atheroma. J Am Coll Cardiol 2014; 63:1134-1140. [DOI: 10.1016/j.jacc.2013.05.088] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 05/10/2013] [Accepted: 05/13/2013] [Indexed: 10/26/2022]
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Advances in mechanisms, imaging and management of the unstable plaque. Atherosclerosis 2014; 233:467-477. [PMID: 24530781 DOI: 10.1016/j.atherosclerosis.2014.01.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/14/2014] [Accepted: 01/15/2014] [Indexed: 01/09/2023]
Abstract
Post-mortem observations demonstrated that plaque fissure was the final event leading to coronary thrombosis and occlusion in about two-thirds of cases of sudden coronary death. Plaques prone to fissure have, therefore, been defined "vulnerable plaques" and are identified by specific anatomic features including thin inflamed fibrous cap, large lipidic core and positive remodeling. Accordingly, elegant imaging modalities have been developed in order to identify this "holy grail". However, the results of prognostic studies based on the identification of vulnerable plaques have not been encouraging because of the low positive predictive value for major cardiovascular events. This observation is not surprising as the pathogenesis of acute coronary syndromes is complex and multifactorial. In this review we propose a pathogenetic classification of acute coronary syndromes in the attempt to identify homogeneous groups of patients with a common mechanism of coronary instability which can be identified by using specific biomarkers and imaging techniques, and become a specific therapeutic target.
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Tan HC, Poh KK. New Insights into Mechanisms of Acute Myocardial Infarction: A Journey of 100 Years. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2013. [DOI: 10.47102/annals-acadmedsg.v42n9p425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Huay Cheem Tan
- National University Heart Center, National University Health System, Singapore
| | - Kian Keong Poh
- National University Heart Center, National University Health System, Singapore
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Escaned J, Echavarría-Pinto M, Gorgadze T, Gonzalo N, Armengol F, Hernández R, Jiménez-Quevedo P, Nuñez-Gil IJ, Pérez-Vizcayno MJ, Alfonso F, Bañuelos C, Ibañez B, García E, Fernández-Ortiz A, Macaya C. Safety of lone thrombus aspiration without concomitant coronary stenting in selected patients with acute myocardial infarction. EUROINTERVENTION 2013; 8:1149-56. [PMID: 23425541 DOI: 10.4244/eijv8i10a178] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Although the benefit of concomitant thrombus aspiration (TA) in primary percutaneous coronary intervention (PPCI) treatment of acute ST-segment elevation myocardial infarction (STEMI) has been demonstrated, very little information is available on its safety as a lone revascularisation technique in this setting. We present our experience in a cohort of patients with STEMI treated only with TA, without concomitant interventional devices. METHODS AND RESULTS In 28 patients with STEMI, PPCI was performed using only TA on the grounds of an excellent angiographic result and in order to avoid the potential risks associated with balloon dilatation or stenting. The patients were younger than in the overall PPCI population (n=1,737) at our institution (52±18 vs. 63±14 years, p<0.001), with a history of atrial fibrillation in six (21%), cocaine abuse in three (11%) and mechanical cardiac valves in two (7%). Twenty-eight patients (89%) presented STEMI with Killip class I, two (7%) with cardiogenic shock, and two (7%) with sudden cardiac death. A significant reduction in TIMI thrombus grade (5 [4-5] to 1 [0-1.75], p<0.001) and coronary stenosis percentage (%) (87.2±21.3 to 11.3±0.9, p<0.001) as well as an increase in final TIMI flow (0 [0-2] to 3 [3-3], p<0.001) and minimum luminal diameter (mm) (0.89±1.01 to 2.42±0.70, p<0.001) were noted after TA. Transient no-reflow phenomenon, residual intracoronary thrombus and minor distal thrombus embolisation were observed in two (7.1%), 11 (39.3%) and 10 (25.7%) patients, respectively. All but one patient remained asymptomatic during hospital admission. Scheduled control angiography was performed 6±2 days (min-max, 3-10 days) after PPCI in 11 (39%) patients, demonstrating coronary artery patency and TIMI flow grade 3 in all patients. During clinical follow-up, successfully performed in all patients at 40±23 months (min-max, six to 95 months), there was one sudden cardiac death (4%) and three (11%) non-cardiac deaths. One patient (4%) was admitted with non-STEMI (new coronary angiogram without stenosis) and the remaining 22 (78.5%) remained asymptomatic and free of cardiac events. CONCLUSIONS Our series suggests that lone TA might be safely performed as a primary revascularisation procedure in STEMI in selected cases. Further information based on additional and larger studies is recommended to confirm our findings.
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Affiliation(s)
- Javier Escaned
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain.
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Ghaffari S, Erfanparast S, Separham A, Sokhanvar S, Yavarikia M, Pourafkari L. The Relationship between Coronary Artery Movement Type andStenosis Severity with Acute Myocardial Infarction. J Cardiovasc Thorac Res 2013; 5:41-4. [PMID: 24251009 DOI: 10.5681/jcvtr.2013.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 05/30/2013] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The severity of coronary artery stenosis which leads to myocardial infarction (MI) has been a matter of controversy. Historical data are in favor of mild luminal stenosis (<50% diameter stenosis) while recent studies suggest hemodynamically-significant coronary stenosis as the main substrate for subsequent MI. Also, mechanical stress resulted from coronary artery movement (CAM) may be responsible for plaques rupture. In this study, we evaluated the severity of plaques leading to MI and common CAM patterns in the involved coronary segments. METHODS In a cross-sectional descriptive-analytical study, on patients with acute ST-segment myocardial infarction (STEMI) undergoing coronary angiography, the relationship between coronary artery movement type and stenosis severity with acute MI was evaluated. Lesions with stenosis diameter greater than 50 percent were defined as moderate and those equal or higher than 70% were defined as severe stenosis. Three different patterns of coronary artery motion including compression, bending and displacement types were evaluated in segments with culprit lesion. RESULTS One hundred and sixty two patients were enrolled. Ninety patients (55.6%) were male and 72 (44.4%) were female. Mean age of the patients was 60.56±13.43 years. In terms of Infarct related lesions (IRLs), 86% of the cases had at least moderate stenosis and in 67%, severe stenosis was present. More than 50% stenosis was found in all patients with anterior STEMI involving LAD. Among three types of coronary motion patterns, compression pattern was significantly higher in LAD (P<0.001), RCA (P<0.001), Diagonal artery (P<0.001) and OM branch (P=0.044), but not in proper LCX (P=0.307). CONCLUSION Most of the lesions leading to myocardial infarction have a diameter stenosis of at least 50% and mainly are located in the coronary segments with compression movement pattern.
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Affiliation(s)
- Samad Ghaffari
- Cardiovascular Research Center, Tabriz University of Medical sciences, Tabriz, Iran
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Is there a role for coronary angiography in the early detection of the vulnerable plaque? Int J Cardiol 2013; 164:262-6. [DOI: 10.1016/j.ijcard.2012.01.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 10/29/2011] [Accepted: 01/10/2012] [Indexed: 11/17/2022]
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McCormick LM, Hoole SP, Brown AJ, Dutka DP, West NEJ. A contemporary re-evaluation of culprit lesion severity in patients presenting with STEMI. ACTA ACUST UNITED AC 2012; 14:111-6. [DOI: 10.3109/17482941.2012.712140] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ndrepepa G, Tada T, Fusaro M, Cassese S, King L, Hadamitzky M, Haase HU, Schömig A, Kastrati A, Pache J. Association of coronary atherosclerotic burden with clinical presentation and prognosis in patients with stable and unstable coronary artery disease. Clin Res Cardiol 2012; 101:1003-11. [DOI: 10.1007/s00392-012-0490-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 06/21/2012] [Indexed: 01/17/2023]
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Sharif F, Lohan DG, Wijns W. Non-invasive detection of vulnerable coronary plaque. World J Cardiol 2011; 3:219-29. [PMID: 21860703 PMCID: PMC3158870 DOI: 10.4330/wjc.v3.i7.219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 06/16/2011] [Accepted: 06/23/2011] [Indexed: 02/06/2023] Open
Abstract
Critical coronary stenoses have been shown to contribute to only a minority of acute coronary syndromes and sudden cardiac death. Autopsy studies have identified a subgroup of high-risk patients with disrupted vulnerable plaque and modest stenosis. Consequently, a clinical need exists to develop methods to identify these plaques prospectively before disruption and clinical expression of disease. Recent advances in invasive and non-invasive imaging techniques have shown the potential to identify these high-risk plaques. Non-invasive imaging with magnetic resonance imaging, computed tomography and positron emission tomography holds the potential to differentiate between low- and high-risk plaques. There have been significant technological advances in non-invasive imaging modalities, and the aim is to achieve a diagnostic sensitivity for these technologies similar to that of the invasive modalities. Molecular imaging with the use of novel targeted nanoparticles may help in detecting high-risk plaques that will ultimately cause acute myocardial infarction. Moreover, nanoparticle-based imaging may even provide non-invasive treatments for these plaques. However, at present none of these imaging modalities are able to detect vulnerable plaque nor have they been shown to definitively predict outcome. Further trials are needed to provide more information regarding the natural history of high-risk but non-flow-limiting plaque to establish patient specific targeted therapy and to refine plaque stabilizing strategies in the future.
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Affiliation(s)
- Faisal Sharif
- Faisal Sharif, Department of Cardiology, Regional Hospital Galway, and Regenerative Medicine Institute, National University of Ireland Galway, County Galway, Ireland
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Chan KH, Chawantanpipat C, Gattorna T, Chantadansuwan T, Kirby A, Madden A, Keech A, Ng MK. The relationship between coronary stenosis severity and compression type coronary artery movement in acute myocardial infarction. Am Heart J 2010; 159:584-92. [PMID: 20362716 DOI: 10.1016/j.ahj.2009.12.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Accepted: 12/28/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Acute myocardial infarction is thought to occur at sites of minor coronary stenosis. Recent data challenge this and also propose a role for coronary artery movement (CAM) in plaque instability. We examined the relationship between coronary stenosis severity, CAM pattern, and infarct-related lesions (IRLs) in acute myocardial infarction. METHODS We investigated 203 consecutive patients with ST-segment elevation myocardial infarction after successful fibrinolysis. Quantitative coronary angiography, CAM pattern, and extent score (atheroma burden) analysis was performed for each coronary artery segment. RESULTS The IRL stenosis was at least moderate (>50%) and severe (>70%) in 78% and 31% of patients, respectively. Culprit arteries were associated with higher atheroma extent scores (25.2 vs 21.6, P < .001). Analysis of 2,228 coronary segments showed that stenosis severity and IRLs were highly correlated, such that the likelihood of being a culprit segment progressively increased with worsening stenosis (odds ratio [OR] 30.0, 95% confidence interval [CI] 19.0-47.6, P < .001, for >70% vs <30% stenosis). Compression CAM was also strongly associated with culprit segments (OR 3.4, 95% CI 2.6-4.5, P < .001). In addition, compression CAM and stenosis severity were strongly correlated, with the likelihood of a coronary segment having compression CAM progressively increasing with worsening stenosis (OR 56.4, 95% CI 37.9-83.8, P < .001, for >70% vs <30% stenosis). CONCLUSIONS In patients with ST-segment elevation myocardial infarction, there is a strong relationship between stenosis severity and IRLs. Our study also raises the hypothesis that compression CAM may accelerate atherosclerosis and predispose to plaque vulnerability.
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Abstract
Critical coronary stenoses have been shown to contribute to only a minority of acute coronary syndromes (ACS) and sudden cardiac death. Autopsy studies have identified a subgroup of high-risk patients with disrupted vulnerable plaque and modest stenosis. Consequently, a clinical need exists to develop methods to identify these plaques prospectively before disruption and clinical expression of disease. Recent advances in invasive and noninvasive imaging techniques have shown the potential to identify these high-risk plaques. The anatomical characteristics of the vulnerable plaque such as thin cap fibroatheroma and lipid pool can be identified with angioscopy, high frequency intravascular ultrasound, intravascular MRI, and optical coherence tomography. Efforts have also been made to recognize active inflammation in high-risk plaques using intravascular thermography. Plaque chemical composition by measuring electromagnetic radiation using spectroscopy is also an emerging technology to detect vulnerable plaques. Noninvasive imaging with MRI, CT, and PET also holds the potential to differentiate between low and high-risk plaques. However, at present none of these imaging modalities are able to detect vulnerable plaque neither has been shown to definitively predict outcome. Nevertheless in contrast, there has been a parallel development in the physiological assessment of advanced atherosclerotic coronary artery disease. Thus recent trials using fractional flow reserve in patients with modest non flow-limiting stenoses have shown that deferral of PCI with optimal medical therapy in these patients is superior to coronary intervention. Further trials are needed to provide more information regarding the natural history of high-risk but non flow-limiting plaque to establish patient-specific targeted therapy and to refine plaque stabilizing strategies in the future.
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Affiliation(s)
- Faisal Sharif
- Department of Cardiology, St James' Hospital, St James' Street, Dublin 8, Ireland.
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Pijls NH. Acute myocardial infarction and underlying stenosis severity. Am J Cardiol 2009; 103:1204-5. [PMID: 19406259 DOI: 10.1016/j.amjcard.2009.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Revised: 01/09/2009] [Accepted: 01/09/2009] [Indexed: 10/21/2022]
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Manoharan G, Ntalianis A, Muller O, Hamilos M, Sarno G, Melikian N, Vanderheyden M, Heyndrickx GR, Wyffels E, Wijns W, De Bruyne B. Severity of coronary arterial stenoses responsible for acute coronary syndromes. Am J Cardiol 2009; 103:1183-8. [PMID: 19406256 DOI: 10.1016/j.amjcard.2008.12.047] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2008] [Revised: 12/21/2008] [Accepted: 12/21/2008] [Indexed: 10/21/2022]
Abstract
Acute myocardial infarctions were generally believed to result from plaque rupture and thrombosis at the site of a "mild to moderate" coronary stenosis. To assess the severity of coronary stenoses that predisposed to acute coronary syndrome, the 317 patients prospectively included were (1) 102 patients with acute ST-elevation myocardial infarction (STEMI) referred for primary percutaneous coronary intervention (PCI), (2) 135 patients with non-STEMI or unstable angina pectoris (UAP) referred for semiurgent PCI, and (3) 80 patients with stable angina pectoris (SAP) admitted for elective PCI. Patients with STEMI were included if thrombus aspiration could restore normal antegrade coronary blood flow. After aspiration (but before PCI), a high-quality angiogram was obtained and the reference diameter, minimal luminal diameter, and percentage of diameter stenosis of the culprit lesion were quantified. In patients with non-STEMI/UAP and SAP, aspiration was not performed. Average diameter of stenosis was similar in patients with STEMI and those with SAP (66 +/- 12% vs 65 +/- 10%, respectively; p = NS), but was slightly larger in patients with non-STEMI/UAP (71 +/- 12%; p <0.05 vs both STEMI and SAP). In patients with STEMI, only 11% of culprit stenoses were found to have diameter stenosis <50% after removal of the thrombus. In conclusion, most STEMIs occurred at the site of severe coronary stenosis. Diameter stenosis severity was <50% in a minority of cases.
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