Plaque Rupture and Intact Fibrous Cap in Patients With ACS
Plaque Rupture and Intact Fibrous Cap in Patients With ACS
Aims Patients presenting with acute coronary syndrome (ACS) may have different plaque morphologies at the culprit lesion. In particular, plaque rupture (PR) has been shown as the more frequent culprit plaque morphology in ACS. However, its prognostic value is still unknown. In this study, we evaluated the prognostic value of PR, compared with intact fibrous cap (IFC), in patients with ACS.
Methods and results We enrolled consecutive patients admitted to our Coronary Care Unit for ACS and undergoing coronary angiography followed by interpretable optical coherence tomography (OCT) imaging. Culprit lesion was classified as PR and IFC by OCT criteria. Prognosis was assessed according to such culprit lesion classification. Major adverse cardiac events (MACEs) were defined as the composite of cardiac death, non-fatal myocardial infarction, unstable angina, and target lesion revascularization (follow-up mean time 31.58 ± 4.69 months). The study comprised 139 consecutive ACS patients (mean age 64.3 ± 12.0 years, male 73.4%, 92 patients with non-ST elevation ACS and 47 with ST-elevation ACS). Plaque rupture was detected in 82/139 (59%) patients. There were no differences in clinical, angiographic, or procedural data between patients with PR when compared with those having IFC. Major adverse cardiac events occurred more frequently in patients with PR when compared with those having IFC (39.0 vs. 14.0%, P = 0.001). Plaque rupture was an independent predictor of outcome at multivariable analysis (odds ratio 3.735, confidence interval 1.358–9.735).
Conclusion Patients with ACS presenting with PR as culprit lesion by OCT have a worse prognosis compared with that of patients with IFC. This finding should be taken into account in risk stratification and management of patients with ACS.
Acute coronary syndromes (ACSs) are still a large burden of morbidity and mortality in patients affected by ischaemic heart disease. Thrombotic occlusion of a coronary artery is the final common event leading to blood flow reduction to the underlying myocardium in ACS. However, plaque causing thrombotic occlusion may have variable characteristics, and both postmortem studies and in vivo observations provided by intracoronary imaging modalities have suggested that thrombus may complicate a plaque with either a ruptured [plaque rupture (PR)] or intact fibrous cap (IFC). Plaque rupture is, indeed, the most common substrate of coronary thrombosis in nearly 50% of patients, but an eroded plaque is the substrate in up to one-third of patients with ACS, typically, women, younger, and smokers. Of note, vasoconstriction at the level of the culprit plaque or of the microcirculation may also cause ACS with IFC, as suggested by recent studies that used a provocative test or biomarkers related to vasospastic angina.
The advent of optical coherence tomography (OCT), an intracoronary light-based technology, has allowed to accurately characterize the plaque underlying coronary thrombosis, due to its high resolution. Importantly, ruptured plaques when compared with IFC plaques have different severity, plaque and thrombus composition and pathogenesis that may drive different outcomes. In particular, recent observations suggest that patients with PR may have widespread vulnerable features of the entire coronary tree. However, studies focused on the prognostic role of PR vs. IFC are lacking. In this study, we aim at comparing clinical outcome of patients with ACS undergoing OCT evaluation of the culprit plaque according to the plaque morphology (either PR or IFC) that caused clinical instability.
Abstract and Introduction
Abstract
Aims Patients presenting with acute coronary syndrome (ACS) may have different plaque morphologies at the culprit lesion. In particular, plaque rupture (PR) has been shown as the more frequent culprit plaque morphology in ACS. However, its prognostic value is still unknown. In this study, we evaluated the prognostic value of PR, compared with intact fibrous cap (IFC), in patients with ACS.
Methods and results We enrolled consecutive patients admitted to our Coronary Care Unit for ACS and undergoing coronary angiography followed by interpretable optical coherence tomography (OCT) imaging. Culprit lesion was classified as PR and IFC by OCT criteria. Prognosis was assessed according to such culprit lesion classification. Major adverse cardiac events (MACEs) were defined as the composite of cardiac death, non-fatal myocardial infarction, unstable angina, and target lesion revascularization (follow-up mean time 31.58 ± 4.69 months). The study comprised 139 consecutive ACS patients (mean age 64.3 ± 12.0 years, male 73.4%, 92 patients with non-ST elevation ACS and 47 with ST-elevation ACS). Plaque rupture was detected in 82/139 (59%) patients. There were no differences in clinical, angiographic, or procedural data between patients with PR when compared with those having IFC. Major adverse cardiac events occurred more frequently in patients with PR when compared with those having IFC (39.0 vs. 14.0%, P = 0.001). Plaque rupture was an independent predictor of outcome at multivariable analysis (odds ratio 3.735, confidence interval 1.358–9.735).
Conclusion Patients with ACS presenting with PR as culprit lesion by OCT have a worse prognosis compared with that of patients with IFC. This finding should be taken into account in risk stratification and management of patients with ACS.
Introduction
Acute coronary syndromes (ACSs) are still a large burden of morbidity and mortality in patients affected by ischaemic heart disease. Thrombotic occlusion of a coronary artery is the final common event leading to blood flow reduction to the underlying myocardium in ACS. However, plaque causing thrombotic occlusion may have variable characteristics, and both postmortem studies and in vivo observations provided by intracoronary imaging modalities have suggested that thrombus may complicate a plaque with either a ruptured [plaque rupture (PR)] or intact fibrous cap (IFC). Plaque rupture is, indeed, the most common substrate of coronary thrombosis in nearly 50% of patients, but an eroded plaque is the substrate in up to one-third of patients with ACS, typically, women, younger, and smokers. Of note, vasoconstriction at the level of the culprit plaque or of the microcirculation may also cause ACS with IFC, as suggested by recent studies that used a provocative test or biomarkers related to vasospastic angina.
The advent of optical coherence tomography (OCT), an intracoronary light-based technology, has allowed to accurately characterize the plaque underlying coronary thrombosis, due to its high resolution. Importantly, ruptured plaques when compared with IFC plaques have different severity, plaque and thrombus composition and pathogenesis that may drive different outcomes. In particular, recent observations suggest that patients with PR may have widespread vulnerable features of the entire coronary tree. However, studies focused on the prognostic role of PR vs. IFC are lacking. In this study, we aim at comparing clinical outcome of patients with ACS undergoing OCT evaluation of the culprit plaque according to the plaque morphology (either PR or IFC) that caused clinical instability.
