Morphology (PREDICTION) Study were to determine the role of local hemodynamic and vascular characteristics in coronary plaque progression and to relate plaque changes to clinical events. Methods and Results-Vascular profiling, using coronary angiography and intravascular ultrasound, was used to reconstruct each artery and calculate endothelial shear stress and plaque/remodeling characteristics in vivo. Three-vessel vascular profiling (2.7 arteries per patient) was performed at baseline in 506 patients with an acute coronary syndrome treated with a percutaneous coronary intervention and in a subset of 374 (74%) consecutive patients 6 to 10 months later to assess plaque natural history. Each reconstructed artery was divided into sequential 3-mm segments for serial analysis. One-year clinical follow-up was completed in 99.2%. Symptomatic clinical events were infrequent: only 1 (0.2%) cardiac death; 4 (0.8%) patients with new acute coronary syndrome in nonstented segments; and 15 (3.0%) patients hospitalized for stable angina. Increase in plaque area (primary end point) was predicted by baseline large plaque burden; decrease in lumen area (secondary end point) was independently predicted by baseline large plaque burden and low endothelial shear stress. Large plaque size and low endothelial shear stress independently predicted the exploratory end points of increased plaque burden and worsening of clinically relevant luminal obstructions treated with a percutaneous coronary intervention at follow-up. The combination of independent baseline predictors had a 41% positive and 92% negative predictive value to predict progression of an obstruction treated with a percutaneous coronary intervention. Conclusions-Large plaque burden and low local endothelial shear stress provide independent and additive prediction to identify plaques that develop progressive enlargement and lumen narrowing. Clinical Trial Registration-URL: http:www.//clinicaltrials.gov. Unique Identifier: NCT01316159. (Circulation. 2012;126:172-181.) Key Words: atherosclerosis Ⅲ endothelium Ⅲ natural history Ⅲ shear stress A therosclerosis is a systemic disease with focal and eccentric manifestations. 1 In a patient with coronary artery disease (CAD) and systemic risk factors, each coronary lesion progresses, regresses, or remains quiescent in an independent manner, 2 indicating that local vascular factors must be a major determinant responsible for the behavior of individual plaques. Editorial see p 161 Clinical Perspective on p 181The vascular endothelium is in a unique and pivotal position to respond to the extremely dynamic forces acting on the vessel wall because of the complex 3-dimensional (3D) Received January 27, 2012; accepted May 16, 2012. Identification of an early coronary atherosclerotic plaque likely to acquire high-risk characteristics and precipitate a new coronary event may allow for development of preemptive strategies to avert adverse events. The recent Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PR...

Large thrombus burden is an independent predictor of MACE and IRA-ST in patients treated with DES for STEMI.

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Background-The natural history of heterogeneous atherosclerotic plaques and the role of local hemodynamic factors throughout their development are unknown. We performed a serial study to assess the role of endothelial shear stress (ESS) and vascular remodeling in the natural history of coronary atherosclerosis. Methods and Results-Intravascular ultrasound-based 3-dimensional reconstruction of all major coronary arteries (nϭ15) was performed serially in vivo in 5 swine 4, 11,16,23, and 36 weeks after induction of diabetes mellitus and hyperlipidemia. The reconstructed arteries were divided into 3-mm-long segments (nϭ304). ESS was calculated in all segments at all time points through the use of computational fluid dynamics. Vascular remodeling was assessed at each time point in all segments containing significant plaque, defined as maximal intima-media thickness Ն0.5 mm, at week 36 (nϭ220). Plaque started to develop at week 11 and progressively advanced toward heterogeneous, multifocal lesions at all subsequent time points. Low ESS promoted the initiation and subsequent progression of plaques. The local remodeling response changed substantially over time and determined future plaque evolution. Excessive expansive remodeling developed in regions of very low ESS, further exacerbated the low ESS, and was associated with the most marked plaque progression. The combined assessment of ESS, remodeling, and plaque severity enabled the early identification of plaques that evolved to high-risk lesions at week 36. Key Words: atherosclerosis Ⅲ endothelial shear stress Ⅲ natural history Ⅲ remodeling A therosclerosis is a systemic disease with multifocal heterogeneous manifestations. 1 Because multiple plaques at different stages of progression and variable morphology typically coexist within the same patient or even artery, 2 characterizing and risk-stratifying each individual plaque in vivo would be invaluable. Increasing attention has focused on the in vivo identification of high-risk plaques most likely to rupture and cause an acute coronary event. Although previous evidence exists on the heterogeneous nature of atherosclerotic disease, there have been no previous in vivo studies to characterize the natural history of atherosclerosis and to determine the factors responsible for the heterogeneity of plaque development. As a result, no widely accepted method to prospectively identify high-risk plaque in vivo is available at present. Conclusions-The Clinical Perspective on p 2101The focal distribution and heterogeneity of plaques, despite the exposure of the entire vasculature to the same systemic risk factors, have been attributed to the effect of local hemodynamic forces. Endothelial shear stress (ESS) critically determines the regional localization of atherosclerosis and the evolution of individual lesions. 1,3,4 However, previous studies were often limited by the use of only 2 time points to assess Received August 25, 2009; accepted March 15, 2010 [5][6][7] or by the lack of animal models of humanlike coronary atheroscl...

Within the PCI and CABG arms of the all-comers SYNTAX trial, angiographically determined ICR has a detrimental impact on long-term clinical outcomes, including mortality. This effect remained consistent in patients with and without TOs.