Incidence and Predictors of Multiple Coronary Plaque Ruptures: A 3-Vessel Optical Coherence Tomography Study

Abstract

C oronary plaque rupture with subsequent thrombosis is the most common substrate of acute coronary syndrome and sudden cardiac death. 1-4 Although this phenomenon is often considered to result from a local instability, many of the patho-physiological factors believed to trigger plaque rupture (eg, inflammation or mechanical stress modulated by sympathetic tone) exert a widespread effect within the coronary tree. 5,6 In a seminal coronary angiography study, Goldstein et al 7 found that a substantial proportion of patients (≈40%) presenting with acute myocardial infarction (AMI) harbors multiple complex coronary lesions, which are related to adverse clinical outcomes. Subsequent intravascular ultrasound investigations yielded variable results, with a prevalence of plaque rupture at sites remote from the culprit lesion ranging from 14% to 79% in patients with acute presentations. 8-11 Interestingly, some of these studies suggested that additional plaque ruptures may occur even in stable or asymptomatic patients. 9,10 Using coronary angioscopy, Asakura et al 12 observed the diffuse presence of yellow plaques in patients with recent AMI, although the detection of thrombus distant from the culprit lesion was relatively rare. However, the imaging techniques used in these studies were limited in their spatial resolution and were not the modalities of choice for detecting and characterizing plaque rupture. 13 Therefore, the exact incidence and morphological features of plaque rupture at sites remote from the culprit lesion remain unknown. In addition, the clinical background and pancoronary atherosclerotic phenotype of patients experiencing multiple plaque ruptures have not been fully characterized, and it remains unclear whether multiple plaque ruptures occur simultaneously as the result of a generalized acute plaque destabilization. Optical coherence tomog-raphy (OCT) is a novel intracoronary imaging modality with high spatial resolution (≈10-15 μm), which enables detailed in vivo characterization of atherosclerotic plaques 14 and readily Objective-Plaque rupture may be the local expression of a widespread coronary instability. This study aimed to investigate: (1) the prevalence and characteristics of nonculprit plaque rupture; (2) the pancoronary atherosclerotic phenotype in patients with and without nonculprit plaque rupture; and (3) the prevalence and predictors of multiple plaque ruptures. Approach and Results-Six hundred and seventy-five nonculprit plaques from 261 patients (34 acute myocardial infarction, 73 unstable angina pectoris, and 154 stable angina pectoris) were analyzed by 3-vessel optical coherence tomography. Nonculprit plaque ruptures were identified in 51 patients (20%). Patients with nonculprit plaque ruptures had higher prevalence of thin-cap fibroatheroma (51% versus 13%; P<0.001) in the 3 major epicardial coronary vessels. Multiple plaque ruptures were observed in 20% of patients (38% acute myocardial infarction versus 10% unstable angina pectoris versus 19% stable angina pectoris; P=0.042). Thin...

Vulnerable Plaques Producing an Acute Coronary Syndrome Exhibit a Different CT Phenotype than Those That Remain Silent

“…6 Vergallo et al found that nonculprit lesions present smaller lipidic pools with thicker fibrous caps compared to culprit lesions that had ruptured. 37 The results of our study are concurrent with the observations according to which the fibrotic content is directly proportional with the stability of the plaque.…”

Three-Dimensional Fibrous Cap Structure of Coronary Lipid Plaque ― ST-Elevation Myocardial Infarction vs. Stable Angina ―

“…14 Moreover, patients with culprit plaque ruptures have a 4-fold higher prevalence of TCFA in non-culprit regions. 15 As observed in the PROSPECT study, however, plaques with TCFA do not necessarily lead to plaque rupture and MACE, and are instead indicators of increased risk of future cardiac events. In fact, not all of the studies found an association between TCFA and increased risk of cardiovascular events.…”

Fractional Flow Reserve-Guided Hybrid Coronary Revascularization in Multi-Vessel Coronary Arteries Disease

“…Although, the use of FFR is most established among patients presenting with stable angina, revascularization of non-infarctrelated coronary arteries at the time of an acute myocardial infarction (AMI) remains controversial. Nevertheless, the concern is that patients with AMI may have multiple ruptured plaque and thus target lesions that may be underestimated by the use of FFR [10]. Recent evidence suggests that culprit lesions of patients presenting with a non-ST-segment elevation myocardial infarction (non-STEMI) that were deferred based on a «negative» FFR have a relatively high event rate, calling into question the use of FFR in that patient population [11].…”