Multimodality Intravascular Imaging Assessment of Plaque Erosion versus Plaque Rupture in Patients with Acute Coronary Syndrome

Abstract

Background and ObjectivesWe assessed plaque erosion of culprit lesions in patients with acute coronary syndrome in real world practice.Subjects and MethodsCulprit lesion plaque rupture or plaque erosion was diagnosed with optical coherence tomography (OCT). Intravascular ultrasound (IVUS) was used to determine arterial remodeling. Positive remodeling was defined as a remodeling index (lesion/reference EEM [external elastic membrane area) >1.05.ResultsA total of 90 patients who had plaque rupture showing fibrous-cap discontinuity and ruptured cavity were enrolled. 36 patients showed definite OCT-plaque erosion, while 7 patients had probable OCT-plaque erosion. Overall, 26% (11/43) of definite/probable plaque erosion had non-ST elevation myocardial infarction (NSTEMI) while 35% (15/43) had ST elevation myocardial infarction (STEMI). Conversely, 14.5% (13/90) of plaque rupture had NSTEMI while 71% (64/90) had STEMI (p<0.0001). Among plaque erosion, white thrombus was seen in 55.8% (24/43) of patients and red thrombus in 27.9% (12/43) of patients. Compared to plaque erosion, plaque rupture more often showed positive remodeling (p=0.003) with a larger necrotic core area examined by virtual histology (VH)-IVUS, while negative remodeling was prominent in plaque erosion. Overall, 65% 28/43 of plaque erosions were located in the proximal 30 mm of a culprit vessel-similar to plaque ruptures (72%, 65/90, p=0.29).ConclusionAlthough most of plaque erosions show nearly normal coronary angiogram, modest plaque burden with negative remodeling and an uncommon fibroatheroma might be the nature of plaque erosion. Multimodality intravascular imaging with OCT and VH-IVUS showed fundamentally different pathoanatomic substrates underlying plaque rupture and erosion.

Assessment of Coronary Plaque Vulnerability in Acute Coronary Syndromes using Optical Coherence Tomography and Intravascular Ultrasound. A Systematic Review

“…It consisted of the analysis of five studies reporting on a total of 368 coronary plaques assessed by OCT and IVUS in 261 patients. 15,19,20,22,25 Part 2 compared the IVUS-and OCT-derived plaque characteristics in 587 ruptured versus non-ruptured cor- 15 Tian et al 20 Takahashi et al 19 Kume et al 25 Roleder et al 28 Kato et al 27 Yonetsu et al Table 2. (Table 3).…”

Optical Coherence Tomography Guidance in Management of Acute Coronary Syndrome Caused by Plaque Erosion

“…Kwon et al reported that identification of PE is challenging for IVUS because of its low resolution. 20 Other previous ex vivo studies have shown that standard …”

“…19 Recently, Kwon et al reported that in most cases of PE the coronary angiogram is nearly normal, which might result in misdiagnosis in an ACS patient. 20 IVUS is a widely used technique to assess vascular geometry and morphology, including plaque burden, and the external elastic membrane, which are challenging for OCT in most of cases. Nonetheless, the ability to identify plaque tissue characteristics by IVUS is limited.…”

A Comparative Preliminary Study on CT Contrast Attenuation Gradient Versus Invasive FFR in Patients with Unstable Angina

“…However, intravascular ultrasound (IVUS) studies demonstrated that not all culprit lesions that have triggered an acute coronary syndrome produce a significant narrowing of the coronary lumen. 6,7 At the same time, the PROSPECT trial demonstrated that the amount of plaque burden evaluated by IVUS was the strongest predictor of mortality in patients with vulnerable plaques. 8 Also, the COURAGE trial demonstrated the non-superiority of visual cineangiography-guided revascularizations compared to the correct medication in regards to mortality, myocardial infarction, and other cardiovascular complications.…”