Relationship Between Endothelial Wall Shear Stress and High‐Risk Atherosclerotic Plaque Characteristics for Identification of Coronary Lesions That Cause Ischemia: A Direct Comparison With Fractional Flow Reserve

Abstract

BackgroundWall shear stress (WSS) is an established predictor of coronary atherosclerosis progression. Prior studies have reported that high WSS has been associated with high‐risk atherosclerotic plaque characteristics (APCs). WSS and APCs are quantifiable by coronary computed tomography angiography, but the relationship of coronary lesion ischemia—evaluated by fractional flow reserve—to WSS and APCs has not been examined.Methods and Results WSS measures were obtained from 100 evaluable patients who underwent coronary computed tomography angiography and invasive coronary angiography with fractional flow reserve. Patients were categorized according to tertiles of mean WSS values defined as low, intermediate, and high. Coronary ischemia was defined as fractional flow reserve ≤0.80. Stenosis severity was determined by minimal luminal diameter. APCs were defined as positive remodeling, low attenuation plaque, and spotty calcification. The likelihood of having positive remodeling and low‐attenuation plaque was greater in the high WSS group compared with the low WSS group after adjusting for minimal luminal diameter (odds ratio for positive remodeling: 2.54, 95% CI 1.12–5.77; odds ratio for low‐attenuation plaque: 2.68, 95% CI 1.02–7.06; both P<0.05). No significant relationship was observed between WSS and fractional flow reserve when adjusting for either minimal luminal diameter or APCs. WSS displayed no incremental benefit above stenosis severity and APCs for detecting lesions that caused ischemia (area under the curve for stenosis and APCs: 0.87, 95% CI 0.81–0.93; area under the curve for stenosis, APCs, and WSS: 0.88, 95% CI 0.82–0.93; P=0.30 for difference).ConclusionsHigh WSS is associated with APCs independent of stenosis severity. WSS provided no added value beyond stenosis severity and APCs for detecting lesions with significant ischemia.

Balloon Deflation Strategy during Primary Percutaneous Coronary Intervention in Acute ST-Segment Elevation Myocardial Infarction: A Randomized Controlled Clinical Trial and Numerical Simulation-Based Analysis

“…High WSS assessed by intravascular ultrasound images is also associated with longitudinal development of high-risk plaque, including intraplaque necrotic core or expansive remodeling [ 15 , 18 , 19 ]. Indeed, higher WSS in the proximal segments of atherosclerotic lesions is predictive of myocardial infarction in patients with stable coronary artery disease (CAD) [ 18 , 20 ]. During primary PCI for STEMI, the rapid balloon deflation leads to higher WSS, which might be associated with adverse cardiovascular events .…”

Physiology and coronary artery disease: emerging insights from computed tomography imaging based computational modeling

“…In another CTA based study, in 100 patients who underwent CTA and invasive coronary angiography, high ESS was associated with adverse plaque characteristics (i.e. low attenuation plaque, positive remodeling, napkin-ring sign, and spotty calcification) independent of stenosis severity [54]. Despite promising evidence to assess ESS based on CTA, a more detailed study comparing CTA to the higher resolution invasive imaging modalities should be performed to provide more assurance that CTA captures the same ESS pattern as invasive imaging modalities ( Fig.…”

Association of Coronary Wall Shear Stress With Atheromatous Plaque Vulnerability: A Systematic Review

“…Coronary regions exhibiting a high ESS presented significantly plaque lower density (p=0.05), a higher remodelling index (p=0.025) a higher proportion of low attentuation plaque (p=0.003) and napkin ring sign (p<0.0001). Furthermore, presence of at least one feature of vulnerable plaque was encountered in 29.4% to 51.9% in low-to-intermediate ESS areas versus 38.2% to 76.9% in high ESS area (p=0.018), while presence of at least 2 features of vulnerability was encountered in 23.3% in low-to-intermediate ESS areas versus 53.5% in high ESS areas (p=0.006) [14,15].…”

“…In total, a number of 692 patients were included in the 10 studies analyzed. Baseline overall characteristics of the subjects analyzed, inclusion/exclusion criteria, study aims and endpoints for each study included in this systematic review are listed in Table 1 [6,7,8,9,10,11,12,13,14,15].…”

“…Both studies assessing the CTA features of vulnerability in relation to shear stress identified presence of vulnerability markers in a significantly higher extent in the region exposed to a high ESS as compared to those exposed to a low ESS (Table 2) [14,15]. Coronary regions exhibiting a high ESS presented significantly plaque lower density (p=0.05), a higher remodelling index (p=0.025) a higher proportion of low attentuation plaque (p=0.003) and napkin ring sign (p<0.0001).…”