Atherosclerotic cardiovascular disease,
which results in more than 6.3 million
deaths annually, is the leading cause of
The major underlying cause of acute
coronary syndromes and sudden cardiac
death is vulnerable plaque, which is often
associated with hypercoagulability and/or
preexisting myocardial damage.
Underlying pathology of acute coronary syndrome
(unstable angina, acute MI) and sudden cardiac death
• Culprit Plaque, a Retrospective
• Vulnerable Plaque, a Prospective
Vulnerable Plaque = Future Culprit Plaque
Different Types of Vulnerable Plaques
Major Underlying Cause of Acute Coronary Events
Critical Stenosis Hemorrhage
A vulnerable patient is a person with
vulnerable plaque, and/or vulnerable
blood, and/or vulnerable myocardium who
has a high likelihood of developing a
sudden cardiac event (acute coronary
syndrome and sudden cardiac death).
The risk of a vulnerable patient is affected by
vulnerable plaque and/or vulnerable blood and/or
Markers of vulnerable plaque:
• Active Inflammation
• Very Thin Cap and Large Lipid Core
• Endothelial Denudation with Superficial Platelet
• Fissure / Wounded Plaque
Markers of vulnerable blood:
• Increased Platelet Aggregation
• Increased Coagulation Factors
• Decreased Anti-Coagulation Factors
• Other Thrombogenic Factors
• Transient Hypercoagulemia by External Factors
Markers of vulnerable myocardium:
Non-Esterified Fatty Acid
It may be more appropriate to
measure the total risk of vulnerability
in a patient rather than searching for
a single vulnerable plaque.
As reported in VP Watch of this
week, Albert, Ridker, and colleagues
in Physician’s Health Study showed
that baseline CRP level was
significantly associated with the risk
of sudden cardiac death (SCD) over
the ensuing 17 years of follow-up.
They found that increase in risk
associated with CRP levels was primarily
seen among men in the highest quartile,
who were at a 2.78-fold increased risk of
SCD compared with men in the lowest
In contrast to the positive relationship
observed for CRP, neither homocysteine
nor lipid levels were significantly
associated with risk of SCD.
Unlike other risk factors, high-sensitivity
CRP is a strong independent predictor of
sudden cardiac death in healthy men.
Therefore CRP may serve as a valuable
measure for risk stratification of
• Is CRP an independent predictor of
sudden cardiac death in women as well?
• Is this predictive value of CRP
independent from its association with
atherosclerosis and atherosclerosis-
derived myocardial injury?
• Is association of CRP and sudden
cardiac death confounded by MI?
• Can CRP directly play a role in
development of arrhythmia?
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Prospective Study of C-Reactive Protein, Homocysteine, and Plasma Lipid Levels as Predictors of Sudden
Cardiac Death. Circulation 2002 105: 2595 - 2599
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rupture into a lipid core. A frequent cause of coronary thrombosis in sudden coronary death. Circulation.
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