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Rumberg 4

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Rumberg 4

  1. 1. Plaque Severity and Coronary Occlusion:Plaque Severity and Coronary Occlusion: Or, Why Plaque Severity is More Important Than StenosisOr, Why Plaque Severity is More Important Than Stenosis “…“…the less obstructive plaques gave risk to more occlusionsthe less obstructive plaques gave risk to more occlusions than did the severely obstructed plaques because ofthan did the severely obstructed plaques because of their much greater numbertheir much greater number....”....” Falk, Shah, Fuster: Coronary Plaque DisruptionFalk, Shah, Fuster: Coronary Plaque Disruption Circulation 1995;92:pg. 658Circulation 1995;92:pg. 658 ““Because the aggregate risk of rupture associated with manyBecause the aggregate risk of rupture associated with many nonsignificant lesions exceeds that of the fewer significantnonsignificant lesions exceeds that of the fewer significant lesions, a myocardial infarction will more likely originatelesions, a myocardial infarction will more likely originate from a nonsignificant lesion.”from a nonsignificant lesion.” Kern, Meier: Evaluation of the Culprit PlaqueKern, Meier: Evaluation of the Culprit Plaque Circulation 2001;103;3142Circulation 2001;103;3142
  2. 2. EBT and Coronary Artery CalciumEBT and Coronary Artery Calcium No calcification – EBT/CACNo calcification – EBT/CAC 55 year old woman with chest pain55 year old woman with chest pain ? “low density” plaque?? “low density” plaque? ““low density” plaquelow density” plaque With stenosisWith stenosis EBAEBA
  3. 3. CAC by EBT and Atherosclerotic PlaqueCAC by EBT and Atherosclerotic Plaque Although not all plaque is visualized by EBCTAlthough not all plaque is visualized by EBCT and “soft” plaque is currently not measured,and “soft” plaque is currently not measured, the greater the calcium score,the greater the calcium score, the greater the plaque burdenthe greater the plaque burden
  4. 4. CAC by EBT:CAC by EBT: ““vulnerable” plaque vs “vulnerable” patientvulnerable” plaque vs “vulnerable” patient ““Risk” increases as an individuals CACRisk” increases as an individuals CAC score and/or percentile rank increasesscore and/or percentile rank increases Thus, although EBCT and CAC is not ableThus, although EBCT and CAC is not able to identify the “vulnerable” plaque, it CANto identify the “vulnerable” plaque, it CAN identifyidentify “the“the vulnerable patient”vulnerable patient”
  5. 5. EBT and Coronary Artery CalciumEBT and Coronary Artery Calcium  Estimate Prognosis? YESEstimate Prognosis? YES but does so based upon estimates ofbut does so based upon estimates of total coronary atherosclerotic plaque burdentotal coronary atherosclerotic plaque burden and not on visualization of “hard” vs “soft” plaqueand not on visualization of “hard” vs “soft” plaque
  6. 6. EBT and CAC:EBT and CAC: coronary remodeling and CACcoronary remodeling and CAC CAC LM/LAD RCA 43 y/o woman +FHx 5.5 mm 8 mm Is this patient at higher risk due to coronary artery remodeling?
  7. 7. Annualized Rates of Progression - EBTAnnualized Rates of Progression - EBT 30.2%/year 12%/year 0 10 20 30 40 50 60 Untreated Treated n = 792 n = 292 Range 5%-20% Range 22%-52% Composite of 9 studies – weighted averageComposite of 9 studies – weighted average
  8. 8. EBT is the only non-invasive method visualizingEBT is the only non-invasive method visualizing the coronary arteries that has been shown tothe coronary arteries that has been shown to • Track changes in coronary “plaque” in responseTrack changes in coronary “plaque” in response to lipid lowering medications, andto lipid lowering medications, and • AndAnd suggest that the magnitude of serial changes cansuggest that the magnitude of serial changes can potentially be of value to predict the development ofpotentially be of value to predict the development of acute coronary syndromesacute coronary syndromes The Search for the Vulnerable Patient
  9. 9. MRI 1. Plaque composition 2. ?Contrast? Inflammatory Markers 1. hs-CRP 2. fibinogen 3. ? ?????? ? historical ? other imaging ? lipoproteins The Search for the Vulnerable Patient Pieces of the Puzzle EBCT 1. Calcium [percentile] 2. Calcium – serial changes 3. Remodeling 4. Contrast (soft plaque?)
  10. 10. MRI 1. Plaque composition 2. ?Contrast? Inflammatory Markers 1. hs-CRP 2. fibinogen 3. ? ?????? ? historical ? other imaging ? lipoproteins The Search for the Vulnerable Patient Pieces of the Puzzle EBCT 1. Calcium [percentile] 2. Calcium – serial changes 3. Remodeling 4. Contrast (soft plaque?)

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