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Vp schoenhagen

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Vp schoenhagen

  1. 1. Arterial Remodeling In Stable VersusArterial Remodeling In Stable Versus Unstable Coronary Syndromes:Unstable Coronary Syndromes: An Intravascular Ultrasound StudyAn Intravascular Ultrasound Study Arterial Remodeling In Stable VersusArterial Remodeling In Stable Versus Unstable Coronary Syndromes:Unstable Coronary Syndromes: An Intravascular Ultrasound StudyAn Intravascular Ultrasound Study Paul Schoenhagen, MD,FAHAPaul Schoenhagen, MD,FAHA Steven E Nissen, MD,FACCSteven E Nissen, MD,FACC E Murat Tuzcu, MD,FACCE Murat Tuzcu, MD,FACC The Cleveland Clinic FoundationThe Cleveland Clinic Foundation Paul Schoenhagen, MD,FAHAPaul Schoenhagen, MD,FAHA Steven E Nissen, MD,FACCSteven E Nissen, MD,FACC E Murat Tuzcu, MD,FACCE Murat Tuzcu, MD,FACC The Cleveland Clinic FoundationThe Cleveland Clinic Foundation
  2. 2. BackgroundBackground • Originally, Glagov described arterial remodeling as anOriginally, Glagov described arterial remodeling as an increase in external elastic membrane area withinincrease in external elastic membrane area within atherosclerotic lesions.atherosclerotic lesions. • In early CAD, remodeling maintains lumen area despiteIn early CAD, remodeling maintains lumen area despite increasing plaque burden.increasing plaque burden. • Although first observed in necropsyAlthough first observed in necropsy studiesstudies, remodeling, remodeling has been confirmedhas been confirmed in vivoin vivo by intravascular ultrasound.by intravascular ultrasound. • The relationship between remodeling and various clinicalThe relationship between remodeling and various clinical ischemic syndromes remains uncertain.ischemic syndromes remains uncertain.
  3. 3. Intravascular UltrasoundIntravascular Ultrasound vessel wall/ plaquelumen IVUS Catheter
  4. 4. Objectives and Study DesignObjectives and Study Design •• Retrospectively analyze intravascular ultrasoundRetrospectively analyze intravascular ultrasound images in a series of patients with either stable anginaimages in a series of patients with either stable angina or recent onset of unstable symptomatology.or recent onset of unstable symptomatology. •• Examine the relationship between clinical presentationExamine the relationship between clinical presentation and plaque features at the culprit lesion, including:and plaque features at the culprit lesion, including: • Presence, direction and extent of arterial remodelingPresence, direction and extent of arterial remodeling • Plaque morphology (echogenicity)Plaque morphology (echogenicity) • Plaque eccentricityPlaque eccentricity
  5. 5. Methods: PatientsMethods: Patients Patients with pre-interventionalPatients with pre-interventional ultrasound of native coronary arteriesultrasound of native coronary arteries (n=216)(n=216) Excluded (n=85) Study Patients (n=131)Study Patients (n=131) Stable (n=46)Stable (n=46) Stable Angina (n=37)Stable Angina (n=37) (+) ETT (n=9)(+) ETT (n=9) Unstable (n=85)Unstable (n=85) Unstable Angina (n=76)Unstable Angina (n=76) Acute MI (n=9)Acute MI (n=9) Ostial or bifurcation lesions,Ostial or bifurcation lesions, heavy calcium, image qualityheavy calcium, image quality
  6. 6. Methods: Image AnalysisMethods: Image Analysis • Intravascular ultrasound images obtained from aIntravascular ultrasound images obtained from a proximal reference site and culprit lesion site.proximal reference site and culprit lesion site. • Quantitative variables:Quantitative variables: – EEM area, lumen area, and plaque areaEEM area, lumen area, and plaque area • Plaque morphology:Plaque morphology: – Echolucent, echodense, mixed, calcifiedEcholucent, echodense, mixed, calcified • Eccentricity Index:Eccentricity Index: MaximumMaximum -- Minimum Plaque ThicknessMinimum Plaque Thickness Maximum Plaque ThicknessMaximum Plaque Thickness xx 100100
  7. 7. Positive Remodeling Culprit Lesion EEM Contour Proximal Reference Proximal Reference Direction of Arterial RemodelingDirection of Arterial Remodeling Schoenhagen et al. Circulation 2000; 101:598-603 Negative Remodelin g Culprit Lesion EEM Contour Remodeling Ratio (RR) = EEM area lesion / EEM area proximal reference Negative Remodeling RR < 0.95 Positive Remodeling RR > 1.05
  8. 8. Example: Positive RemodelingExample: Positive Remodeling RemodelingRemodelingIndexIndex == 18.918.9 mmmm22 14.914.9 mmmm22 == 1.271.27 Proximal Reference Lesion EEM = 14.9 mm2 EEM = 18.9 mm2
  9. 9. Example: Negative RemodelingExample: Negative Remodeling Proximal ReferenceProximal Reference LesionLesion EEMEEM = 16.0 mm= 16.0 mm22 EEMEEM = 11.5 mm= 11.5 mm22 RemodelingRemodelingIndexIndex == 11.511.5 mmmm22 16.016.0 mmmm22 == 0.720.72
  10. 10. Clinical and Demographic FeaturesClinical and Demographic Features Stable (n = 46)Stable (n = 46) Unstable (n = 85)Unstable (n = 85) p = NS for all characteristics AgeAge 62.6 years62.6 years 59.5 Years59.5 Years MaleMale 71.7 %71.7 % 64.7 %64.7 % FemaleFemale 28.3%28.3% 35.3 %35.3 % LADLAD 56.6%56.6% 51.8%51.8% LCxLCx 21.7%21.7% 17.6%17.6% RCARCA 21.7%21.7% 30.6%30.6%
  11. 11. Clinical and Demographic CharacteristicsClinical and Demographic Characteristics SSttaabblle (e (nn=4=466)) UUnsnsttaabblle (e (nn==885)5) DiDiaabbeteteess 226.6.11%% 119.9.77%% HHypypeerrtteennsisioonn 447.7.88%% 663.3.22%% HHypypeerrlilippidideemimiaa 446.6.77%% 550.0.00%% SSmomokikinngg 552.2.22%% 660.0.55%% CCAAD FaD Fammililyy HHisisttoorryy 226.6.11%% 228.8.99%% Risk Factors for Coronary Artery Disease p = NS for all characteristics
  12. 12. Reference and Lesion MeasurementsReference and Lesion Measurements Stable Unstable p value Proximal Reference Plaque Area 6.20 mm2 6.10 mm2 NS EEM Area 14.1 mm2 15.2 mm2 NS % Area Reduction 42.3 40.3 NS Target Lesion Plaque Area 11.1±4.8 mm2 13.9±5.5 mm2 0.005 EEM Area 13.0±4.8 mm2 16.1±6.2 mm2 .04 % Area Reduction 83.1±6.7 85.0+6.4 NS Remodeling Index 0.94 1.06 0.008
  13. 13. Results: Extent of RemodelingResults: Extent of Remodeling 00 2020 4040 6060 Percent of Cohort Positive Remodeling Absence of Remodeling Negative Remodeling Unstable Stable *p=0.0003 *p=0.3 *p=0.006 Schoenhagen et al. Circulation 2000; 101:598-603
  14. 14. Results: Plaque MorphologyResults: Plaque Morphology 0 10 20 30 40 Percent of Cohort Echolucent Echodense Mixed Calcified Unstable Stable p=0.02 p=0.4 p=1.0 p=0.3 Schoenhagen et al. Circulation 2000; 101:598-603
  15. 15. Stable Presentation and Negative RemodelingStable Presentation and Negative Remodeling Proximal ReferenceProximal Reference LesionLesion EEMEEM = 10.5 mm= 10.5 mm22 EEMEEM = 7.5 mm= 7.5 mm22 Mixed Morphology with Remodeling Index = 0.71 Schoenhagen et al. Circulation 2000; 101:598-603
  16. 16. Unstable Presentation: Positive RemodelingUnstable Presentation: Positive Remodeling Echolucent Plaque with Remodeling Index = 1.42 Proximal ReferenceProximal Reference EEMEEM = 14.3 mm= 14.3 mm22 EEMEEM = 20.3 mm= 20.3 mm22 Culprit LesionCulprit Lesion Schoenhagen et al. Circulation 2000; 101:598-603
  17. 17. LimitationsLimitations • Selection bias:Selection bias: – The cohort included only relatively severe lesionsThe cohort included only relatively severe lesions selected for pre-interventional ultrasound imaging.selected for pre-interventional ultrasound imaging. • Presence of ultrasound catheter within severePresence of ultrasound catheter within severe lesions may alter vessel geometry.lesions may alter vessel geometry. • Classification of plaque morphology based uponClassification of plaque morphology based upon subjective visual criteria.subjective visual criteria.
  18. 18. ConclusionConclusion • Significant differences in ultrasound characteristicsSignificant differences in ultrasound characteristics between unstable and stable lesions:between unstable and stable lesions: – Greater plaque burden despite similar luminal narrowingGreater plaque burden despite similar luminal narrowing – Greater extent of positive remodelingGreater extent of positive remodeling • A prospective study of the relationship between clinicalA prospective study of the relationship between clinical presentation and plaque morphology is warranted:presentation and plaque morphology is warranted: – Hypothesis: Bulky remodeled plaques may be moreHypothesis: Bulky remodeled plaques may be more vulnerable to mechanical forces, thus leading to plaquevulnerable to mechanical forces, thus leading to plaque rupture and acute coronary syndromes.rupture and acute coronary syndromes.
  19. 19. Remodeling and Clinical PresentationRemodeling and Clinical Presentation Stable and Unstable Syndromes and Remodeling: IVUS Pathology Smits et al. Schoenhagen et al. Nakamura et al. Filardo et al. Nishioka et al. Alibelli-Chemarin et al. Burke et al. Varnava et al. Cardiovas. Res.’99;41:458-464 Circulation ‘00;101:598-603 J Am Coll Cardiol ‘01;37:63-9 Am J Cardiol ‘00;85:760-762 JACC ‘97;29:125A, abstract JACC ‘98;31:276A, abstract Circulation ’02;105:297-303 Circulation ’02;105:939-943
  20. 20. Coronary RemodelingCoronary Remodeling ProgressioProgressio nn EEM shrinkageEEM shrinkage NormalNormal vesselvessel MinimalMinimal CADCAD EEM expansionEEM expansion Lumen shrinkageLumen shrinkage SevereSevere CADCAD ModerateModerate CADCAD SevereSevere CADCAD Period of Instability?Period of Instability? Regression?Regression? Schoenhagen et al. JACC 2001;38:297-306

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