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Tct recognition of vulnerable plaque guidelines
1. Total victims
of new heart
attacks in
2003
Will die before
reaching hospital.
>50%
Damaged
Myocardium
Pre-Hospital Delay
10year mortality ticket issued
on the way reaching hospital!
Future heart
failure…
Cardiology of Today CANNOT
Reach >50% of Its Target Population
~ 500,000 in the
USA
3. Carl von Rokitansky (1804-1878)
Rokitansky gaveearly
detailed descriptionsof
arterial disease. Heis
alleged to haveperformed
30,000 autopsies.
Rokitansky in 1841 championed theThrombogenic Theory. Heproposed that the
depositsobserved in theinner layer of thearterial wall derived primarily from fibrin and other
blood elementsrather than being theresult of apurulent process. Subsequently, theatheroma
resulted from thedegeneration of thefibrin and other blood proteinsasaresult of apreexisting
crasisof theblood, and finally thesedepositsweremodified toward apulpy masscontaining
cholesterol crystalsand fatty globules.
Thistheory cameunder attack by Virchow
4. First studies on inflammation of vessels, particularly phlebitis, Started at
a time when Cruveilhier2had just stated: La phlebite domine toute la
pathologie.3 First a great number of preparatory studies on fibrin,
leukocytes, meta-morphosis of blood, published separately. …
Rudolf Virchow 1821-1902
The Father of
Cellular
Pathology
Virchow appreciates prior works.
Virchow presented hisinflammatory theory. Heutilized thenameof "endarteritisdeformans." By thishe
meant that theatheromawasaproduct of an inflammatory processwithin theintimawith thefibrous
thickening evolved asaconsequenceof areactivefibrosisinduced by proliferating connectivetissuecells
within theintima.
5. Olcott 1931 “plaque rupture”
Leary 1934 “rupture of atheromatous abscess”
Wartman 1938 “rupture-induced occlusion”
Horn 1940 “plaque fissure”
Helpern 1957 “plaque erosion”
Crawford 1961 “plaque thrombosis”
Gore 1963 “plaque ulceration”
Friedman 1964 “macrophage accumulation”
Byers 1964 “thrombogenic gruel”
Chapman 1966 “plaque rupture”
Plaque Fissure in Human Coronary Thrombosis (Abstract) Fed. Proc. 1964, 23, 443
Paris Constantinidis
“Thedestruction of thehyalinized wall separating lumen from theatheromawas
almost alwaysobserved to bepreceded by or associated with itsinvasion by
lipid containing macrophages.” Friedman and van den
Bovenkamp 1965
Unheralded Pioneers
6. N Engl J Med 1999
“Atherosclerosis; an
inflammatory disease”
Ross R.
Russell Ross
Atherosclerosis; arterial “Response to Injury”
N Engl J Med 1976 Aug 12;295(7):369-77
The pathogenesis of atherosclerosis (first
of two parts).
Ross R, Glomset JA.
7. James T. Willerson 1981
N Engl J Med 1981 Mar 19;304(12):685-91
Plaque Thrombosis
8. Erling Falk Michael Davies
Autopsy Series
Thin Fibrous Cap + Large Lipid Core + Dense Macrophage
A culprit ruptured plaque
1981-1990
9. Seymour Glagov
Compensatory Enlargement
of Human Atherosclerotic Coronary
Arteries N Engl J Med 1987 May
28;316(22):1371-5
<50%
stenosis
Luminal area is not endangered until more than 40% of
internal elastic lamina is destructed and occupied by plaque
Coronary artery disease is a disease of arterial wall
disease not lumen.
Positive(expansive) Remodeling
<80%
stenosis
10. Angiographic progression of coronary
artery disease and the development of
myocardial infarction.
Ambrose JA, Tannenbaum MA, Alexopoulos D, Hjemdahl-Monsen CE, Leavy J, Weiss M, Borrico S, Gorlin R, Fuster V.
Department of Medicine, New York Cardiac Center, Mount Sinai Medical Center, New York 10029.
Simultaneously, Little et al, Haft et al reported that majority of culprit
lesions are found on previously non-critical stenosis plaques.
Conclusion:
“Myocardial infarction frequently develops from non-severe lesions.”
J Am Coll Cardiol 1988 Jul;12(1):56-62
Ambrose, Fuster, and colleagues
Angiographically Invisible Plaques
11. Falk E., Shak P.K., Fuster V. Circulation 1995
Non-stenotic (<75%) plaques cause about 80% of deadly MI
12. Macrophage-
driven MMPs
soften plaquecap
and prompt it to
rupture
P.K. Shah
Peter Libby
Thefateof atherosclerosisand
itsthrombotic complication are
governed by immunesystem.
Goran Hansson
and others
Allard van der
Wal
and others
13. •Eroded Plaque
Rupture-prone
plaques are not the
only type of
vulnerable plaque
•Calcium Nodule
van der Wal - Netherlands
Renu Virmani -USA
Thiene - Italy
Kolodgie F., Burk A.P., Farb A., and Virmani R.
14. Muller JE, Abela GS, Nesto RW, Tofler GH.
Triggers, acute risk factors and vulnerable plaques:
the lexicon of a new frontier.
J Am Coll Cardiol. 1994 Mar 1;23(3):809-13
James E. Muller 1994
Muller coined the term of “Vulnerable” Plaque
Muller likened Vulnerable Plaques to American nuclear missiles stored underground in
Nevada desert where they could be vulnerable to Russians’ long-range missile attack!
“Vulnerableto disruption and thrombosis”
16. Total victims
of new heart
attacks in
2003
Will die before
reaching hospital.
>50%
Damaged
Myocardium
Pre-Hospital Delay
10year mortality ticket issued
on the way reaching hospital!
Future heart
failure…
The major underlying cause of
this long standing failure in
cardiology.
~ 500,000 in the
USA
17.
18. Potential Underlying Cause of All (fatal and non-fatal) Heart Attacks
(Sudden Cardiac Death + Acute Coronary Syndrome)
With Occlusive Thrombi
With Rupture
>70% Stenosis
With Significant Atherosclerosis or
Ischemic Heart
<70% Stenosis
Without Significant Atherosclerosis or
Atherosclerosis-Derived Myocardial Damage
Without Occlusive Thrombi
Without Rupture With
Old Myocardial Damage
Without
Old Myocardial Damage
Only Myocardial-Derived Factors
(conductive disorders, …)
Erosion Calcified Nodule Others
With Critical Stenosis Without Critical Stenosis
With Expansive
Remodeling
Without Expansive
Remodeling
19. Ruptured Plaques (~70%)
1. Stenotic (~20%)
2. Non-stenotic (~50%)
Non-ruptured Plaques (~
30%)
1. Erosion (~20%)
2. Calcified Nodule (~5%)
Plaque Pathology Responsible for Coronary Thrombotic Death
In summary:
21. Different Types of Vulnerable Plaques
Major Underlying Cause of Acute Coronary Events
Normal
Rupture-prone
Fissured Eroded
Critical Stenosis Hemorrhage
Naghavi et al, Cur Ath Rep 2001
24. Fissured / Healed Plaque
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Mural thrombi
Wounded
plaque
25. Plaque with a Intimal Calcified Nodule
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Calcified nodule
26. Intra-Plaque Hemorrhage with Intact Cap
Vulnerable Plaque Naghavi et al, Cur Ath Rep 2001
Leaking
angiogenesisor
ruptureof vasa
vaserum
27. Critically Stenotic but Asymptomatic Plaque
Naghavi et al, Cur Ath Rep 2001Vulnerable Plaque
>75% lumina
narrowing
28. Different Types of Vulnerable Plaques
Major Underlying Cause of Acute Coronary Events
Normal
Rupture-prone
Fissured Eroded
Critical Stenosis Hemorrhage
Naghavi et al, Cur Ath Rep 2001
29. Proposed Histopathological and
Clinical Criteria for Definition of
Vulnerable Plaque
• Major Criteria:
1. Active Inflammation (monocyte/
macrophage infiltration)
2. Thin Cap with Large Lipid Core
3. Endothelial Denudation with Superficial
Platelet Aggregation
4. Fissured / Wounded Plaque
30. Proposed Histopathological and
Clinical Criteria for Definition of
Vulnerable Plaque
• Minor Criteria:
1. Superficial Calcified nodule
2. Glistening Yellow
3. Intraplaque Hemorrhage
4. Critical Stenosis
5. Positive Remodeling?