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Vulnerable patient talk in poland
The document summarizes research on vulnerable plaques and markers of vulnerability. It finds that ruptured plaques are the most common type of culprit lesion, accounting for around 70% of cases. Major criteria for defining vulnerable plaque include outward remodeling, endothelial dysfunction, and a thin fibrous cap with a large lipid core. Both plaque morphology and activity need to be assessed to identify vulnerability.
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Vulnerable patient talk in poland
- 2. Introducing The Vulnerable PatientConsensus Statement Published in
- 3. Circulation Journal Vol108,No14; October 7, 2003
- 4. Abstract Circulation Journal Vol108,No14; October 7, 2003
- 5. Naghavi et al.Circulation. 2003;108:1664
- 6. Naghavi et al.Circulation. 2003;108:1664
- 8. Underlying Pathologies of"Culprit" Coronary Lesions Naghavi et al. Circulation. 2003;108:1664 Ruptured plaques ( ~ 70%) • Stenotic ( 20%) • Nonstenotic ( 50%) Nonruptured plaques ( ~ 30%) • Erosion • Calcified nodule • Others/Unknown *Adapted from Falk and associates,6 Davies,7 and Virmani and colleagues.7
- 9. Plaque rupture1966Constantinides Plaque rupture1966Chapman Thrombogenicgruel1964Byers Plaque ulceration1963Gore Plaque thrombosis1961Crawford Plaque erosion1957Helpern Plaque fissure1940Horn Rupture-induced occlusion1938Wartman Rupture of atheromatous abscess1934Leary Plaque rupture1931Olcott Description UsedYearAuthor Descriptions Used by Pioneers for Culprit Plaques Naghavi et al. Circulation. 2003;108:1664 Plaque ruptureFriedman 1966
- 10. Plaque rupture illustratedin 1966
- 11. The Challenge ofTerminology • Culprit Plaque; A Retrospective Term Naghavi et al. Circulation. 2003;108:1664 Vulnerable Plaque = Future Culprit Plaque • Vulnerable Plaque; A Prospective Term
- 12. • Outward (positive)remodeling • Endothelial dysfunction • Intraplaque hemorrhage • Glistening yellow • Superficial calcified nodule Minor criteria • Critical Stenosis • Fissured plaque • Endothelial denudation with superficial platelet aggregation • Thin cap with large lipid core • Active inflammation (monocyte/macrophage and sometimes T-cell infiltration) Major criteria Criteria for Defining Vulnerable Plaque Based on the Study of Culprit Plaques Naghavi et al. Circulation. 2003;108:1664
- 13. • Shear stress(flow pattern throughout the coronary artery) • Calcification burden and pattern (nodule vs scattered, superficial vs deep, etc) • Collagen content versus lipid content, mechanical stability (stiffness and elasticity) • Color (yellow, glistening yellow, red, etc) • Remodeling (expansive vs constrictive remodeling) • Plaque stenosis (luminal narrowing) • Plaque lipid core size • Plaque cap thickness Plaque Morphology / Structure Markers of Vulnerability at the Plaque/Artery Level Naghavi et al. Circulation. 2003;108:1664
- 14. • Certain microbialantigens (eg, HSP60, C. pneumoniae) • Matrix-digesting enzyme activity in the cap (MMPs 2, 3, 9, etc) • Angiogenesis, leaking vasa vasorum, and intraplaque hemorrhage • Rate of apoptosis (apoptosis protein markers, coronary microsatellite, etc) Superficial platelet aggregation and fibrin deposition (residual mural • thrombus) • Plaque oxidative stress • Endothelial denudation or dysfunction (local NO production, anti- /procoagulation properties of the endothelium) • Plaque inflammation (macrophage density, rate of monocyte infiltration and density of activated T cell) Plaque Activity / Function Markers of Vulnerability at the Plaque/Artery Level Naghavi et al. Circulation. 2003;108:1664
- 15. • Total arterialburden of plaque including peripheral (eg, carotid IMT) • Total coronary vasoreactivity (endothelial function) • Total coronary calcium burden • Transcoronary gradient of serum markers of vulnerability Pan-Arterial Markers of Vulnerability at the Plaque/Artery Level Naghavi et al. Circulation. 2003;108:1664
- 16. Naghavi et al.Circulation. 2003;108:1664 The most common type
- 17. Naghavi et al.Circulation. 2003;108:1664 The Most Common Type of Vulnerable Plaque
- 18. Naghavi et al.Circulation. 2003;108:1664
- 19. Writer and Director:Morteza Naghavi, MD Design and Animation: Mark Johnson Music: Eric Jarvis Natural History of Atherosclerosis and Vulnerable Plaques
- 20. Naghavi et al.Circulation. 2003;108:1664 Both Morphology and Activity Assessments are Needed
- 22. Naghavi et al.Circulation. 2003;108:1664 • Abnormal lipoprotein profile (e.g. high LDL, low HDL, abnormal LDL and HDL size density, lipoprotein (a), Lp-PLA2 …) • Serum markers of insulin resistance syndrome (e.g. diabetes, hyper triglyceridemia ) • Non-specific markers of inflammation (e.g. hsCRP, CD40L, ICAM-1, VCAM-1, P-selectin, leukocytosis, and other serologic markers related to the immune system. These markers may not be specific for atherosclerosis or plaque inflammation) • Specific markers of immune activation (e.g. anti-LDL antibody, anti-HSP antibody) • Markers of lipid-peroxidation (e.g. ox-LDL and ox-HDL) • Homocysteine • Pregnancy-associated plasma protein A (PAPP-A) • Circulating apoptosis marker(s) (e.g., Fas/Fas ligand, not specific to plaque) • Asymmetric dimethylarginine (ADMA) / dimethylarginine dimethylaminohydrolase (DDAH) • Circulating nonesterified fatty acids (e.g. NEFA) Serologic Markers of Vulnerability (Reflecting Metabolic and Immune Disorders)
- 23. • Markers ofblood hypercoagulability (e.g. fibrinogen, D-dimer, and factor V Leiden) • Increased platelet activation and aggregation (e.g., gene polymorphisms of platelet glycoproteins IIb/IIIa, Ia/IIa, and Ib/IX) • Increased coagulation factors (e.g., clotting of factors V, VII, VIII, von Willebrand factor, XIII) • Decreased anticoagulation factors (e.g., proteins S, C, thrombomodulin, and antithrombin III) • Decreased endogenous fibrinolysis activity (e.g. reduced t-PA, increased PAI- 1, certain PAI-1 polymorphisms) • Prothrombin mutation (e.g. G20210A) • Other thrombogenic factors (e.g., anticardiolipin antibodies, thrombocytosis, sickle cell disease, polycythemia, diabetes mellitus, hypercholesterolemia, hyperhomocysteinemia) • Increased viscosity • Transient hypercoagulability (e.g. smoking, dehydration, infection, adrenergic surge, cocaine, estrogens, postprandial, etc.) Blood Markers of Vulnerability (Reflecting Hypercoagulability) Naghavi et al. Circulation. 2003;108:1664
- 25. With atherosclerosis-derived myocardialischemia as shown by: ECG abnormalities: - During rest - During stress test - Silent ischemia (e.g. ST changes on Holter monitoring) Perfusion and viability disorder: - PET scan - SPECT Wall motion abnormalities: - Echocardiography - MR imaging - X-ray ventriculogram - MSCT Naghavi et al. Circulation. 2003;108:1664 Conditions and Markers Associated with Myocardial Vulnerability
- 26. Without atherosclerosis-derived myocardialischemia: • Sympathetic hyperactivity • Impaired arterial baroreflex • Left ventricular hypertrophy • Cardiomyopathy (dilated, hypertrophic, restrictive, or right ventricular) • Valvular disease (aortic stenosis and mitral valve prolapse) • Electrophysiologic disorders: - Long QT syndrome, Brugada syndrome, Wolff-Parkinson-White syndrome, sinus and atrioventricular conduction disturbances, catecholaminergic polymorphic ventricular tachycardia, T-wave alternans, drug-induced torsades de pointes • Commotio cordis • Anomalous origination of a coronary artery • Myocarditis • Myocardial bridging Naghavi et al. Circulation. 2003;108:1664 Conditions and Markers Associated with Myocardial Vulnerability
- 27. Diagnostic Criteria: - Arrhythmia -QT dispersion - QT dynamics - T wave alternans - Ventricular late potentials - Heart rate variability Diagnostic Techniques: Non-Invasive: Resting ECG Stress ECG Ambulatory ECG Signal averaged electrocardiogram (SAECG) Surface high-resolution ECG Invasive: Programmed ventricular stimulation (PVS) Real-time 3D magnetic-navigated activation map Available Techniques for Electrophysiologic Risk Stratification of Vulnerable Myocardium Naghavi et al. Circulation. 2003;108:1664
- 28. Electrode vest measures ECG potentials Instrumentation setup TransverseCT Images Body Surface potentials Heart-torso geometry 224-channel ECG CT provides geometry a b c d e f g Electrode vest measures ECG potentials Instrumentation setup Transverse CT Images Body Surface potentials Heart-torso geometry 224-channel ECG CT provides geometry a b c d e f g
- 29. Naghavi et al.Circulation. 2003;108:1664
- 30.
- 31. The VP Pyramid Screening>> Diagnosis Treatment>> Outlines for Annual
- 32. CVD Genotyping? Naghavi etal. Circulation. 2003;108:1664
- 33. Out-of- hospital screening (EF, serumtests, physician visit) Non-Invasive Imaging Diagnostic Cath Drug-Eluting Stent Statin and other Drugs
- 34.
- 35. Annual Cost of HeartAttacks in the USA