European Heart Journal Advance Access originally published online on July 13, 2006
European Heart Journal 2006 27(16):1921-1927; doi:10.1093/eurheartj/ehl104
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Global characterization of coronary plaque rupture phenotype using three-vessel intravascular ultrasound radiofrequency data analysis
Department of Cardiology of the Thoraxcenter, Erasmus MC, Bd-406, Dr Molewaterplein 40, PO Box 1738, 3015-GD Rotterdam, The Netherlands
Received 12 December 2005; revised 5 May 2006; accepted 26 May 2006; online publish-ahead-of-print 13 July 2006.
* Corresponding author. Tel: +31 10 4635260; fax: +31 10 4369154. E-mail address: p.w.j.c.serruys{at}erasmusmc.nl
See page 1889 for the editorial comment on this article (doi:10.1093/eurheartj/ehl129)
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Abstract |
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Aims To compare the global characteristics of patients with and without evidence of plaque rupture (PR) in their coronary tree and to evaluate the phenotype of ruptured plaques using intravascular ultrasound (IVUS) radiofrequency data analysis (IVUS-VH).
Methods and results Forty patients underwent three-vessel IVUS-VH interrogation. Twenty-eight PRs were diagnosed in 26 vessels (25.7% of the vessels studied) of 20 patients (50% of the population). Ruptures located in the left anterior descending were clustered in the proximal part of the vessel, whereas ruptures located in the right coronary artery were more distally located (P=0.02). Patients with at least one PR presented larger body mass index (BMI) (28.4±3.7 vs. 25.8±2.6 kg/m2, P=0.01) and plaque burden (40.7±7.6 vs. 33.7±8.4%, P=0.01) than patients without rupture, despite showing similar lumen cross-sectional area (9.6±3.3 vs. 9.2±2.3 mm2, P=0.60). Among current smokers, 66.7% presented a PR in their coronary tree. Finally, PR sites showed a higher content of necrotic core compared with minimum lumen area sites (17.48±10.8 vs. 13.10±6.5%, P=0.03) and a trend towards higher calcified component.
Conclusion Patients with at least one PR in their coronary tree presented larger BMI and worse IVUS-derived characteristics compared with patients without PR.
Key Words: Plaque rupture • Ultrasonography • Atherosclerosis • Vulnerable plaque
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Introduction |
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It has been established that coronary plaque rupture (PR) is the cause of death in a large proportion of sudden coronary death patients.1 Despite its pre-conceived dire prognosis, retrospective studies have determined that PR is a common finding in both coronary and non-coronary sudden death patients.1,2 In addition, clinically silent PR has been identified as a cause of plaque progression.3,4 The fate of a given atherosclerotic plaque is thus linked not only to its severity but also to its histological composition, and the presence of a rich necrotic core has been consistently related to plaque fissuring.5,6
Intravascular ultrasound (IVUS) has been largely demonstrated to be an accurate diagnostic tool able to provide a high resolution, real-time, tomographic view of the coronary arteries. As such, several studies have portrayed the prevalence of PR in living patients by means of IVUS.7,8 IVUS has, though, a suboptimal predictive value to estimate the composition of coronary arteries, particularly of lipid deposits.9 In turn, spectral analysis of IVUS radiofrequency data has demonstrated improved accuracy for tissue characterization.10 Besides, to date, no study has reported the global burden of the disease and its relationship with PR by means of IVUS.
The purpose of our study was two-fold: first, to compare the global characteristics of patients with and without evidence of PR in their coronary tree, and secondly, to evaluate the phenotype of ruptured against non-ruptured plaques using IVUS radiofrequency data analysis (IVUS-VH).
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Methods |
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Patients
In this single-centre, investigators-driven, observational, prospective study, patients referred to our institution for elective or urgent PCI with the absence of extensive calcification, severe vessel tortuosity and haemodynamic instability and with suitable anatomy underwent IVUS interrogation of the three main epicardial coronary arteries. The patients included in this study, are part of published (IBIS-1)11 and unpublished (LICO, BETAX) mono-centre studies conducted at our centre.
Patients with stable angina, unstable angina, and acute myocardial infarction (MI) were included. MI was diagnosed by an increase in the creatine kinase MB level to more than two-fold the normal limit. Acute coronary syndrome (ACS) patients encompassed patients presenting with unstable angina, non-ST-segment elevation MI, or ST-segment elevation MI. The institution's Ethics Committee approved the study protocol, which complies with the Declaration of Helsinki, and written informed consent was obtained from all patients.
Intravascular ultrasound
IVUS acquisition
The IVUS catheters used were commercially available mechanical and electronical catheters (UltracrossTM 30 MHz catheter, Boston Scientific, Santa Clara, USA; Eagle EyeTM 20 MHz catheter, Volcano Corporation, Rancho Cordova, USA). After administration of intracoronary nitrates, the IVUS catheter was introduced up to the distal coronary bed of the three coronary vessels. IVUS was aimed to be performed prior to any intervention. Using an automated pullback device, the transducer was withdrawn at a continuous speed of 0.5 mm/s until the ostium was seen. Cine runs, before and during contrast injection, were performed to define the position of the IVUS catheter before the pullback was started. IVUS-VH (Volcano Corporation) acquisition was ECG-gated using a dedicated console (Volcano Corporation). IVUS-VH data were stored on CD-ROM/DVD and sent to the imaging core lab for offline analysis.
IVUS-VH analysis
IVUS B-mode images were reconstructed from the RF data by customized software, and contour detection was performed using cross-sectional views with a semi-automatic contour detection software to provide geometrical and compositional output (IvusLab 3.0 for 30 MHz acquisitions and IvusLab 4.4 for 20 MHz acquisitions, respectively; Volcano Corporation). The RF data were normalized using a technique known as ‘Blind Deconvolution’, an iterative algorithm that deconvolves the catheter transfer function from the backscatter, thus accounting for catheter-to-catheter variablity.11
Details regarding the validation of IVUS-VH on explanted human coronary segments have previously been reported.10 Briefly, IVUS-VH uses spectral analysis of IVUS radiofrequency data to construct tissue maps that classify plaque into four major components. In preliminary in vitro studies, four histological plaque components (fibrous, fibrolipidic, necrotic core, and calcium) were correlated with a specific spectrum of the radiofrequency signal.10 These different plaque components were assigned colour codes. Calcified, fibrous, fibrolipidic, and necrotic core regions were labelled white, green, greenish-yellow, and red, respectively.
The contours of the external elastic membrane (EEM) and the lumen–intima interface enclosed an area that was defined as the coronary plaque plus media area. Plaque burden was calculated as [(EEMarea–lumenarea/EEMarea)x100]. Following a previously reported classification, PR was defined as a ruptured capsule with an underlying cavity (Figure 1) or plaque excavation by atheromatous extrusion with no visible capsule.7,8 Rupture sites separated by at least 5 mm length of rupture-free vessel were considered as different ruptures. Screening for diagnosis of a PR required the independent review and agreement between two experienced IVUS observers (G.A.R.-G. and H.M.G.-G.), who had no knowledge about demographical data of the patients. Disagreement was solved by consensus between the observers. Lumen contour detection at the rupture site was performed following the intima–lumen interface, excluding the rupture cavity from the plaque cross-sectional area (CSA) calculation. Absolute geometrical data and absolute and relative compositional data were obtained for each CSA and an average was calculated for each coronary and for the total coronary tree. Finally, measurements were calculated in CSAs meeting criteria of PR and at the site of the minimum lumen area (MLA).
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As pre-specified subanalysis, we compared the different geometrical and compositional characteristics of the three main epicardial coronaries. In addition, the difference between culprit/target and non-culprit/non-target vessels was assessed.
Statistical analysis
Discrete variables are presented as counts and percentages. Continuous variables are presented as means±SD or medians (25th, 75th percentile) when indicated. On the basis of previous histopathological findings showing that ruptured plaques presented 34% of necrotic core, 10% more than non-ruptured plaques,1 we calculated a sample size of 36 subjects to achieve a power of 80% to detect a true difference in population means, considering a type I error of 0.05 (two-sided) and a within group standard deviation of 15.
Comparisons between groups were performed using paired and independent Student's t-test, or 
2 tests as indicated. For variables with a non-normal distribution, we used Kruskal–Wallis or Wilcoxon signed ranks tests as indicated. A two-sided P-value of less than 0.05 indicated statistical significance. Statistical analyses were performed with the use of SPSS software, version 13.0 (Chicago, IL, USA).
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Results |
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Patients
Forty-six patients were included in the study protocol. Subsequently, six patients were excluded from the final analysis due to the absence of coronary plaque outside the stented segment in one patient, and bad quality acquisition owed to non-continuous pullback in five patients. Accordingly, 40 non-consecutive patients were prospectively included in the study. IVUS interrogation of the three main coronaries was attempted in all patients. Two-vessel IVUS interrogation was achieved in all patients and three-vessel IVUS imaging was achieved in 31 (77.5%) cases. Five vessels were excluded from the analysis due to the lack of a diseased non-stented segment. Patient characteristics are provided in Table 1. The mean age was 55.7±11.0 years. Twenty-nine (72.5%) patients were male. There was a low prevalence (10.0%) of diabetes. Thirteen (32.5%) patients presented with stable angina (SA), 12 (30.0%) with unstable angina, and 15 (37.5%) with AMI. The global geometrical and compositional characteristics of the coronary tree are presented in Table 1.
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PR: prevalence and location
Twenty-eight PRs were diagnosed in 26 vessels (25.7% of the vessels studied) of 20 patients (50% of the population). Sixteen (59.3%) ACS patients presented at least one PR in their coronary tree, whereas such finding was observed in four (30.8%) stable patients. The tear was located in the shoulder of the plaque in 18 (64.3%) cases and in the centre of the plaque in 10 (35.7%) cases.
Ruptures were located in the left anterior descending (LAD) artery in 13 cases (34.2%), in the left circumflex (LCx) in seven cases (21.2%), and in the right coronary artery (RCA) in eight cases (24.2%). Ruptures located in the LAD were clustered in the proximal part of the vessel [median mm from the ostium (interquartile range, IQR): 14.16 (8.5–26.5)], ruptures located in the LCx were widely distributed [median (IQR): 21.9 (5.7–35.5)], and ruptures in the RCA were more distally located [median (IQR): 38.8 (28.8–60.0)]. PRs were located at the MLA in six cases (21.4%), proximal to the MLA in nine cases (32.1%) and distal to the MLA in 11 cases (39.3%). The MLA could not be identified accurately in two (7.1%) cases due to the presence of diffuse disease. Six (28.6%) of the culprit vessels of ACS contained a PR, whereas such finding was present in 16 (31.4%) of non-culprit vessels.
Multiple PR was present in six ACS patients (22% of all ACS patients). No multiple PR was identified in stable patients. Two patients presented two different ruptures in the same vessel.
PR: demographical and IVUS-derived characteristics
Table 2 depicts the demographical characteristics and the IVUS-VH measurements of patients with and without the presence of PR in their coronary tree. Body mass index (BMI) was significantly higher in patients with rupture (28.4±3.7 vs. 25.8±2.6 kg/m2, P=0.01). Of note, 66.7% of current smokers presented a ruptured plaque in their coronary tree.
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Patients with ruptured plaques in their coronary tree had globally more severe disease (plaque burden 40.7±7.6 vs. 33.7±8.4%, P=0.01) (Table 2).
Finally, PR sites showed a higher relative content of necrotic core compared with MLA sites (16.7, 7.9–26.5 vs. 11.8, 8.4–17.1%, P=0.03) (Table 3).
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Differences between coronaries and culprit vs. non-culprit lesions
The LAD presented more severe plaques (plaque burden; LAD 42.2±9.9 vs. LCx 33.17±9.2% vs. RCA 33.96±10.3), more calcified plaques (LAD 3.15; 1.74–4.91 vs. LCx 2.10; 1.17–3.79 vs. RCA 1.49; 0.39–2.53%), and showed larger necrotic core content (LAD 11.68; 5.3–15.8 vs. LCx 7.71; 4.15–13.6 vs. RCA 9.18; 3.87–13.3%) of plaques compared with the LCx and the RCA, respectively (Table 4).
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There were no significant differences in IVUS-VH measurements between SA (n=13) and ACS (n=27) patients. IVUS-VH parameters other than mean plaque burden (40.62±10.7 % vs. 35.26±10.2 %, P=0.02) did not differ significantly between culprit/target and non-culprit/non-target vessels. Furthermore, in ACS patients, geometrical and compositional characteristics did not differ significantly between culprit and non-culprit vessels, only showing trends for larger plaque burden (39.39±10.0 vs. 34.60±10.0%, P=0.07) and relative necrotic core content (12.16; 5.4–16.6 vs. 9.66; 5.2–13.8%, P=0.17) in culprit vessels.
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Discussion |
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Several histopathological and, more recently, IVUS studies have described the distinctive morphological features present in PR sites. Nevertheless, none has prospectively compared the clinical and IVUS-derived characteristics of patients with and without the presence of PR in their coronary tree.
In the present prospective three-vessel IVUS study, patients with at least one PR in their coronary tree presented larger BMI and overall worse IVUS-derived (geometrical and compositional) characteristics compared with patients without evidence of PR. In addition, PR sites had a worse phenotype than the MLA sites of the same vessels.
Coronary PR is the ultimate consequence of the progressive accumulation of lipid-rich atheroma and fibrous cap thinning, commonly involving haemodynamically non-significant lesions.13 For decades, the corollary of such event has been deemed an acute occlusion of the corresponding artery with the subsequent ACS and its inherent dire prognosis. Ex vivo studies have challenged such concept by providing evidence that subclinical rupture is not rare in sudden death patients.2,4 Furthermore, recent IVUS studies have reported a prevalence of PR of 20–30% in SA patients.7,12,14 In agreement with such previous reports, we identified PR in 30.8% of SA patients, whereas 59.3% of the ACS patients presented PR.
Patients with at least one PR in their coronary tree (50% of the population) showed a larger BMI and were more likely current smokers. These findings have a physiopathological basis because both high body weight15 and smoking16 are associated with an increase in the expression of matrix-metalloproteinases, enzymes involved in the collagen breakdown of fibrous caps.17 Patients with PR also showed more severe burden of the disease and larger calcium, fibrous, and necrotic content of plaques than patients without rupture.
Several studies showed increased inflammatory marker levels, larger lipid cores, and pronounced medial thinning in positive remodelled vessels.18–20
Our study extends those earlier findings and establishes a link between PR and coronary remodelling. Despite larger mean plaque CSAs, patients with the presence of at least one PR in their coronary tree showed similar lumen CSAs. The lack of lumen encroachment despite a significant increase in plaque burden was probably driven by a positive remodelling phenomenon, clearly shown as a significant increase in vessel CSA.
At site-specific locations, ruptured sites showed an overall worse phenotype than MLA sites. In particular, ruptured sites showed a higher necrotic core content (16.7; 7.9–26.5 vs. 11.8; 8.4–17.1%, P=0.03). These results were in line with histopathological findings supporting the role of the atheromatous core as the most thrombogenic component of atherosclerotic plaques.21 Of interest, and in agreement with Farb et al.22 who frequently found calcium in ruptured plaques, ruptured sites showed a larger calcium content than the MLA sites and the overall population.
It is noteworthy yet confirmatory of a previous ex vivo study23 that there was no significant difference in plaque composition between culprit and non-culprit vessels, supporting the validity of the interrogation of a single vessel to estimate the global burden of the disease.24 Nevertheless, several differences were detected between the three major epicardial arteries. Interestingly, the LAD showed more severe lesions and a worse phenotype than the LCx and RCA. In addition, ruptures located in the LAD were clustered in the proximal part of the vessel, ruptures located in the RCA were more distally located, and ruptures in the LCx showed no apparent site specificity. A recent IVUS study found a similar distribution throughout the coronary tree.25 Overall, these findings might potentially explain the higher re-stenosis rates seen in the LAD, particularly in the proximal LAD, compared with the LCx and RCA, respectively.26
Clinical and ex vivo studies have conclusively established that there is commonly a delay between the rupture of a plaque and its clinical consequence, if any.14,27,28 Indeed, Rittersma et al.28 have recently studied thrombectomy material of STEMI patients and found that 51% of the patients had day-to-week-old thrombotic material. Thrombotic occlusion of a vessel seems to be an episodic event4 and the underlying prevailing composition of the cavity (Figure 1) might potentially have a prognostic value in identifying plaques at higher risk of occlusion. Large prospective studies using IVUS-VH might shed light into this question.
Limitations
All analyses and comparisons performed in the present manuscript beyond the assessment of the necrotic core content in ruptured vs. non-ruptured plaques should be regarded as exploratory and hypothesis-generating because we cannot rule out the possibility that inflation of type I error due to multiple comparisons may have confounded our results. The relatively small population included may limit this study. Small ruptures, ruptures masked by overlying thrombus and the lack of assessment of minor branches may lead to an underestimation of the prevalence of such finding. Finally, prioritizing patient's safety, the decision to perform pre-intervention and three-vessel IVUS was at the discretion of the operator, potentially inducing a selection bias.
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Conclusions |
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The present study extends earlier findings about the prevalence, distribution, and morphology of PR in the coronary tree. In this prospective three-vessel IVUS study, patients with at least one PR in their coronary tree had larger BMI and overall worse IVUS-derived characteristics compared with patients without evidence of PR. In addition, PR sites had a worse phenotype than the MLA sites of the same vessels.
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Acknowledgements |
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We thank Mrs Inés Dávalos Michel for her generous contribution to the study. We declare that G.A.R.-G. has received a research grant from Volcano Corp.
Conflict of interest: none declared.
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References |
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